Can talking about failure transform the “toxic” culture of medical education?
Note from Rajesh Mangrulkar, M.D., associate dean for medical student education and associate professor of internal medicine and learning health sciences: In Medical School, many think failure is not an option. In reality, it is a necessity, because failure and struggles are part of any learning endeavor. They certainly have been part of mine. Historically, the culture in medicine has not been conducive to acknowledging this, but James Richardson, M.D., professor of physical medicine and rehabilitation, is working with us to change this. His Parallel Universe program strives to improve the Medical School culture, thereby helping our students become better physicians.
It's something no one talks about. Ever.
There's fear associated with it.
Yet on November 11, in an unassuming Zoom meeting, a Michigan Medicine faculty member said something the gathered medical students were not expecting to hear.
"I failed Step 1," he said. "Very spectacularly."
It's a moment of vulnerability that has almost a palpable ripple effect on those in attendance. "The imagery he used when he said he came home after learning he failed step one: white coat on, backpack on, shoes on, falling face first on his bed. I don't know that that imagery will ever leave me," says M1 Rachel Gotlieb.
People who have been to medical school know that failing Step 1 is a big deal, and failing can be a big embarrassing deal. For the rest of us, Step 1 is likely something we've never heard of. It's the first part of the U.S. Medical Licensing Examination ("the boards") that comes at the end of the second year of medical school, and it's used to test foundational medical knowledge. Step scores are one of the factors considered by residency programs in selecting applicants.
"I was a terrible medical student," the faculty member admits. He says it shouldn't have been a surprise that he failed, but it was. However, he was determined to try again. "It's almost offensive as a medical student to think about not trying again. I'm paying $60,000 a year for the right to be tortured on an hourly basis. Of course I'm trying again."
The joke about the torturous nature of medical school gets laughs from the students in attendance at a Zoom event cheekily titled "Leaders and Worst." They've shown up to hear esteemed faculty members (and one resident) talk about something that almost never gets talked about in the world of medicine: failure.
The Tyranny of Constant Evaluation
It is a truth universally acknowledged that medical school is dang hard.
But is it possible that it's harder than it needs to be?
Yes, according to James Richardson, M.D., professor of physical medicine and rehabilitation. The unnecessary difficulty comes from "the tyranny of constant evaluation," says Richardson, who came up with the idea for "Leaders and Worst" several years ago. The November Zoom event was the fifth annual talk, which is usually held in the spring. (This year's event was postponed due to the pandemic).
What Richardson experienced in medical school and what he saw his own students experiencing was a hidden curriculum that taught students how to appear knowledgeable and engaged, even when they were clueless and exhausted. Richardson saw this disconnect, between how students appeared and how they felt, taking a huge emotional toll.
Once upon a time, students in their clinical year of medical school gathered together every Friday for seminars. Richardson says their goals were threefold: "To see their friends, to sleep, and maybe to learn something."
Richardson used to give lectures at these seminars a couple times a year. At the beginning of his talk, he'd ask, "How's your clinical year going?" They'd all nod and say it was going well.
"Then the next slide, in huge font, would say, 'LIARS,'" says Richardson.
"No, it isn't. It's horrible. You have no idea what you're doing. As soon as you learn where the bathrooms are, you're on to the next rotation. You're lost on rounds. They're talking over your head, and you feel useless."
It may seem counterintuitive, but after being called liars and being told that things aren't going well for them, the students felt relieved. "They loved this."
They also loved the story of Richardson's first clinical rotation, in surgery. After four weeks, he was given an evaluation. His score was not desirable; it was not even within the range printed on the paper. "They put arrows off the page to indicate 'below poor.' There was no descriptor to describe how atrocious I was.
"I was invited to leave the entire field of medicine during my first clinical rotation," he says, retelling the story at the November Zoom event. "It was not humorous at the time. It hurt bad."
"Every day you go in and you fail a little bit," said another physician at the event. "You'll be on your peds rotation, and there will be literally 50 people there. They'll ask you a question, like, 'Where is the heart?'
"You'll say, 'chest,' but you start second guessing yourself. 'Abdomen?'
"You feel like an idiot, and you have to stand there and keep going for five more minutes."
Building a Parallel Universe
Richardson often talks about the ways it is detrimental to the learning process — not to mention emotionally excruciating — to maintain the appearance of being knowledgeable while trying to learn. Especially when you're trying to learn high-stakes concepts and skills that will one day help you save lives.
That's why he created a program called Parallel Universe, a series of communications with medical students that includes talks like the November event and others, such as "The Illusion of Linear Progress" and "The Tyranny of Constant Evaluation." Created with the full support of the Office of Medical Student Education, the program was supported in its startup phase by funding from the Marguerite S. Roll Professorship in Medical Education, which is held by Rajesh Mangrulkar, M.D., associate dean for medical student education and associate professor of internal medicine and learning health sciences. Now it is fully part of the medical school.
In addition to those lectures, Parallel Universe also includes what Richardson calls "Jimmy Kimmel interviews" with faculty members, about difficult moments in their medical training and beyond. The program is also working on a newer how-to series, but in countercultural fashion, it's "How Not To." For example, a faculty member may give a lecture on "How Not to Read a Chest X-Ray."
"Parallel Universe has been a student-driven enterprise from the start," says Richardson. "Students, whether on the advisory committee or more informally, have always guided me. As I often tell them, 'I have a lot of ideas, and most of them are bad. Your job is to tell me when we hit upon a good one.'" Richardson gives particular credit to two former students, Cody Schultz (M.D. 2016) and Salomeh Salari (M.D. 2019). "Without them, Parallel Universe doesn't exist. I remain so grateful to them."
Dealing with Imposter Syndrome
"Parallel lines — the further they go along they look like they converge on a common goal," says Richardson. The emotional work of medical school — figuring out how to contend with an onslaught of failures and setbacks in a highly competitive environment — exists alongside the formal training. "Even though it is separate from medical training, it is not separate from the long-term goal of becoming an integrated person, which will help you become a better doctor."
The series is offered through M-Home, a learning community created about five years ago to foster connections, community, and well-being for medical students. It's no secret that burnout is a big problem in the medical field. Almost 30% of medical students experience depression, and 10% report suicidal thoughts. M-Home, in partnership with Student Services, helps address those mental health concerns.
"There are many arenas, not only in health care, but also in finance, law, fill in the blank, where discussing your failures and nonlinear path hasn't typically been welcomed," says Deborah Berman, M.D., associate professor of obstetrics and gynecology and the faculty director of M-Home. "The problem is that although many of us have had difficult experiences during our journeys, these challenges are often not spoken about. So, through Parallel Universe and M-Home, we are trying to normalize that we have all had struggles and to let people know they're not alone."
"We read article after article, [saying] we need to create a culture of failure and deal with imposter syndrome," says Jennifer Imsande, Ph.D., program director of M-Home. "People are talking about what we need to do, and Jim Richardson is actually doing it."
The Superhero's Origin Story
Part of the reason Richardson's work resonates so strongly is because of the relationship between medical students and established physicians. "I have been surprised to learn the extent to which students, at times, look up to us," says Richardson. "This is completely unearned, of course, because we faculty are only in this position, relative to these extremely talented and accomplished students, due to an accident of birth order. But, regardless, to medical students, esteemed faculty are often seen in various shades of fabulous."
Like a Spiderman fan loves watching a young Peter Parker get his butt kicked while he figures out how to hone his "spidey sense," medical students get a thrill from learning about their heroes' early mistakes. But for the medical student, the experience offers something even more: a chance to see how they, too, could become heroes. "For us to get up there and say unequivocally and in the rawest of terms that we, at times, absolutely stunk as students and residents — as learners — is huge for them. And, to be honest, it is huge for us as well. There is a relief in us allowing ourselves to be human."
Learning by Failing: The Medical School Community Reacts to Parallel Universe
"When I first started getting these emails for Parallel Universe, it seemed like some sort of inside joke from a club I somehow ended up on the listserv for. … I was glad I had someone tell me how important it was." —Rachel Gotlieb, M1
"[Parallel Universe] was a huge breath of fresh air in the medical community. Even in the first year, the environment can be pretty toxic at times. … I always leave [the] talks feeling better about myself than when I went in. …. It's been really helpful for my own mental health and conceptualization of who I am in relation to medicine. I'm not just a medical student. I won't be just a resident. I'm also a person." —Annie Murphey, M4
"The spaces to talk about where medical education is going are really formal, [like] philosophical discussions on the role of competition and hierarchy in medicine. Parallel Universe is a space to explore those exact themes, but through comedy. There's something about the comedy of it that disarms you. … When we're joking about how messed up medical education can be, everyone just agrees. It's a really fun space to be a part of. … And it's a good space to build relationships that are pretty real with doctors." —Kiley Adams, M2
"Failure isn't getting an 80% instead of 90% on a test. It's not matching at your 2nd-, 3rd-, or even 5th-ranked program. A lot of medical students need to hear that. … And for those true failures, [Parallel Universe] helps normalize these events and teaches us to learn what we can from the experience. … It's so reassuring to know that your favorite attendings have also been in your shoes, where you thought you finally hit a wall that you couldn't get over. … Everyone has failure. Everyone has imposter syndrome. But it's incredibly lonely to go through when it's not talked about openly." —Salomeh Salari (M.D. 2019)
The expectations in medicine and the sense of what is normal can become a little bit warped. We are expected never to fail, never to not know an answer. … Parallel Universe peels back that veneer of medical perfection to the human doctors underneath. … [E]veryone fails, and … this failure is an essential part of our training as doctors, as people. —Alec Bernard, M4
Again and again, students say, "I just felt better after leaving that space." … You can just see their shoulders dropping three inches. … The collective joy and sense of connection that happens in a space when people are openly talking about this is miraculous. If people could bottle it, that would be a vaccine. —Jennifer Imsande, Ph.D.