Failure and Error among Doctors and Teachers

I had a conversation with a friend* last week about the two posts detailing my failures as a teacher with three students I have had over the years. He has practiced Family Medicine for over a half-century in Pittsburgh and for years helped resident physicians in doing medical research and now works with hospital residents in improving communication with patients.  He pointed out to me how similar teachers experiencing failures with students is to physicians erring in diagnoses or treatments (or both) of their patients.

I was surprised at his making the comparison and then began to think about the many books I have read about medicine and the art and science of clinical practice. In my library at home, I had two with well-thumbed pages authored by doctors who, in the  first dozen pages, detailed mistakes either they had made with patients or errors committed by other physicians on them or their families.

In one, Jerome Groopman, an oncologist, described what occurred with his 9-month old child after a series of doctor misdiagnoses that almost caused his son’s death. A surgeon, who was a friend of a friend, was called in at the last moment to fix an intestinal blockage and saved his son.

In the other book, surgeon Atul Gawande described how he almost lost an Emergency Room patient who had crashed her car when he fumbled a tracheotomy only for patient to be saved by another surgeon who successfully got the breathing tube inserted. Gawande also has a chapter on doctors’ errors. His point, documented by a paper in the New England Journal of Medicine (1991) and subsequent reports  is that nearly all physicians err.

If nearly all doctors make mistakes, do they talk about them? Privately  with people they trust, yes. In public, that is, with other doctors in academic hospitals, the answer is also yes. There is an institutional mechanism where hospital doctors meet weekly called Morbidity and Mortality Conferences (M & M for short) where, in Gawande’s words, doctors “gather behind closed doors to review the mistakes, untoward events, and deaths that occurred on their watch, determine responsibility, and figure out what to do differently (p. 58).” He describes an M & M (pp.58-64) at his hospital and concludes: “The M & M sees avoiding error as largely a matter of will–staying sufficiently informed and alert to anticipate the myriad ways that things can go wrong and then trying to head off each potential problem before it happens” (p. 62). Protected by law, physicians air their mistakes without fear of malpractice suits.

Nothing like that for teachers in U.S. schools. Sure, privately, teachers tell one another how they goofed with a student, misfired on a lesson, realized that they had provided the wrong information, or fumbled the teaching of a concept in a class. Of course,  there are scattered, well-crafted professional learning communities in elementary and secondary schools where teachers feel it is OK to admit they make mistakes and not fear retaliation. They can admit error and learn to do better the next time. In the vast majority of schools, however, no analogous M & M exists (at least as far as I know).

Of course, there are substantial differences between doctors and teachers. For physicians, the consequences of their mistakes might be lethal or life-threatening. Not so, in most instances, for teachers. But also consider other differences:

*Doctors see patients one-on-one; teachers teach groups of 20 to 35 students four to five hours a day.

*Most U.S. doctors get paid on a fee-for-service basis; nearly all full-time public school teachers are salaried.

*Evidenced-based practice of medicine in diagnosing and caring for patients is more fully developed and used by doctors than the science of teaching accessed by teachers.

While these differences are substantial in challenging comparisons, there are basic commonalities that bind teachers to physicians. First, both are helping professions that seek human improvement. Second, like practitioners in other sciences and crafts, both make mistakes. These commonalities make comparisons credible even with so many differences between the occupations.

Helping professions.

From teachers to psychotherapists to doctors to social workers to nurses, these professionals use their expertise to transform minds, develop skills, deepen insights, cope with feelings and mend bodily ills. In doing so, these helping professions share similar predicaments.

*Expertise is never enough. For surgeons, cutting out a tumor from the colon will not rid the body of cancer; successive treatments of chemotherapy are necessary and even then, the cancer may return.

Some high school teachers of science with advanced degrees in biology, chemistry, and physics believe that lessons should be inquiry driven and filled with hands-on experiences while other colleagues, also with advanced degrees, differ. They argue that naïve and uninformed students must absorb the basic principles of biology, chemistry, and physics through rigorous study before they do any “real world” work in class.

In one case, there is insufficient know-how to rid the body of different cancers and, in the other instance, highly knowledgeable teachers split over how students can best learn science. As important as expertise is to professionals dedicated to helping people, it falls short—and here is another shared predicament–not only for the reasons stated above but also because professionals seeking human improvement need their clients, patients, and students to engage in the actual work of learning and becoming knowledgeable, healthier people.

*Helping professionals are dependent upon their clients’ cooperation. Physician autonomy, anchored in expertise and clinical experience, to make decisions unencumbered by internal or external bureaucracies is both treasured and defended by the medical profession. Yet physicians depend upon patients for successful diagnoses and treatments. If expertise is never enough in the helping professions, patients not only constrain physician autonomy but also influence their effectiveness.

While doctors can affect a patient’s motivation, if that patient is emotionally depressed, is resistant to recommended treatments, or uncommitted to getting healthy by ignoring prescribed medications the physician is stuck. Autonomy to make decisions for the welfare of the patient and ultimate health is irrelevant when patients cannot or do not enter into the process of healing.

For K-12 teachers who face captive audiences among whom are some students unwilling to participate in lessons or who defy the teacher’s authority or are uncommitted to learning what the teacher is teaching, then teachers have to figure out what to do in the face of students’ passivity or active resistance.

Failure and error occur in both medical and teaching practices.
Both doctors and teachers, from time to time, err in what they do with patients and students. Patients can bring malpractice suits to get damages for errors. But that occurs sometimes years after the mistake. What hospital-based physicians do have, however, is an institutionalized way of learning (Mortality and Morbidity conferences) from their mistakes so that they do not occur again. So far, among teachers there are no public ways of admitting mistakes and learning from them (privately, amid trusted colleagues, such admissions occur). For teachers, admitting error publicly can lead directly to job loss).

So while doctors, nurses, and other medical staff have M & M conferences to correct mistakes, most teachers lack such collaborative and public ways of correcting mistakes (one exception might be in special education where various staff come together weekly or monthly to go over individual students’ progress).

Books and articles have been written often about how learning from failure can lead to success. Admitting error without fear of punishment is the essential condition for such learning to occur. There is no sin in being wrong or making mistakes, but in the practice of schooling children and youth today, one would never know that.

_______________________

* Dr. Joel Merenstein and I have been close friends since boyhood in Pittsburgh (PA)

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32 Comments

Filed under comparing medicine and education

32 responses to “Failure and Error among Doctors and Teachers

  1. This piece generates lots of good idea’s, thanks!!

  2. Gary Ravani

    It would be helpful to have this posted as a op/ed. or at the EdSource website, to provide some context for the debate around the Vergara lawsuit.

  3. Mark Ragnone

    Hi Larry,

    I wonder if you think this happens (teachers not formally sharing in their failures) simply out of fear of losing their jobs, or if it might also be an issue with credibility. As with physicians, teachers have their professional credibility on the line when teaching students. And when they mis-instruct or make a critical error, it causes them to lose their integrity as an expert in their field. What is the real difference with teachers? Why are their mistakes so guarded compared to doctors who could be sued for money or their license? With doctors’ mistakes not being as “high-stakes” as with educators, why not professionally share and confide in others to build educators up and give them a means to reflect upon what went wrong? (Would this be with the principal, a department, or by paring novice and master teachers?) Also, even though a teacher is struggling, they might not know what exactly went wrong and how to rectify it. As a second year teacher, I would love the opportunity to engage with those more experienced; to pick their brains as to the cause of my folly. In my first year teaching I was able to pick a “mentor” to ask questions of and to ensure that I transitioned into my building and position comfortably. As time went on and we both became more pressed for time, we starting meeting together less and less. Basically, if time wasn’t set aside for it, we were not going to meet. We do, however, spend an awful lot of time on professional development. Time spent developing new skills, or learning new teaching techniques, or time spent changing the practices that we have established because of a new pedagogy our district is adopting. As you mention in the post, there are documented benefits to learning from our mistakes. We ask our students to do it every day, shouldn’t we take our own advice? My question then is, should we take a portion of this professional development time to admit mistakes and learn form them? Is this the solution, or is it that the teaching profession indeed has so much fear associated with it lately (because of lay-offs and cut-backs, etc.) that few would actually be willing to admit their mistakes, discredit themselves and potentially dig their own graves?
    Thanks Larry.

    • larrycuban

      You ask a tough question at the end of your comment, Mark. The M & M conferences that hospital doctors have is a protected, confidential mechanism that is organizationally legitimate and respected. Nothing like that, as far as I know, exists in schools except sporadically in teacher professional communities that encourage such open-ness and willingness to listen to one another. It sounds like the mentor relationship you had as a first year teacher is an institutional mechanism that fell by the wayside as work piled up for each of you. Not the same as what M & M conferences are, however. So much depends upon teacher leadership, the building of trust among peers, and the confidence that what is said will be confidential and not become grist for retaliation in evaluation of performance. Such cultural norms are uncommon but they do exist in scattered locations where principals and teachers have come to trust one another. Thanks for the comment, Mark.

  4. EB

    Speaking as someone who has both teachers and doctors in the family, I would add that the M&M process enjoys some features that would be hard to duplicate in a school setting. For one, when a patient is in a hospital (and even before when under the care of a doctor in an outpatient setting), there is extensive documentation of everything that is done to/for the patient, and documentation of changes in the patient’s condition through time. This doesn’t exist in a school setting (and we would not want it to because documentation would replace learning). This means that a high proportion of what’s being talked about in M&M is highly specific and highly measurable. Also, the goals of M&M are highly specific: to identify areas where diagnosis or treatment protocols might be inadequate, and to identify actual errors of judgment (which is not the same thing as treatment failure; sometimes treatments fail even if no error has been made).

    I agree that sharing of information about what seems to work (and not work) with specific students or specific classrooms, in a confidential setting, can be highly valuable and has helped me numerous times. But I think it’s unrealistic to think that, even if widely practiced, this sort of sharing could have the same effect as M&M conferences do in a hospital setting.

    • larrycuban

      I find your comments about the differences between doctors and teachers using M&M conferences most useful, Jane. Thank you. How to adapt such a mechanism to school settings is the point of the post. Like yourself, i believe the mechanism cannot be replicated as is. But the sharing of information about what happens with lessons that misfire, things that work and do not work with particular students, and the like is something that can be done among teachers.

  5. Larry,

    Thanks for the piece. I have written a couple of articles for Ed Week arguing this point, and have conducted several studies on the notion of schools in academic decline. In my courses, I often bring up the M&M meetings or the after action reports by the army as means of learning from failure. If readers are more interested, I would suggest reading Normal Accidents by Perrow and The Logic of Failure by Dorner.

    Gratefully,
    Craig

    • larrycuban

      Thanks, Craig, for the references–I am unfamiliar with the Dorner piece. And thanks for writing further on M & M conferences. In another comment by Jane, she–and I concur–points out further differences between teachers and doctors and this mechanism for correct mistakes. Adapting M&M to the different setting of the school is a worthwhile venture, I believe, and does occur sporadically in certain settings where trust has developed between and among teachers and administrators.

  6. Cal

    Interesting to consider this in light of your two great posts on your sense of having “failed” three students. You touch on this issue: doctors have a clear outcome to measure against. Teachers don’t. You couldn’t even get agreement from your readers as to whether you failed these students; how could teachers realistically discuss their failures in a broader, objective setting?

    Another difference between doctors and teachers: if teachers can’t have an objective setting to discuss failure, they can discuss it with their “clients”, the students.

    “Hey, guys, I’ve been thinking about yesterday’s lesson and I don’t think I got the main point across.” or “Hey, I blasted Philip yesterday for rudeness, but it turns out he’d misunderstood me. I’ve apologized to him for judging him too hastily, but I want you to know as well.” or “I think my whole approach to teaching X has been based on the wrong assumption. I’ve talked to some of you about your confusion, and we’re going to try something new.”

    That’s not to say we don’t also discuss our errors with teachers or principals, but we have more flexibility than doctors do to set things right with the affected parties.

    • larrycuban

      I guess what I am after, Cal, is not only an admission of erring–your examples are on that point–but an open discussion among people you trust who have expertise of what to do next time to avoid such mistakes.Talking with students, as you suggest, permits you to admit you erred, and that is a good starting point but the students, while they can make suggestions as to what to do next time, lack the subject and skill expertise that professional teachers would have in a protected, trusting venue. M & M conferences in hospitals do not include patients–students if I close the circle on the analogy. The first point you raise, however, over the difficulty of gaining agreement over what constitutes failure is on the mark. Teachers would have to distinguish among mistakes in teaching content, concepts,organizing activities, instructional slips, treating students, etc. But there are areas, I believe, that teachers can come to agreement on and can discuss openly–as your examples illustrate. You do point out the difficulties in comparing doctors and teachers, Cal, and I thank you for that.

      • Cal

        Oh, I wasn’t in any way suggesting that conversations with students/clients are in any way similar to MM reviews. However, people who research malpractice suits often say that the patient wants in cases of genuine error, more than anything, an acknowledgement of error. It’ s not just the money.

        And that’s an interesting thought: what would teachers agree, unequivocally, are problems they’d like to discuss? Do any of them at all have approach or advice options that aren’t based on the type of teaching? Because if we can’t come up with many of these, then we can’t have an objective review.

        Even in the case of yelling at a student unfairly, which seems obvious. Many teachers think any raising of the voice is a terrible thing. Any “calling out of a student” is sign of bad teaching. Others, like me, are casual yellers. We’re not yelling to get control, we yell because hey, when you spill the drink that isn’t allowed and that I’ve told you once already to put away (which you did and then snuck it back out), yelling seems appropriate. (let’s stipulate not abusive yelling, no insults, just loud voice). Quiet teachers are like heavens, no. You should have referred the student the minute he violated your rules the first time, and if you made that clear, students would be less likely to break rules. Yellers are now rolling their eyes because honestly, what sort of fascist would refer a kid for having an Arizona Tea out? Most kids pay attention to the rules, every so often one tries to sneak by, you tell them to put it away, most of them do. Every so often one tries to get away with it. You yell. Referrals are for serious things. Other teachers now rolling their eyes: rules ARE SERIOUS.

        You see what I mean. And that’s just for one thing.

      • larrycuban

        I do see what you mean, Cal. On the yelling theme, you are contrasting teacher temperament and agreement about rules. I get that. That strikes me to being similar to discussions about doctors’ “bedside” manner, listening skills, etc. and the variations that exist among doctors. And, yes, some teachers would characterize your adherence to the rules you set as an “error” in dealing with students. So I get your larger point of the lack of overall agreement among teachers on what teaching should try to achieve in learning. But I have worked in teaching communities, not many I concede, and have worked with other teachers where there is consensus of what teachers need to do and what they should do to advance student learning. Not the norm by a long shot, but there are groups of teachers in scattered schools who do come to agreement about classroom rules, the content of math, science, history, etc. that should be taught. So while there is much variation among teachers about objective outcomes, there are places where teachers do come to agreement and work together toward common ends for students. Uncommon, to be sure. But worthy, in my opinion, since in such places the concept of making mistakes and getting help to correct them in one’s teaching become possible.

  7. Gary Ravani

    One of the key differences between teaching professionals, medical professionals, other kinds of professionals, and teaching professionals in other countries is that almost all of these other professionals have time to collaborate with colleagues built into their work day. Teachers in the US just plain spend more time in front of students (and students spend more time in their seats) than their peers in other nations. It is much more difficult for classroom teachers in the US to conduct what could be considered routine professional operations than it is for other kinds of professionals within the country, or even other classroom professionals outside the country.

  8. Rick Martinez

    With sincere respect, I believe teachers today are self-afflicted with the same “dis-ease” with medicine’s respiratory therapists of year’s back: The self-sense of not either feeling or being recognized as “professionals.”

    And there’s a bit of reality to their sense. A good portion of teachers are
    not continual or life-long learners: They don’t read about their work, nor do they read any tangential information about what might influence their work.
    It’s like teachers don’t believe who they are, the importance of what they do,
    how they influence the future via their students, what they say, or how they say it. Thus leaving home and going to work is drudgery, and teaching is
    daunting. They are not personally fulfilled, and thus cannot be professionally
    inspired.

    The same could and would be true for medicine…if not for some basic
    distinctions. For example, early on in medical training some basic “people” foundations are inculcated in medical students. For example, a definition of professionalism: When we do our work so well that the persons we serve don’t know if it’s our job…or our nature; 2) We must CARE for the persons we serve beyond the diagnosis and illness they have: They are human beings first, then patients; 3) The distinction between critique and criticism: Critique is always positive and constructive, while criticism is always negative and destructive; and 4) We must use reasoning skills to
    seek and solve for X, and reduce it to its most simple common denominator.

    Here’s the irony. Teachers truly are professionals. Here’s why: They are
    the professionals who make all other professions possible.

    • larrycuban

      Thank you, Rick, for taking the time to comment on the post.

      • Gary Ravani

        And, just where do you get this information on “a good portion of teachers?” Unless teachers have some control over the professional development they receive, the quality of that formal professional learning is problematic. To the extent teachers have difficulty keeping up with informal “professional learning” it would be closely related to the lack of professional time they have to conduct that learning, or conduct professional collaboration. In my 40 years of involvement with the teaching profession, I never met a teacher who was not a “lifelong learner” though not all of the learning efforts were formal in nature.

      • larrycuban

        Thanks for the comments, Gary.

  9. Cal

    (I don’t want to give the impression that I’m howling at my students in anger or frustration ever, just to be clear. More like “Excuse me, WHAT DID I TELL YOU!” “mumblemumble put it away.” “EXACTLY!” and the next time that kid had food out in my class, he’d lost all warnings. And me, the kid, and the class are all chortling underneath it all. Also worth noting I’ve taught very tough kids and get high marks in classroom management.)

    Larry, I understand your point, but I’d like to make one more observation: many MANY teachers actively reject the idea of one style of teaching, one norm of behavior, one definition of what should be taught and how, and so on–even if it’s theirs. I’m one of those teachers. Most of the schools that agree on a rigid set of rules for classroom management have horrible rules that would make me very unhappy. Most of the schools I know that agree on a curriculum either are extremely progressive, often with ideological goals attached and a distressing lack of actual rigor, or they are demanding traditionalist schools, which isn’t bad but they achieve it by not accepting kids who can’t do the work.

    Teaching is a huge profession, with an extensive range of opinions on this topic. I think a good chunk of teachers would happily sign up for a school with one classroom standard, one curriculum–so long as it was theirs. Another chunk know that’s impossible anyway, so wouldn’t fall for the story. But a still sizable chunk, like me, didn’t sign up to work in a North Korean gulag, if you’ll forgive the mixed metaphor there.

    And again, I know you know this. But I think you believe it’d be better if we *could* come to agreement. I disagree.

    Something else I thought of today: many doctors never go near an M&M meeting. Only doctors who operate, and then only for the portion of their patients they operate on, have even a chance of having their mistakes reviewed. The rest of the time, aren’t they more like teachers?

    • larrycuban

      As you have in the past, Cal, you nicely put your finger on important points. The differences between physicians and teachers are obvious and you, as have other readers, added even more.And, of course,you are correct that not all hospital doctors attend M & M weekly conferences. That’s fine.

      I believe that in your comments thus far on this post, the central issue is not only that there are differences between doctors and teachers–with much variation within each group–but also that teacher autonomy, the discretion to make in-class decisions, adapt curriculum to the kids you are teaching, and make choices that satisfy your beliefs in kids doing better on something you have crafted for them. Most teachers, but not all, treasure that autonomy. As they should. But there is another value that comes into play with teachers, administrators, and policymakers that conflicts with autonomy. That is standardization and control. Teachers are public employees and serve the community. There are standards that have to be met that, in their judgment,will help kids become adults and live fruitfully in their communities. So district, state,and fed officials have pursued this value vigorously through test-driven standards and accountability in the past 30 years. The tensions between autonomy vs. control, I believe, underlie some of your points. This tension between autonomy and control, of course, has come to the surface among physicians with evidence-based practices adopted by Medicare and private insurers as to how doctors should diagnose and treat patients. Thus, another similarity between the two professions.

      Thanks, Cal, for taking the time to comment.

  10. Cal

    Just wanted to add: I agree that we are public servants and our autonomy is not absolute. I would also point out that, in the limited areas where there is broad agreement on good practice, teachers submit to these rules. The problem is the lack of broad agreement, as discussed.

    • larrycuban

      As always, Cal, thanks for the comments.

    • Gary Ravani

      To suggest that since the imposition of test and standards based accountability schemes that teachers’ “autonomy is not absolute” is a bit of an understatement i’d suggest. And the less autonomy teachers have had, more the loss to education.

  11. I study teachers’ collective problem solving. I also read Gawande’s description of M & M’s, as well as hearing about them from physician friends. I would love to analyze M&M discussions and think about how they relate to the strong examples of teacher talk I have in my data. One clear difference is that, while anatomical anomalies exist, human anatomy and disease are generally more well defined by the field of medicine than the variation across classrooms and lessons are defined in the field of education. Medicine, in the end, takes place in a physical plane, while education, in the end, takes place in a social one. Further, the standard ways doctors have to represent cases — certain lab tests, medical images, etc — do not have parallels in education.

    Thanks for sharing your thoughts,

    Ilana Horn

    • larrycuban

      And thank you, Ilana, for sharing your thoughts on the differences between teachers’ collective problem solving and M & M hospital conferences.

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