Critical Thinking

I’m trying to remember when I started caring about making mistakes. I think it was the first time I had to read a story aloud in Mrs. Hancock’s first-grade class. I don’t remember the title; possibly Dick and Jane Build an Air-Raid Shelter, given late-’50s sensibilities. I just know I wanted to do well—not to impress my teacher, but because reading the right way made me feel better about myself.

Messing up sentences embarrassed me more than being corrected. When I did mispronounce words, I sensed Mrs. Hancock’s feedback was well-intended, and discovered if I paid attention to her, I’d make fewer errors and go home happier. Even as a 6-year-old, I was starting to understand the value of constructive criticism.

The consequences of screwing up are much greater for me now than in 1959, but I still feel the same about mistakes: If I can’t avoid them, I want to at least learn from them so I don’t make the same ones again. I was happy to see that point emphasized by a poster named Rocketmedic40 on a popular EMS website. (Memo to readers: I don’t know Rocketmedic40’s gender, so I’m going to use the one I’m most familiar with.)

Rocketmedic40, a paramedic student from Yukon, Okla., was writing about his first “code save.” He began by admitting deficiencies: uncertain airway management, “tunnel vision” compromising resource allocation, and delayed medication administration. Next he summarized strengths: IO access, effective CPR and timely defibrillation. He closed by giving credit to colleagues for the favorable outcome.

Overall it was a pretty impressive analysis from someone new to running calls. Such a level-headed self-critique is rare.

Perhaps Rocketmedic40’s preceptor would have added equally constructive comments, but in my experience, tentative, ambiguous feedback from supervisors is more likely. The problem, I think, is a bias not to offend, rather than to educate—a fallacy that discourages quality improvement. Let me offer an example:

In the late ’90s, a law was passed in the state where I worked that mandated quarterly reviews of prehospital care. The guidelines were broad, leaving it up to administrators to decide the nature and scope of calls examined. Confidentiality was considered one of the biggest obstacles—more for providers than patients. There were concerns that criticism might discourage or even offend caregivers, many of whom were serving as volunteers. Reviewers, blinded to the identities of crews, often generated recommendations to the entire community of prehospital practitioners based on the actions of only a few, while missing opportunities to offer meaningful, individualized positive and negative reinforcement.

How do you feel when everyone in your department gets a memo criticizing the group for an error made by an individual? When that happens to me, I might think the published offense sounds like something I did; more likely, I’ll wonder why I’m being remediated for something I didn’t do. In either case, the value of the message is diminished by dilution of reinforcement to avoid conflict—one of the most common management blunders I’ve witnessed in 45 years of employment.

What can EMS providers do to compensate for vague or misdirected feedback? I think we should favor the sort of self-critique Rocketmedic40 demonstrated—not to replace, but to complement external appraisals. Beware of these obstacles, though:

• Ego—Conceding mistakes requires a suspension of disbelief our egos don’t always permit. Robert Townsend, author of 1970’s seminal Up the Organization, suggests we set good examples not just by admitting our own errors but by publicizing them. That encourages others to see the constructive side of fallibility.

• Difficulty applying new knowledge—It’s hard to judge your own performance in an unfamiliar environment. If you’re new to EMS, you won’t have adequate experience for a comprehensive self-assessment. Consider less-technical parts of the job—e.g., if you were your patient, how would you feel about the care you just received?

• Misunderstanding the process—It’s not enough to recognize our mistakes; quality assurance dictates we modify our flawed behavior and see if results improve. That back end of the QA/QI loop is often omitted.

The ability to gauge one’s own performance—calmly, unemotionally and as objectively as possible—is a survival skill learned over time. It takes practice and a willingness to see ourselves as works in progress.

The payoff is gaining insight from your harshest critic: you.

Mike Rubin, BS, NREMT-P, is a paramedic in Nashville, TN, and a member of EMS World’s editorial advisory board. Contact him at mgr22@prodigy.net.