Approaching Failure:
A Physical Therapist’s Perspective
By Luke Pedersen, PT, DPT
Failure is a universal experience that we each deal with many times throughout our lives. If you ever listen to famous celebrities, successful entrepreneurs, or professional athletes, many will say that overcoming adversity and failure is the key to success. From self-help books and podcasts, to post-game interviews, the relationship between failure and success has in many ways become clichéd. Yet, many of us never truly analyze our attitudes and response to failure, and thus, never learn, adapt, or grow professionally or personally.
I recently had the pleasure of reading Black Box Thinking: Why Some People Never Learn from their Mistakes- But Some Do by Matthew Syed. The author provides an in-depth discussion on how different individuals and industries approach failure. He also describes the powerful influences including psychological, societal, and emotional that impede our ability to learn from mistakes and failures. I was able to read this book through the lens of a young physical therapist eager to learn and grow, but who also struggles with his own self-doubts and anxieties. From this unique perspective, I’ve attempted to relate the information from Syed’s book to physical therapists and the profession of physical therapy as a whole.
Syed explains two main viewpoints when it comes to dealing with failure. The first style he calls “black box thinking.” With this style, mistakes lead to progress. Individuals or groups use failures as learning experiences. In these circumstances, it is safe to fail because failure allows critical analysis and feedback to update models, strategies, and behaviors. Syed explains how this style of openness and analysis of mistakes is exemplified by the aviation industry. Just one of the key aspects of the aviation industry is the review of black boxes after crashes to analyze what transpired in the cockpit before and during the crash. The second approach to failure that Syed explains is one where error is stigmatized. In these environments, individuals are not open about their errors and conceal failures. Individuals look for something or someone to blame: a scapegoat. In these circumstances, when mistakes occur, there is no learning or progress and the same errors and failures happen repeatedly. Syed provides various reasons why the healthcare industry exemplifies this second approach to failure.
So, it seems easy enough. You should approach failure with the first mindset of openness and learning. Why, then, do we not learn from failures and mistakes? As Syed explains, mistakes and failures are threatening. It is a threat to our credibility, competence, reputation, ego, and self-esteem. There is an illusion of perfection and infallibility. Think about the expert in the field, the guru, the senior employee, or the tenured professor. These individuals are not supposed to make mistakes. What would those below them think? What would their clients or patients think? The ability to accept failure becomes nearly impossible and instead, we employ various methods of self-justification. Syed goes into great detail describing how we essentially trick ourselves into thinking no mistake has actually occurred, and we subconsciously avoid acceptance of failure. Examples of some ways that we do this include reframing information, ignoring contradictory information, and manipulating the narrative of events rather than admitting our flaws and mistakes. (Note: lookup cognitive dissonance.)
Now let’s look at approaching failure from the perspective of a physical therapist. We all start out going through PT school. Most of us probably intuitively believe that the school environment is an optimal setting to provide openness to failure and to analyze, learn, and improve following failures. However, consider some of these scenarios: have you ever answered a question during a class of thirty plus students and gotten it wrong? Have you ever demonstrated a treatment or evaluation technique in front of the class and performed it incorrectly? Have you ever as a student practiced a technique on a real individual/patient and messed up? Did you ever have to retake a practical exam because you failed the first time? With each of these scenarios, does anything negative or bad happen because of your mistakes? In the big picture, no, but think about the implications these situations have on your self-esteem or the perceived social impact. A fear of failure develops that can be debilitating, especially when combined with what Syed calls an “illusion of perfection” or “fear of underperforming.”
There are also aspects of clinical-internships and professional practice as a physical therapist that impede our ability to learn from failure. During clinical-internships, you’re thinking don’t make a mistake or it might show up in your CI’s evaluations, or even worse you may fail the clinical. When practicing as a licensed professional, don’t make a mistake or the patient won’t trust your competence, or the physician won’t send you referrals, or your clinical director won’t trust you with more complex patients. These thoughts and ones like them lead to the stigmatization of mistakes and errors. This leads to therapists not being open about their mistakes, while failures don’t lead to learning or progress.
Before we talk about solutions to these problems, let’s consider the profession of physical therapy as a whole. Physical therapy is filled with a variety of evaluation and treatment techniques, strategies, and theories. There are also numerous continuing education courses and certifications that therapists can attend, become certified in, and add to the alphabet soup behind their names. To top things off, you probably can’t go a couple weeks or months without seeing some new device or piece of equipment for therapy treatment that boasts of better and extraordinary effects on patient outcomes. So, why doesn’t the field of physical therapy adapt, grow, and progress in terms of patient care strategies, beliefs, and theories? It is because so many of us are deeply invested in these interventions, techniques, and equipment. The people who created these theories, methods, or products have devoted large amounts of time and money creating these things and then marketing and selling them to people. Then there are the therapists who devoted their hard earned time and money to attend these classes or buy the products. Think about the blow to the self-esteem and reputation of both these groups if these things were found to be ineffective and showed no benefit of improving patient outcomes. We can also think about the more broad long-held theories and beliefs of physical therapy, the beliefs that form the cornerstones of our clinical practice. If these beliefs were proven incorrect, it would have a huge impact on the reputation and competence of physical therapists that have been treating based on these beliefs for decades. Many therapists have so much invested in specific clinical practice beliefs, theories, or equipment that it is overwhelmingly difficult to accept any shortcomings or ineffectiveness. Instead, we trick ourselves. We reframe the evidence, we avoid contradictory evidence or lack of evidence, or we selectively cite supportive evidence or use anecdotal evidence. This quote by psychiatrist and philosopher Frantz Fanon summarizes this concept well: “Sometimes people hold a core belief that is very strong. When they are presented with evidence that works against that belief, the new evidence cannot be accepted. It would create a feeling that is extremely uncomfortable, called cognitive dissonance. And because it is so important to protect the core belief, they will rationalize, ignore and even deny anything that doesn't fit in with the core belief.”
Thankfully, positive changes can be made to encourage a better mindset and approach to failure that allows feedback, learning, and growth. (As a disclaimer, these ideas have been borrowed from Syed’s work and adapted by me to fit the field of physical therapy.) As individual students and clinicians, it all boils down to supporting an environment that is open to failure and even encourages failure. We cannot fear failure, but instead, we need to be willing to jump in, have experiences, and get our hands dirty. In his book, Syed provides a quote from psychologists Babineaux and Krumboltz that states, “If I want to be a great musician, I first have to play a lot of bad music.” If you want to be a great physical therapist, you have to perform a lot of bad evaluations, interventions, and treatments. You have to stumble, pick yourself up, and learn from your experiences. Furthermore, it is key that schools, clinics, and hospitals support this mindset, too. We cannot stigmatize failures. We must critically analyze mistakes, learn from them, and use this feedback to grow as professionals. As Syed describes, we must learn to “fail well.”
For the field of physical therapy as a whole, the answer is evidence-based practice, especially the use of randomized controlled trials. This is the most effective way for us to test theories and practice beliefs and strategies in a relatively safe and controlled manner. Examination and treatment techniques must be held up to the scrutiny of objective research to determine what is best for improving patient outcomes. We should not base our treatments on the new craze or the old cornerstones of treatment. We should base our treatments on theories and techniques that have been through the rigors of research studies and have been analyzed and adapted based on their shortcomings and failures.
I fully understand that all these things sound great while I write them, but accomplishing these goals is much easier said than done. I know there are many great individuals promoting the growth of individual students and clinicians through critical analysis of failures, and I know there are many great individuals promoting the growth of research and evidence-based practice in the field of physical therapy. In both respects, there is still much work to do. There are so many influences to consider when discussing this topic, and the field of physical therapy is too complex to wrap into a nice neat blog post.
“Strive for progress, not perfection.”Everyday, on my way to work, I drive by a school and there is a sign in front of the school that reads, “Strive for progress, not perfection.” We’ll never be perfect as physical therapists or individuals, and that is okay. In fact, that is a good thing. That means we can be open about or mistakes and shortcomings, and instead of fearing failure, we can use failures to learn, grow, and progress as professionals. So, we should strive for progress. We should strive for progress as we learn through the feedback from our mistakes and failures, but we should also strive for progress in our approach and mindset to failure, too.
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