Seeing but not believing: Insights into the intractability of failure to fail

BACKGROUND Inadequate documentation of observed trainee incompetence persists despite research-informed solutions targeting this failure-to-fail phenomenon. Documentation could be impeded if assessment language is misaligned with how supervisors conceptualize incompetence. Since frameworks tend to itemize competence while being vague about incompetence, assessment design may be improved by better understanding and describing how supervisors experience being confronted with a potentially incompetent trainee. METHODS Following constructivist grounded theory methodology, analysis using a constant comparison approach was iterative and informed data collection. We interviewed 22 physicians about their experiences supervising trainees who demonstrate incompetence; we quickly found that they bristled at the term "incompetence", so we began to use "underperformance" in its place. RESULTS Physicians began with a belief and an expectation: all trainees should be capable of learning and progressing by applying what they learn to subsequent clinical experiences. Underperformance was therefore unexpected, and evoked disbelief in supervisors, who sought alternate explanations for the surprising evidence. Supervisors conceptualized underperformance as: an inability to engage with learning due to illness, life event, or learning disorders so that progression was stalled, or an unwillingness to engage with learning due to lack of interest, insight, or humility. CONCLUSION Physicians conceptualize underperformance as problematic progression due to insufficient engagement with learning that is unresponsive to intensified supervision. Although failure-to-fail tends to be framed as a reluctance to document underperformance, the prior phase of disbelief prevents confident documentation of performance and delays identification of underperformance. The findings offer further insight and possible new solutions to address under-documentation of underperformance.