The meta-narrative (metaphor, characters, setting, and plot)
Our analysis illustrates that generalist physicians can make sense of their errors in a way that encourages growth within the profession, but only after the experience of an emotional trough, acknowledgement of the error, and taking ownership of their role in the error (Figure 1).
(INSERT FIGURE 1 HERE).
Applying this trajectory, we developed a metaphor comparing the experiences of the physician to those of an athlete who plays a professional team sport. The following meta-narrative will help contextualize the characters, setting, and main features of the plot.
Characters and setting: The characters of this meta-narrative include: 1) the elite athlete (the physician who displays confidence, competence, care, empathy, honesty, and a sense of humour); 2) spectators (family members observing the physician and his/her interactions with patients); 3) team coach (typically a trusted senior clinical colleague or supervisor who is supportive, gives honest feedback for growth, and provides guidance for emotional development and improvement to professional practice); 4) veteran teammates (clinical peers who may be relied on to provide affirmations on the course of actions or expected to lie to make the protagonist feel better about the outcome of error); 5) rookie teammates (trainees who are junior to the physician, who may be able to learn from the story of errors); 6) and overall team (clinic or hospital). It is important to note that although the patient is highly regarded, valued, and remembered with great detail, within this meta-story, they are embedded within the physician’s experience of their error. This became apparent as physicians often remembered the event, day, and patient in great detail, frequently intertwining such details within the context of the clinical situation.
The playing field (clinical setting) is a decision-dense, chaotic space where frequent, brief, and hurried interactions occur. All of these interactions exist within rules and regulations that need to be followed and respected.
The Emergent Meta-narrative: The story plot is based around the emotional and skills-based maturation of a soccer team composed of a diversely skilled group of elite players, both veterans and rookies. This metaphor stems from the growth of the protagonist athlete who embarks on an emotional and difficult journey to improve their skills and perception after an error costs the team a significant loss (e.g., championship game). The coach, veteran team members, and rookies play important roles in supporting the maturation process. Furthermore, although a single player is not solely responsible for the error at hand, the protagonist, through reflexivity, taking some level of personal responsibility, serves as the steppingstone to engaging in strategies that have the potential to support the recovery process.
The plot: Primarily, the plot consists of 5 main components: 1) the pre-error state; 2) occurrence of the error (which is unknown in the moment); 3) realization of the outcome; 4) acknowledgement of the error (reflexivity); 5) post-error maturation and growth within the profession (Figure 1).
The pre-error state is one where the protagonist has not yet experienced a self-labelled unforgettable or memorable error in their professional career. Likened to a decorated athlete committed to perfecting their skill, this phase was often defined by participants using words such as ‘overconfident’ or ‘not diligent enough.’ For example, one physician said the following about his pre-error state, “I think that’s a very common thing as we go through residency. I think you kind of go through stages, but there is a point somewhere at that transition where you probably get overconfident” (Participant 001).
Analogized to a set play defined for the protagonist athlete, but an unexpected change of events prevents them from delivering on the original plan, these errors often leave a long-lasting imprint on the athlete. The unexpected change of events could be due to something that occurs within their own team or due to the actions of the opposing team. Similarly within a clinical setting, these errors have an unforgettable nature to them, where it is often burned into one’s memory in a way where minute details can be recalled about the day of the event (e.g., what the patient was wearing, what the weather was like outside, etc.,). Furthermore, they often occur when there is an unexpected change in the originally defined course of action; the error is also unknown to the physician in the moment but leads quickly to an unfavorable patient outcome.
Likened to the point where the protagonist athlete realizes the team has experienced a critical loss, the realization of this unanticipated outcome often leads to an emotional trough (dip in self-perception) due to one of or a combination of the following sentiments: depression, confusion, shame, embarrassment, and sadness. When reflecting on the moment where the error is realized, many participants describe it as shocking, “you think you’re doing something right and then the rug is pulled out from underneath you and you quickly realize, ‘oh god, this is all wrong”’ (Participant 005).
Through the support of others, the protagonist is better able to acknowledge the error and through reflexivity, take ownership/responsibility for the outcome. This phase relates to the athlete’s ability to be reflexive about the error that was made; and the level of support and collegiality they receive from their team and coach after the error is made are crucial components that contribute to this realization. Having a supportive coach and team would help catalyze the athlete’s growth from the error, whereas a blame culture would regress their potential for improvement and reinstation of their confidence in future games. Likened to the clinical environment, this phase is described by participants as “I felt responsible…”, “Looking back, I knew I should have done x” or “I had failed to consider that diagnosis.” The realization sparks the recovery process to emotional growth and positive changes made to professional practice (e.g., building resilience, big picture thinking, newfound diligence, newfound humility, etc.,). Such adaptations were described as “instilling a sense of humility…”, “I became more thorough…”, and “I’ve kind of cognitively put a strategy in place to avoid this in the future.” Participants also highlighted the importance of mentors and colleagues, a supportive work environment, and the value in sharing such stories with others. For example, one participant said, “you have something that ends up in an outcome like that, and you tend to internalize it and feel like you’re the only person this has happened to and your decisions were to blame for this. I think, talking with other people about it, it was pretty clear that lots of other people had stories like this. There were lots of other things that contributed to this bad outcome. So, you know, it helps just kind of knowing you’re not alone, and that other people have been through this” (Participant 001). In most of the instances, taking the initiative to be reflexive and having a supervisor or colleague who offered support and reassurance catalyzed the growth process. In contrast, the absence of these approaches toward optimal growth, slowed or halted the recovery process. This could include supervisors not taking the time, effort, or diligence to handle errors in a constructive way or the culture of the clinic/hospital being unsupportive or blaming physicians when errors are made.
The protagonist athlete may also choose to use their error as an example to teach junior teammates about their recovery journey, advocate for regulation changes in the sport, and/or help encourage positive collegiality through workshops, seminars, or team-building activities. Likewise within the clinical environment, additional approaches toward optimal growth include using components of previous errors as teaching points (e.g., writing and presenting an in-depth lecture on the content area to junior learners), sharing the emotions of the story with trainees, supporting avenues for policy change, and contributing to a medical culture that is eager to empathize with medical error dialogues.
Due to the growth and change associated with the error, the protagonist will be inclined to view their identity as who they were before the error and who they have become after the error. It is important to acknowledge that there are many opportunities that must align for an error to occur and the course often involves the actions of several players, although it is the protagonist who takes on the responsibility of the error. This is represented by the various positions that exist within a team sport and on a medical team. In line with these major phases, it is important to consider the typology of each character and how they can all play a role in the post-error growth of the protagonist’s career. In sports, if there is meaningful coaching, strong team spirit, and continuous review of practice, athletes are able to seek out the necessary supports to improve their game. Likewise, if the clinical supervisor is able to contribute to a medical culture where work spaces can be used to share and grow from stories of medical errors, physicians can feel more encouraged to discuss their strengths with humility, celebrate accomplishments, be open and honest by asking what knowledge/skills/expertise they need to develop further, accept criticism, and continually reassess their own performance. Developing this culture can also contribute toward easing the implementation of strategies and practices to improve patient safety.
In the cases where personal responsibility is attributed but support is not provided by either team coaches, medical supervisors, or colleagues, there is a deeper emotional trough and delayed progression. This may include the protagonist being much less enthusiastic about their career or wanting to leave the profession prematurely. Above all, similar to how meaningful coaching can help athletes grow from errors by unlocking further potential, clinical supervisors serve as vital catalysts in advocating for post-error growth within the profession.