Learning failure for doctors: The Kobayashi Maru simulation in medicine

Report to Starfleet medical immediately.


Learning objectives

1. Understand the nature of the Kobayashi Maru simulation

2. Consider how experiencing no-win situations could be useful for doctors

3. Reflect on your own experiences of failure and whether you could have anticipated your feelings


In arguably the best Star Trek film we have perhaps one of the franchises most iconic scenes: the Kobayashi Maru training exercise. If you’re not a Trekkie, here is a clip:

The test is a simulation. It takes place in a realistic environment with role players following the instructions of the candidate being tested. What makes the Kobayashi Maru particularly memorable is that it is considered a no-win simulation, testing instead the character of the participant and how they manage an insurmountable scenario.

Captain Kirk however finds his notoriously unique solution to the test by reprogramming the simulation so that a supposed win can indeed be achieved. Some might consider this cheating, others may say it is a creative way to undergo the test. Either way, we do learn something about Kirk’s character, which I suppose is the aim of the test.

I’m a doctor Jim, not a fictional television character!

What on Earth has any of this got to do with medicine? Although the Kobayashi Maru is used to test the qualities of fictional Starfleet command cadets, there are many parallels for those working in the reality of healthcare who encounter no-win situations.


Questions

Can you think of any no-win situations in healthcare?


It might be helpful for us to define what we mean when we use the term no-win and how it would apply in medicine. We could use it to describe a situation where despite the choices that an individual makes, the overall outcome is a net loss. For example, consider a patient with red flag symptoms of a upper gastrointestinal malignancy. The doctor may decide that an urgent endoscopy should be performed but a complication leads to catastrophic perforation and death of the patient in horrible circumstances. Alternatively, the doctor instead decides not to perform the endoscopy, the cancer is missed and the patient dies horribly a few months later with the doctor also facing charges of clinical negligence.

The consequences of individual choice are significant as highlighted in the hypothetical no-win scenario outlined above. However, sometimes the choices we make may or may not affect the overall outcome. For example, deciding to order a chest x-ray for someone with haemoptysis will not change whether or not that person has lung cancer.

Finally, the progress of a no-win scenario may be completely unconnected to the choices an individual makes. To pick one of the most extreme examples I can think of, consider a severe earthquake during routine surgery where the hospital is collapsing and on fire around you. Or imagine the sudden death of the senior operating surgeon in theatre.


Questions

Do you equate the outcome of a no-win situation lead with failure?


Perhaps the term failure when used in the context of a no-win situation is a misnomer. Yet, it may feel like true failure. Experiencing failure is not only a very personal experience but one that may have consequences on others. Doctors, perhaps more than individuals in many other walks of life will know this well. Maybe not.

Medical students (like Starfleet Cadets) are often considered some of the brightest individuals in their cohort when it comes to academic and non-academic pursuits. In order to get into medical school, students have usually not only passed every exam thrown at them but done so with exceptionally high grades. Therefore, the concept of how such an individual may respond to a supposed no-win situation would be particularly interesting since working in healthcare will inevitably involve failure at some point or another, real or simply perceived, despite best efforts.

Understanding how doctors respond to no-win situations should not only be important to managing healthcare systems that are invariably under-resourced but also to the individual themselves in terms of understanding their own feelings and emotions when those inevitable failures arrive. These failures may be clinical or related to other aspects of life.


Questions

When was the last time you failed at something?


Simulation has become an accepted and valued means of testing medical students and doctors in a variety of scenarios. Perhaps the most well known medical simulation is that of cardiopulmonary resuscitation (CPR) but we also see simulation used to train undergraduates and qualified doctors how to communicate and undertake practical skills.

So it seems that we accept simulation in situations, like CPR, where an external assessor can judge whether the candidate has done something according to protocol or not. There is seemingly a right or wrong way to complete the simulation. But what about a simulation where there is no correct process?

Indeed, the simulation of failure using a no-win scenario does somehow feel different to those who have undertaken modern medical training. Perhaps it is because we have become used to tests being measured summatively in numerical terms (e.g. percentage score) or binary outcomes (pass/fail). Testing someone’s character feels very subjective, unscientific and possibly unfair. But to view the no-win test from purely the examiners perspective would miss the true importance of the process: the experiential process for the candidate.


Questions

How would you judge success in a no-win scenario?
Is such success measurable?
Should such success be measured?


True, we could observe if a candidate becomes angry, rude, dangerous or even frozen when faced with a no-win scenario. It may also highlight desirable characteristics such as the demonstration of compassion, integrity and honesty. But arguably more importantly it allows the candidate to experience, reflect and process perceived failure before it happens in reality. Is this not an important outcome in itself? And if so, why should we try to measure it?

“Experiencing failure has made me more tolerant of colleagues, students, and, most importantly, patients”

Ayan Panja
Failures can be the pillars of success

The use of a Kobayashi Maru no-win situation in medical simulation has been considered before. Lee and Skog undertook a pilot study on the effect of simulated patient death on students. The particular case used was that of a 6-year-old simulated patient in respiratory distress. Participants were randomised to either have the patient regain spontaneous circulation or remain dead. One month later, the group that experienced the simulated death of the patient felt “more prepared” in dealing with the situation in the future than their counterparts. The authors point out that “contrary to common sentiment in simulation education, a poor outcome for the simulated patient did not result in the experienced learner reporting a damaging psychological effect… learners who experience a poor outcome with their simulated patient may feel better prepared long-term to manage similar patients.”

Similarly, emergency medical services in Springfield College Massachusetts have attempted to use the Kobayashi Maru to prepare students for the pressure they may face in real life by learning in simulated stressful situations. These sessions, known as Kobayashi Maru Nights are designed to shock and induce unpleasant emotions. The process is considered a rite of passage and though not the primary intention, students who may not be ready for the real-world encounters faced locally can be identified early. They highlight that students get a taste of the complexities they may face, that patients will die despite their best efforts or because they didn’t follow medical protocol. Not every patient can be saved. The team from Springfield College point out

“…sometimes patient care is just being a compassionate person”.


Questions

What no-win situations could be translated to a medical simulation?


An array of possible topics come to mind. Real world complexities aren’t just limited to pure clinical issues such as procedural complications. What about time management problems, Kafkaesque administrative issues, vexatious complaints or opaque regulatory investigations?

The team at Springfield College point out that the scenario has to be unexpected to the candidate. This unpreparedness may be an anathema to most undergraduates but there is no doubt that it is a reality of healthcare. A routine and anticipated OSCE failure station will not produce the same type of post-examination reflection that an unforeseen simulation will allow. Inevitably, there will be knowledge amongst candidates that a no-win station may be encountered which could hinder the experience.

Therefore, some of the scenarios will also have to be subtle in their quality for the candidates not to realise the true nature of the simulation. An outlandish simulation will easily be recognised as such and therefore negate the aim of the test. Candidates will not doubt their decisions nor subsequently reflect on the various permutations they could have tried to achieve a more successful outcome. High intensity simulations may need to be followed by a debrief session. Some candidates may even express a desire to leave medical training. The real question for doctors and educationalists is whether this process and reflection is useful?

Some doctors may feel that the healthcare system they work within is the real no-win situation and the reprogramming that Kirk does is akin to simply leaving. Using a Kobayashi Maru simulation to measure the resilience of the candidate is something that needs careful consideration. Framing the onus of failure to cope in on the candidate when the system itself may be truly responsible doesn’t help doctors and it doesn’t help patients. The culture of the healthcare system needs to be such that a Kobayashi Maru test doesn’t perpetuate learned helplessness.


Questions

What about Kirk and his unique solution to the Kobayashi Maru?


In many respects, Kirk never really faced the true test. He knew the Kobayashi Maru was coming and that it could not be beaten. However, by preparing and adjusting the conditions of the simulation he was able to achieve his supposed victory. He cheated.

Learning how to cheat is in itself a useful skill. Using cheating to win has been advocated by some in other disciplines such as the military and cyber warfare. But the characteristic of trust is considered essential for doctors.


Questions

Should doctors bend the rules in the interest of patient care?

Is bending the rules the same as cheating?


Kirk reprogrammed the simulation. If Kirk was a doctor, how would he win a medical Kobayashi Maru? Exaggerating clinical symptoms in order to obtain a radiological investigation? Or perhaps changing the criteria on a referral form to obtain a specialist review? It doesn’t matter because Kirk failed to understand the true nature of the test. Spoiler alert: in adopting the attitude that he doesn’t believe in a no-win scenario, Kirk finds it even more difficult facing Khan Noonien Singh, the death of Spock and then subsequently the death of his son David in the following movie. While dying during an act of self-sacrifice, Spock even asks Kirk “I never took the Kobayashi Maru test until now. What do you think of my solution?”

Please share your thoughts and ideas about no-win situations in healthcare in the comments section below.


Summary

Many medical students may have never failed anything of consequence in their lives before medical school. Understanding and accepting that failure is normal in healthcare is an important part of professional development. Educational institutions should be able to test medical students in realistic simulations including those where seemingly unsatisfactory outcomes are inevitable. This is increasingly pertinent in an era of elevated patient expectation and physician burnout. If doctors themselves cannot manage to understand their own feelings and emotions in times of distress, how can we ever credibly expect our patients to do the same?


Further resources

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