Recently I was surprised to hear that Harvard University is conducting a project devoted to failing. Not failing entirely, the project is fully named The Success- Failure Project (https://successfailureproject.bsc.harvard.edu/quotations) but the intent is to highlight failures along with the successes that have always been celebrated at an Ivy League university. Many students at schools like Harvard have only experienced success and shaped their very identify on the ability to outsmart, out rank and out think their peers. But even Harvard knows that Harvard isn’t the real world. Failure will happen. So what do we achieve when we fail?
For most of us working in the world of diabetes education our failures can feel overwhelming. Truly, our jobs can at times be life or death. The cost of failure on our part may be paid by patients with the currency of health or quality of life. The stakes are high, made all the more so because most of us working in healthcare define ourselves as caregivers; helping is part of our identity.
Recently I experienced a failure of communication with a patient. She was insightful and from the first visit identified that her multiple daily injection insulin regimen (set doses of the same amount at all 3 meals and a bed time basal insulin) wasn’t working for her. With highs and lows following her meal times she knew she needed a variable dose and we worked on a correction and coverage scale. During her visit I set myself to work, furiously calculating an insulin sensitivity factor and insulin to carbohydrate ratio based on her weight and other co-morbidities. I carefully wrote down the scale for her (noting at the top that I used a weight based approach to jog my memory for future visits) and we worked through several scenarios where she correctly calculated her meal time dose. We both felt confident that her new regimen would work well for her.
A week or so passed and I received a call from the patient reporting episodes of hypoglycemia. We discussed backing off of her basal insulin and timing of her meal time insulin along with carbohydrate counting, possible mis-calculations, but nothing seemed to add up. Finally, exasperated she exclaimed “it’s this weight based thing, every time I weigh myself it’s the same and when I take insulin for my weight it’s just too much!” Suddenly it clicked, she wasn’t dosing based on her blood sugar, she was weighing herself and following her coverage scale based on her weight! I felt sick to my stomach. How had I missed such a gap in learning? Why did I make notes for myself on directions intended for the patient? Hadn’t I explained it right? Didn’t we work through scenarios? Imagine what could have happened.
After a quick discussion with the patient, reviewing how to correct for a high blood sugar based on her METER readings, she expressed a bit of sheepishness, relief, then complete gratitude. I also expressed the same emotions in the same order. Then I took stock of my failure.
So what did I gain from this mess-up, this mistake, this miss-communication…this failure? First I learned how to be wrong. In the face of a big mistake I learned that blame is no one’s friend. As a barrier to communication, blame is a diversion, blocking a clear view of the problem. I could have quickly shifted blame to my patient, I mean how did she NOT understand what I taught her? I could have become mired in guilt, swallowed by the quicksand of my own shame. Instead I put blame in check to focus on the problem.
I also learned humility, owning my part in this miss-communication and sharing with my patient a humble human connection that cultivated trust between us, when she could have felt angry with me and completely skeptical of my knowledge and ability.
Next I learned the art of reexamination. I learned to look at the issue like a detective, objectively asking questions, searching for clues and listening closely to my patient when unexpected answers were given. Then I let this experience change my practice, marching forward better equipped to avoid similar mistakes in the future.
Lastly I observed resiliency, not just my own, but my patient’s as well. She went on to dose her insulin with minimal complications. She learned, I learned, we both refused to give up.
I often tell my patients there’s a reason we say we practice medicine…no one says we’ve mastered it. Practice may someday make perfect, but initially practice usually means mistakes. Winston Churchill once said “Success is the ability to go from failure to failure with no loss of enthusiasm”. Harvard University understands this principle. For those of us working with people with diabetes, success and failures are intrinsically linked and our enthusiasm fertilizes the seeds of both as we evolve into better educators.