Reframing failure

Failure in life – no matter how great or small – can provide a transformational opportunity for growth. In fact, most if not all innovation is the result of trial and error, a consequential response or iteration, and so forth. Indeed, in medicine, progress has relied on the scientific method forever. However, our bad surgical outcomes are often stigmatized as personal failures – an indictment of our competence or attentiveness to detail, or worse yet, evidence of recklessness or irresponsibility. Or, we may assign accountability for a bad outcome to the patient – lack of compliance or “poor protoplasm” – or to just bad luck.

Matthew Syed, in Black Box Thinking makes the observation that cognitive dissonance – mental tension when we cannot embrace that we may be fallible – prohibits our appropriate response to failure. Rather than using failure as a gift of sorts, because we as humans may be fallible, we often re-frame failure in a manner that dismisses it, alleviating the feeling of failure that we may instinctively strive to reject; in so doing, we deprive ourselves of learning opportunities. Syed makes the point that in healthcare this happens all the time, largely because physicians cannot accept failure without it jeopardizing their expertise or sense of self. In a similar way, Carol Dweck in Mindset: The new psychology of success reveals the perils of a fixed mindset as opposed to a growth mindset, which might cause one to regard a learning opportunity as an indication of a lack of innate intellectual capacity.

As I reflect on my development as a physician and surgeon during this past year and on some memorable second opinions I provided to patients who were unhappy with their status following operations elsewhere, I reflected on my own capacity to evaluate the quality of my work without necessarily having to rebuke my less-than-perfect results as utter failure or a personal indictment.

• I saw a patient 12 months following a wrist fusion for failed PRC who developed carpal tunnel syndrome immediately thereafter. This was a worker’s compensation case, but he was told the newly developed numbness had nothing to do with his work injury or surgery. His lateral x-ray showed a healed fusion, however the capitate was positioned in the dorsal 25% of the lunate fossa and, as a result, the median nerve’s new course resulted in a significant nerve entrapment – nearly fully ameliorated by a carpal tunnel release.
• I saw a woman who had a suture suspensionplasty for basal joint arthritis. The metacarpal had completely settled by 6 months to the point that she had very painful scapho-metacarpal impingement and a severely narrowed thumb-index web space. After 3 cortisone shots and a Medrol dosepack failed to bring her relief, now 18 months following her surgery, I performed a revision suspensionplasty with a slip of APL. I don’t know if she will be happy, but she certainly appreciated understanding why she was having so much pain and having been given the option of revision surgery.
• I saw a young 32-year-old woman 8 months following ORIF of an extraarticular distal radius fracture using a volar plate. She had significant residual dorsal wrist pain and no wrist flexion. After being told that it might take a full year for recovery she went elsewhere. Additional radiographic views suggested that one of the pegs might have been penetrating the dorsal cortex – camouflaged, if you will, by lister’s tubercle. Before I removed the plate, a small dorsal incision revealed, indeed, a 30% partial tear of the ECRB from the end of a too lengthy peg. One week after surgery she could flex her wrist 45 degrees with minimal discomfort.
• I saw a woman who required a thumb MP fusion, but despite healing, complained of IP stiffness and pain. The screw that was used had backed out and she was told that it could just be advanced again, and that the lack of IP flexion was normal. But, the x-ray clearly showed a lucency in P2 consistent with a previous drill path that had crossed the IP joint, and there was no mention of the potential for EPL tenolysis and IP joint release, in addition to screw removal.

Rather than taking credit for identifying what others did not see based on my experience or expertise, I have come to believe that these examples, which we all have seen, reflect the peril of an imperfect prism that we look through. Optics! It is indeed possible that we may misperceive what is happening if we frame a poor outcome as a personal indictment. I recently fixed a very distal comminuted radius fracture with a volar plate and took special care with each distal peg placement to fluoroscopically ensure that I was not violating the radiocarpal joint. For 8 weeks after the surgery my patient had pain that left me concerned that she was developing a CRPS. She was taking Vitamin C and was working with my hand therapist to improve digital motion, but I was concerned, and on each occasion that I checked x-rays in the office I shared with her that I had done my best but that I was  concerned that I may have been imperfect in my execution. She appreciated my honesty and never doubted my commitment. Ultimately, I recommended removal of her plate and pegs at 3 months, before risking any further joint injury as range of motion progressed.  I have another patient who had a 3-tendon cuff tear that I fixed, and on a postoperative x-ray I suspected that one of my lateral row anchors had skived the bone and was perched beneath the more posterior infraspinatus insertion. She appreciated my pointing this out and went on to heal nonetheless. Along the way she understood that I was willing to scope her again if this became problematic but never doubted my competence or commitment.

We all aspire to have a “zero tolerance” for error for surgical imperfection, but our practice is not a perfect science. While many factors contribute to a successful outcome, it’s worthwhile remembering that patient expectation is one of those independent variables. I think it’s valuable to cover what could challenge a perfect outcome when it comes to our surgical execution — so that our patients have at least a modicum of shared appreciation of the complexity of what we aspire to do on their behalf. And when we “fail to deliver perfectly” we should embrace our imperfection as an opportunity for development.