Good News, You Failed!

Andy Lee, MD, is the founder of an innovation lab embedded in the Los Angeles County Department of Health Services – University of Southern California Medical Center (LAC+USC). This is where physicians dream up the changes that will transform care for the county’s 600,000 patients.

That incubator? “It was built on failure,” says Lee, a professor of medicine at USC.

“In trying to implement new models for the Medicaid population, the majority of the things we were pitching, delivering, and trying to implement resulted in failure,” he says of his experience in the early 2010s.

Now he recognizes that if his initial attempt to integrate diabetes care into primary care in 2013 hadn’t failed, he wouldn’t have thought differently about how to implement changes in large systems, and he wouldn’t have created the medical innovation incubator. Ultimately, that equates to success for him as a leader and for the system as a whole.

“I hate to fail; it hurts every single time,” he says. “But as you usher in new things, it really requires you to rapidly fail.”

Science is starting to back up Lee’s sentiment. As healthcare continues to evolve, learning how to manage failure is critical. The key to that, experts say, may be to reframe failure and learn to fail better going forward.

“Failure is actually quite essential to make you better,” says failure researcher Dashun Wang, PhD, associate professor of management and organizations at Northwestern University’s Kellogg School of Management. “It’s not just that you should persevere; it’s that maybe you should enjoy it because this actually improves you.”

Aspiring Leaders, Taking on Failure

Cardiologist Tariq Ahmad, MD, wouldn’t call himself a leader, even though the New England Journal of Medicine’s Catalyst has. As someone in his first five years as assistant professor of cardiovascular medicine at Yale University School of Medicine and a heart failure specialist at Yale New Haven Health System, he sees himself squarely in the midst of the kind of early career failures that can define a career for good or ill.

“Especially in academic medicine, there’s a lot more failure than positive feedback,” Ahmad says. “You get a lot of grants turned down. You have to be writing manuscripts, and a lot of those get rejected — the majority of them. And then you deal with the sickest patients in the hospital, with end stage heart failure, and a lot of them die. It’s really a lot of failure.”

But Ahmad — who can recite Aequanimitas, Marcus Aurelius’s code from Sir William Osler’s 1889 prescription for good doctoring, by heart — attempts to deal with setbacks the way Aurelius describes: “Thou must be like a promontory of the sea, against which, though the waves beat continually, yet it both itself stands, and about it are those swelling waves stilled and quieted.”

“Now I think it’s known as grit,” he says. “I certainly don’t have that, but I looked up to it as something I’d like to develop in myself.”

To that end, he takes his cues for weathering failures from his many mentors. There’s the late Ken Baughman, MD, the so-called Clint Eastwood of Cardiology, who recited Osler’s imperative to Ahmad when Ahmad was training under him at Brigham and Women’s Hospital in Boston. There’s Christopher O’Connor, MD, former chief of cardiology at Duke University and chief executive officer of Inova Health, who has a very different way of walking through setbacks.

“He’s not the strong, quiet type. He’s very boisterous, but he always stays positive no matter what happens,” Ahmad explains. “That uplifts people around him.”

Most significantly, there’s his grandfather, who served under the British in World War II Iraq, worked as a physician in London, and then as a surgeon in his native Pakistan.

As a child, Ahmad spent years visiting his grandfather at the hospital after school, seeing the sick patients, the families sobbing at the passing of their loved ones. There were times when his family had to sell cars and household items to cover expenses when patients didn’t pay medical bills. There were times when Ahmad’s grandfather described having better surgical outcomes than some of his colleagues, but still was given fewer opportunities. Throughout it all, Ahmad describes his grandfather as “a stiff upper lip kind of guy.” Not much seemed to get to him.

“What I learned from him,” Ahmad says, “was that stuff happens and you just keep making it through.”

The New Science of Failure

While all those approaches are important ways to reframe failure, Wang is finding in his lab at Northwestern that leveraging failure is about more than continuing to move forward in the face of obstacles. It’s about how you do it, how you think about it as you formulate a response.

Take physician-scientists like Wang. An October 2019 paper in Nature Communications details how Wang and colleagues reviewed data from grant submissions to the National Institutes of Health (NIH) between 1990 and 2005 and categorized the junior scientist applicants according to whether their scores put them just above the threshold to win the grant or just below the threshold. From an economic standpoint, the scientists were “identical twins” and made a perfect natural experiment to see how success and failure shaped them.

“After that day, one [group] had $1 million for five years,” Wang says. “The other got nothing. So the question is, if 10 years later they come back for a job interview, who gets the job?”

The answer isn’t what you might expect. Success didn’t beget success — failure did.

“It was the losers who ended up being much, much better,” Wang says.

Wang says the team was stumped when they tried to figure out why, despite early setbacks, individuals with near-misses ended up outperforming those with the narrow wins. The eventual success of those who failed the first time around could not be explained by the history of having received NIH grants, the size and prestige of the research institution, the probability of creating a hit paper, or even gender differences.

“It all points toward this ‘psychological boost’ story from failures — the idea that it didn’t work out, so I am going to try harder,” Wang explains.

In other words, “It’s not ‘survival of the fittest;’ it’s ‘what doesn’t kill you makes you stronger,’ ” he says.

‘Failure Is Developing Insight’

Back in the early 2010s, LAC+USC’s Lee had an idea spurred by the passage of the Affordable Care Act’s Medicaid expansion: What if the growing numbers of Medicaid patients in Los Angeles County could get better diabetes care through their primary care providers rather than through specialists?

An endocrinologist, Lee postulated that by increasing primary care providers’ training and offering e-consultations with specialists, patients could receive integrated primary and specialty care for diabetes, which is an epidemic in Los Angeles County.

The goal was to build a successful outpatient infrastructure with better cost containment, better outcomes, and, hopefully, reduction in emergency department use. It’s the way a lot of care is delivered today, but in 2013, it was novel.

The strategy worked at LAC+USC Medical Center, where Lee had managed to break down silos and bring primary care physicians and specialists on board. But when he tried to implement it among the county’s 15 outpatient departments and at its 168 clinics, he hit barrier after barrier.

At the same time he was trying to implement integrated care, the county was rolling out electronic medical records and attempting to make them function across sites and specialties.

His approach called for integrating six service lines into one clinic — asking six chiefs to share nurses, exam rooms, and space efficiently. But each department was its own fiefdom, Lee says. Physicians were unaccustomed to accepting failure if it meant getting the new system right. The union objected. Front-line staff resisted deviating from a set protocol meant to ensure no medical errors.

“One of the initial failures for me was to think that this was going to be easy,” Lee says.

In the end, he had to step back and admit he wasn’t going to force this change in such a short period of time. He applied for and got a leadership fellowship with the California Health Care Foundation, where he began to explore why the innovation failed. He started to build from there.

Tipping Points Toward Success

It was in this fellowship with the California Health Care Foundation that Lee learned how health systems in general deal with failure. Only 15 percent of people in any system are visionaries, he says. The rest want clear guidance and a path to do things right every time. Plus, he says, healthcare is a risk-averse industry by its nature — risk-averse being another way of saying fearful of failure.

“The ongoing culture of zero errors in healthcare goes against units that want to innovate,” he says. That’s because new systems always have kinks that have to be worked out. When the unexpected comes up — a piece of equipment isn’t available, the results go a different way than expected, which are all little failures — people have to be flexible enough to walk through it to find a solution.

“People who do that well understand that they have to deviate from the standard work process to get their job done,” he says. “People who are risk-averse literally stop.”

This isn’t just Lee’s opinion. Wang also found this to be the case.

In a study that encompassed data from science, business, and security, Wang and his team tried to calculate what, exactly, was the difference between people who made breakthroughs after failures and those who didn’t. They concluded that people generally fall into two domains. One is a domain of stagnation — they try hard but they can’t seem to get to that success moment. The other is a domain of progression —
they fail over and over again but keep getting better with every failure.

“When you fail, it’s such a great experience because it gives you two things,” Wang says. “One is you’ve done it, so you’ve got something you can reuse when you try again. The second is that you failed, so that means you got some feedback.”

What Wang’s model told them, he says, is that people who eventually succeed refine their approach each time. They keep what works and reinvent what didn’t. Those who keep trying but stay stuck don’t make those distinctions, or they don’t assess the reusable material from the variable they should switch out.

His research seems to resonate. One man to whom Wang described his research exclaimed, “Oh man, you are so right! I am the person who when something doesn’t work out, I panic and I just say, ‘I want to try harder and get better.’ But in doing so, I just throw the baby out with the bathwater and start all over.”

Indeed, Wang found that those who continue to try but don’t succeed are working more hours and take longer to formulate each new attempt. Those who fail on the way to a breakthrough fail faster but improve with each attempt.

This points to a totally different way of thinking about failure, Lee says.

“Failure is not understanding the insight early enough to avert you from big failures in the future,” he explains. “You have to be brave enough to recognize the failure early on and redirect yourself. Some people, though, seeing those insights, are not willing to change course. That’s what leads, in my mind, to larger system failures, because they are just not willing to reconcile those personal insights with the system.”