F***ing up: This is How We Learn

Every doctor fears making mistakes. It’s a baked-in part of the job — the understanding that even a small error could have massive consequences. Sometimes, that fear is paralysing. But if you're going to survive in this career, you need to come to terms with a hard truth: you will make mistakes.

I have. Not constantly, not deliblerately — but they’ve happened. And when they do, the emotional fallout can be brutal. Medical errors can trigger acute stress, shame, and even long-term psychological impact among clinicians - it's taken out a few good people I know in time.

There's a novel thats very problematic but emblematic book amongst Medic types called The House of God by Samuel Shem. Its an American book that's aged about as well as you can expect from a country that set up a system where an ambulance might actually kill you when the bill comes in.

Now I reference it a lot, no because it’s gospel (pun intended), but because some of the characters have never left me. The Yellow Man especially — the poor guy was jaundiced but breathing, and ended up dead not because of his liver, but because a consultant wanted to show off. Death by protocol. Death by hierarchy. Death by the need to be right.

It wasn’t one bad call that killed him — it was a dozen small ones, delivered politely, with clean hands and a confident tone. That stuck with me. Because in the real NHS, I’ve seen my fair share of Yellow Men. People who might have walked out if we’d just done a bit less. Or stopped trying to impress someone.

Mistakes don’t always wear flashing lights. Sometimes they wear lanyards. Sometimes they come dressed as “just one more scan” or “let’s observe overnight.” We talk a lot about clinical error, and rightly so — but the bigger killer is often inertia. Ego. The need to look like you know what you're doing. That’s the part I’ve learned to fear more than forgetting a dose of furosemide. That’s what keeps me reflective.

Not only that - but the drive to mock and ridicule lead to an outcome which - to not spoil the book - characterises exactly why these sort of pressures are often not without consequence.

As Harrison et al. explain, clinicians often struggle with self-doubt and isolation after an error, yet structured support and good debriefings, still, remain rare. Many providers suffer in silence, lacking institutional support to deal with the mental toll of mistakes. Left unprocessed, these experiences can lead to burnout or risk aversion.

Living in fear of error ironically increases the risk of making one. Anxiety makes your thinking rigid, your performance slower, your judgment clouded. You become more reactive, less reflective. You try to second-guess yourself instead of reasoning through things. Anyone who has messed up will recall being more skittish and brittle afterwards - it's a medical student's permanent space of being because, and this is true, they f**k up constantly - but that's kind of their job (see later)

This practice, when it's "justified" is called defensive medicine — over-ordering, over-referring, over-documenting. It’s particularly common in the American system, where litigation looms large. In the UK, we don’t have quite the same legal culture, but we still feel the fear - though from experience it's usually either the fear of complaint (if you're tenured like a Consultant or GP Partner), or Portfolio-review-ambush (if you're a Trainee).

Lets be very clear though - that instinct to “cover yourself” is viscerally real; fear of repercussions pushes even the best of us toward excessive investigation and documentation, which may paradoxically reduce efficiency and increase patient harm. In fact, anecdotally at least, it's a reliable way to spot someone is just about to burnout - when their paperwork gets f***ing fabulous, but they grind to a halt pace-wise.

But here's the thing: the only way to guarantee you’ll never make a mistake is to not practise at all. Sounds nice, but my feet aren't sexy enough for an OnlyFans account (I really hope).

Being a good doctor isn’t about never making a misstep — it’s about how you deal with the ones you inevitably will. You need to become comfortable with uncertainty. That’s especially true in generalist fields like A&E or general practice, where you’re often working without full information and making decisions based on likelihood and risk rather than concrete diagnoses. I often tell students shadowing us to guess how long a GP has been practicing by how little tests they do, or how comfortable they felt they were when they themselves were still not sure - never been wrong yet.

The GMC and BMA both define (I use the term loosely here) a “reasonable” mistake as one that, when reviewed by another practitioner, still looks like a reasonable plan given the information available at the time. In other words, you don’t have to be perfect in hindsight. You just have to be able to justify your decisions at that moment in time.

Part of that justification comes from being transparent. Gallagher et al. found that patients value honesty and emotional openness when clinicians disclose medical errors — it builds trust, not resentment.

Recently, I trialled an inhaler in a young adult whose symptoms were borderline. It wasn’t standard adult guidance, but I explained my thinking to the patient, documented the discussion, and made a plan for review. That’s not rogue practice — that’s thoughtful, documented, patient-centred care. And if it turned out to be wrong? It would still be reasonable.

Mistakes are opportunities. That’s why we do Significant Event Analyses (SEAs) — not just to tick revalidation boxes, but to unpick processes and find flaws. It’s why CPD isn’t a chore; it’s a tool for growth. Staying up to date matters, but being self-aware matters more. Chan et al. emphasize the role of institutional culture in helping clinicians recover — learning environments with open discussion and peer support help providers grow from error rather than collapse under it.

Most of the mistakes I’ve made — the big ones, the ones that still hang around — happened when I was tired, distracted, or personally overwhelmed. One of the worst was during a night shift, attempting a central line on a difficult patient. I was exhausted. The line went in… to the descending aorta. The patient survived, but it didn’t stop me feeling like s**t to know I hadn’t killed a guy.

After that, I re-learned the procedure from scratch. I reviewed my kit setup, my technique, my approach. I didn’t stop doing lines — I made myself better at them. That’s what matters. Engel et al. reinforce this mindset: reflecting, retraining, and persisting after failure is not weakness — it’s professionalism.

If you see someone else make a mistake, show them empathy. Don’t shrug it off, and don’t moralise either. Be the colleague who says, “Yeah, I’ve been there,” and actually means it.

To avoid mistakes, learn to read yourself. Know when you're tired. Take your breaks. Eat something. Seek support. Understand your baseline, and know when you're veering off it. And if you're dealing with neurodivergence, anxiety, ADHD — whatever it is — it’s your responsibility to factor that into how you practise - the world won't accomodate for complacency no matter what tribe you belong to (trust me, I know this all to well)

Big mistakes will stay with you. That’s part of the job. But you don’t have to be haunted by them. Reflect, review, share, and learn.

And above all else, remember: you’re not alone. We all screw up.

As someone once told me in a bad moment, in a brilliant Eastern European accent I will 100% mimic in private and never admit in public if pressed (even with this evidence):

"Remember Dave, some of the best Mushrooms grown from the most disgusting rotton shit imaginable. And your shit, would still make bad Mushrooms"

Stay fungal

DW