Why We Fail

Robert M. Goldwyn

Men are men, they needs must err.

— Euripides, Hippolytus

The ancients were right: to err is human. No patient and no surgeon can live a full life without being the victim or perpetrator of an error. This fact does not condone mistakes but recognizes their reality. The genesis of human fallibility has been variously ascribed to Original Sin, divine retribution, arrested evolution, astral mismatch, capricious fare, simple chance, malice, and poor judgment. Whatever the cause or causes, the effect can be the same: despair and defeat.

After a failure, most of us seek an explanation. Paré’s philosophy, “I dress and God heals,” may be valid for many medical situations, but not all. Should God be blamed for a poorly designed flap? We tend to externalize responsibility: To look heavenward is easier than to look inward.

Oscar Wilde, however, recognized a basic truth: “There is a luxury in self-reproach. When we blame ourselves we feel that no one else has a right to blame us.”

The title of this chapter, “Why We Fail,” was chosen with care. Originally I called it “Why Things Go Wrong,” but that would imply that an unfavorable result occurs because we are helpless victims of circumstances. Responsibility for actions is the cornerstone of Judeo-Christian religion. The burden on the individual is unrelenting. In our Western culture, the development of which has been intimately related to science, it is unacceptable to say only that “something happened.” We are compelled to probe why it occurred, although the explanation may not be obvious. For example, if on a wintry day someone falls, the easy answer might be that it was because of the ice. Indeed, that may be true, but the real cause might have been that the person was in poor health or was not wearing proper shoes or was rushing because he had risen too late from poor planning or laziness.

The purpose of this book is not just to name specific complications and unfavorable results. The reader should become aware of the more subtle conditions and factors that predispose to failure. These situations constitute what might be called the matrix of mistakes. To improve, the surgeon, like any other erring human being, must not only recognize and correct the mistake but, if possible, identify its cause and avoid it in the future. Admittedly, to be able to do this requires the talents of a Sherlock Holmes and a Sigmund Freud. Only by taking an unswerving look at ourselves during the course of treating patients can we find the critical points where errors commonly arise.

Preoperative

Incomplete Initial History and Hasty Physical Examination

The initial consultation can be either the moment of truth or the moment of deception. The most common cause of selecting the wrong patient, making the wrong diagnosis, or recommending the wrong treatment is not spending enough time with that patient. An assembly-line approach in the office invites disaster.

Hazards are inherent in different stages of our professional life. Success, for example, does not always make for continued success. On the contrary, it may confer defeat because of false security. When one begins a practice, one tries to establish a name. Later, the name by itself may come to represent the skills and care that the doctor once had but consciously or unconsciously no longer exercises. The doctor may become sloppy, and the patient is the victim. The traps and trappings of a flourishing practice replace sound judgment and hard work. The surgeon may hire someone to take the history and even to talk to the patient about what to expect from the procedure and how to pay for it. The doctor may do the physical examination but in a superficial manner. Trying to operate on more patients may transform a physician into a policeman directing the medical traffic in the office. Under these circumstances, it is not hard to imagine how an error might occur.

No matter how well the surgeon plans the day, often there is not enough time for an adequate history and physical examination. It is better to inform the patient of that fact and to invite him or her back, at no charge, for proper evaluation. Most patients will appreciate honesty and thoroughness and will not mind the inconvenience of having to make another appointment. Just as the major cause of automobile accidents is driving at excessive speed for existing conditions, so the major cause of error in a physician’s office is seeing too many patients too hastily. Some physicians truly believe that it is their duty to help as many patients as possible. Others, less nobly motivated, realize that more patients mean greater income. High aspirations and income are not in themselves objectionable, but too often the patient becomes the casualty. Perhaps for most physicians, seeing an excessive number of patients results not from design but from inadvertence, the inevitable outcome of the “fit her in somewhere” philosophy. The surgeon and his or her staff over the years gradually may become stretched beyond their capacity.

That most plastic surgeons do aesthetic surgery may predispose them to regard their procedures as just skin deep. Because cosmetic patients usually are in good health, the surgeon may not believe that a thorough physical examination is crucial, the assumption being that, whatever the procedure, the patient will come through unscathed except for local scarring. The surgeon may not inquire about systemic illnesses, past operations and emotional reactions to them, drug sensitivities, smoking history, and so forth. Furthermore, because the patient for aesthetic surgery has a focus, such as the nose or breast, the surgeon may limit his or her attention to one segment of the patient. In fact, it would be considered odd and inappropriate if the plastic surgeon did a pelvic examination on a 40-year-old woman desiring a facelift. However, in viewing the patient narrowly, the plastic surgeon may forget that he or she is a physician with the duty to think of that individual globally and not only regionally. The patient may reinforce the plastic surgeon’s superficial approach because he or she does not want to believe that a rhinoplasty, for example, is a real operation with true hazards.