#KEYLIMEPODCAST 282: The failure of failure to fail formulations

Jon’s selection this week asks, how do physician supervisors conceptualize and recognize incompetence in trainees?

Listen to the episode here!


KeyLIME Session 282

Listen to the podcast


Gingerich et. al., Seeing but not believing: Insights into the intractability of failure to fail Med Educ. 2020 Jun 19. Online ahead of print.


Jon Sherbino (@sherbino)


Let me start with a teaser.  I didn’t see the punch line coming.  This paper has advanced my opinion.  More on that in a bit.

Have you seen the gorilla playing back basketball video?  (If no, check it out here https://www.youtube.com/watch?v=vJG698U2Mvo). If you’re a cognitive psychologist then the concept of selective attention is not going to be novel (or interesting).   Ok, so cognitive load, sensory memory, bias, etc. are cool ideas that allow nerds to play memory tricks on each other.  What does this mean to me, a busy Clinician Educator?  Come on KeyLIME don’t waste my time.

Today’s paper, tackles ‘failure to fail” one of the hot button topics in #MedEd. In my career, I have yet to speak to a room full of program directors, where there has been less than 100% endorsement that they promoted (at least once in a career) a resident that they did not believe to have acquired all the necessary abilities to effectively practice.

Enter Gingrich, Sebok-Syer, Larstone, Watling and Lingard.  These heavy weights of HPE offer a new perspective on failure to fail.  Hint.  It’s not entirely the systems fault.  Maybe educators can’t see the gorilla posting up in the paint.


“We need to identify the social rules regarding what can and cannot be said … to inform further improvement to our assessments, … How do physician supervisors conceptualize and recognize incompetence in trainees?”

Key Points on the Methods

CGT methodology was used to guide data collection and analysis using a constant comparison approach.

Snowball sampling from a single institution with multiple campuses across the province of British Columbia was used to recruit physicians with experience in supervision and assessment at both the UGME and (P)GME levels.

Two investigators were part of each interview.

The term ”incompetent” was modified to “underperformance” early in the series of interviews.

Key Outcomes

22 physicians were interviewed. The majority of participants were from family medicine; there were no surgical educators included.  There was an equal division of physicians practicing in urban and rural areas.  The majority of participants had 10 to 20 years of supervision experience (range 4 to 25+ years).

Key themes:

  1. There was a negative response to the term “incompetence;” it was viewed as perjorative and binary.
  2. Competence requires engagement with learning through a progression of the acquisition of ability (repeated cycles of learning). Trainees were expected to:
    • Come prepared to learn
    • Interact with teaching / feedback
    • Apply themselves
  3. The majority of trainees were expected to be excellent and demonstrate a growth mindset.  This opinion may be a function of the selection process. Supervisors demonstrated disbelief and second guessing when they diagnosed an underperforming trainee.
  4. Underperforming learners were perceived as unable to engage with cycles of learning. Underperforming learners could be indentified by increasing supervision. Underperformance was ascribed to:
    • A temporary, situational, distracting factor.
    • Disinterest in the topic area or unresponsive to teaching.
    • Lack of insight into their own ability and the need to acquire the necessary abilities.

Key Conclusions

The authors conclude…

“Physicians conceptualize underperformance as problematic progression due to insufficient engagement with learning that is unresponsive to intensified supervision. Although failure-to-fail tends to be framed as a reluctance to document underperformance, the prior phase of disbelief prevents confident documentation of performance and delays identification of underperformance.”

Access KeyLIME podcast archives here

The views and opinions expressed in this post and podcast episode are those of the host(s) and do not necessarily reflect the official policy or position of The Royal College of Physicians and Surgeons of Canada. For more details on our site disclaimers, please see our ‘About’ page