What if we could turn learning from error into error-based learning?
I attended the SingHealth Education Conference 2026 on 25 and 26 September. The opening plenary session was “Learning at the Edge of Error – Navigating Risk to Reimagine Education”, presented by Dr Leonardo Aliaga, clinical assistant professor of emergency medicine at Stanford University and a medical education researcher.
His scholarly focus lies in error-based learning strategies and adaptive expertise. I would like to share with you my reflections on the role of error in medical practice.
Dr Aliga’s research demonstrated that more errors in learning translates into better performance in practice and that as both a supervisor and a student you should never let a good mistake go to waste.
Nothing new here! I think it’s ubiquitous in all areas of learning. All you need to do is create a culture where shame or the fear of catastrophised consequences is replaced by celebrating positive lightbulb moments.
Having supervised innumerable trainees, assisted with the development of curricula, completed a Master Medical Education by dissertation (Dundee 2010) and been awarded an Associate Professorship at the University of Queensland’s Rural Medical School (2018), I consider myself a medical educationalist.
I graduated in 1977, prior to the Cochrane Collaboration (founded in 1993), the gush towards demanding evidence-based medicine and clinical governance as we now know it (developed in the late 1990s).
My generation of medical students and specialty trainees were subjected to eminence-based medicine. My experience is limited to the public health sector in the states of NSW and Queensland. My reflections are therefore biased.
The principal bias is my assumption that public health is a politically driven enterprise. I am a disciple of Rudolf Virchow, who wrote: “Medicine is a social science and politics is nothing but medicine writ large”. These words uttered 150 years ago are as true today as they were then.
Prime Minister Gough Whitlam’s Labor government launched Medibank in 1975, after a long political battle that required a historic joint sitting of Parliament.
Designed largely by social security minister Bill Hayden and economists Dick Scotton and John Deeble, Medibank was Australia’s first universal health insurance scheme, providing free public hospital access and subsidised medical services from general practice.
The unspoken social contract was that those without private health insurance could access free healthcare in hospitals. However, they became “practice material” for trainees, supervised to a widely varying degree by honorary or visiting specialists who viewed themselves as subcontractors in this enterprise.
As subcontractors there was a degree of arms-length with regards to clinical outcomes and patient safety. Morbidity and mortality meetings were covert doctors-only business and never made public.
There was certainly recognition that adaptive expertise came from errors and these were euphemistically referred to as complications which could be minor, major or catastrophic.
Furthermore, the learning curve for trainees was very steep with the common mantra “see one, do one, teach one”.
We know that is now defunct in the era of high-fidelity simulation. It is recognised that we need to see many and consistently do many before we are in any way fit to teach. Teaching is invariably a risky business.
Some of the specialist colleges took a pragmatic view. Tertiary hospitals were places for professors, research and other elite specialists. Reputational damage could reflect on them and their turf. Their strategy was to send novice trainees to lower level or regional hospitals to make their mistakes there.
These big city high-fliers didn’t care much about their outlying brothers in arms. The regional specialists repeatedly get up at 2am to bailout their novice trainees. If they were too tired to get out of bed you could always say “don’t be afraid to cope”.
This was likened to throwing trainees under the bus to build professional resilience, as reflected in The House of God, a 1978 satirical novel by Samuel Shem that suggested “patients will live or die in spite of everything”.
I feel duty-bound to recognise and celebrate those many supervisors that I personally encountered who did not adhere to this traditional teaching format.
Then there was a gamechanger.
In the UK it came in the form of the NHS crisis involving high mortality rates in paediatric cardiac surgery at the Bristol Royal Infirmary (1984-1995) and the subsequent 2001 Public Inquiry (The Kennedy Report) served as a major catalyst for sweeping National Health Service reforms, leading to the creation of modern term “clinical governance”.
Hospital boards and chief executives were now directly responsible for patient safety and quality improvement. As predicted, this was subsequently replicated in Australia by The Queensland Health Systems Review (Forster Inquiry) in 2005, which came on the back of the Dr Jayant Patel, widely known as “Dr Death” saga.
Clinical governance is a journey and some of the early iterations, in my view, had counter-productive effects.
Top-down micromanagement of doctors and other clinicians by non-clinicians was one. Rigid clinical pathways that were fit for purpose 80% of the time, eradicated safe-self autonomy and innovation.
Health was becoming increasingly politicised and an unrealistic zero political risk appetite was emerging. Whether by causation or correlation, staff morale fell and burnout rates escalated. Maybe fear of the consequences of error and the ever-escalating numbers of policies which were unreadable, slew discretionary effort.
Evidence-based medicine has in my mind passed the peak of inflated expectations and was sliding down the Alexis Haselberger slope towards the trough of disillusionment.
Even the very best medical research papers are hamstrung by real-life limitations that render them an expert opinion only on highly selective patient cohorts that exclude the reality of multiple co-morbidities in an aging population.
I hone in on the limitations paragraph of research papers and ignore the abstract. We seem to be returning to eminence-based medicine except that the eminent are now politicians and their health economist advisors.
Related
To return to Dr Aliaga’s question: “What if we could turn learning from error into error-based learning (EBL)”. The learning engine uses a scientific method referred to by the acronym CCC, requires we:
- Commit: what’s gonna happen
- Collide: the mental model collides with the result
- Compare: what was wrong with my mental model
Strategically, the essence of EBL is in fact designing for productive failure. EBL undeniably carries risks to patients, learners, educators and policy makers. This plays out at both a population level and an individual patient level. The risk is there anyway, just needing to be managed.
In my glass half full moments, I would like to think that this partly underpins the federal and state governments’ push for pharmacy prescribing, nurse prescribers and all things that fall under the popularist banner that all health practitioners should be working at the top of their scope of practice.
Working at the top of scope ensures early burnout.
The task is to uncouple the CCC learning engine from the risks. Error management training changes what happens when there is an error and uses the error engine. This should involve full disclosure and placing patients back at the centre of the healthcare enterprise.
Life is unfair and occurs at the edge of error. Ironically, the best outcome requires people who can engage, navigate and work across healthcare system-imposed boundaries. This necessitates meeting at the edge. It is only at the edge that quality and innovation thrive.
At present patient-centred care is a hollow tagline for activity-based funding. It reinforces Australia’s constitutional flaw which divided healthcare funding between the Commonwealth and the states. This inevitably leading to its politicalisation, and fear of progress born out of fear of error.
Woe betide us, should we end up with politically-based learning in the public healthcare space; or not.
For the last 27 years I have tried to manage patients with chronic illnesses. I am seldom completely sure if a clinical decision will make me a part of the problem or part of the solution because errors do not appear immediately.
Sir William Osler’s famous quote is: “Medicine is a science of uncertainty and an art of probability”. I didn’t have the heart to inform the good Dr Aliaga that he had not told me anything new. At least he was brave enough to say it.
Medical practice is a perpetual laboratory. We need more humility, honesty and humanity and less hubris.
Associate Professor Kees Nydam was at various times an emergency physician and ED director in Wollongong, Campbeltown and Bundaberg. He has worked as a senior specialist in addiction medicine and taught medical students attending the University of Queensland, Rural Clinical School. He is also a poet and songwriter.
