From the New Yorker, June 4, 2012
FAILURE
AND RESCUE
The following was delivered as the commencement
address at Williams College on Sunday, June 3rd.
We had a patient at my hospital this winter whose story has stuck
with me. Mrs. C. was eighty-seven years old, a Holocaust survivor from Germany,
and she’d come to the emergency room because she’d suddenly lost the vision in
her left eye. It tells you something about her that she was at work when it
happened—in the finance department at Sears.
She’d worked her entire life. When her family left Nazi Germany,
they narrowly avoided the concentration camps but ended up among twenty
thousand Jewish refugees relocated to the Shanghai ghetto in Japanese-occupied
China. She was a teen-age girl and spent eight years there, helping her family
just to live and survive, until liberation in September, 1945. Denied a formal
education, she worked as a seamstress upon admission to the United States. She
rose to head seamstress at Bloomingdale's in Chestnut Hill, outside Boston. She
married at twenty-three, had two sons, and was widowed at forty-four. She
herself remained in remarkably good health.
At eighty-seven, she still lived independently in a second-floor
apartment in Norwood, Massachusetts. She drove a Honda Civic. She did all her
own shopping and cooking. And she still worked—three and a half days a week at
Sears, doing office work, and her other weekdays volunteering at New England
Sinai Rehabilitation Hospital.
She was sitting at her desk at Sears when the vision in her left
eye went completely black. It came back after three minutes. She dismissed the
episode, but the next day the same thing happened again, only this time the
vision didn’t come back. Her doctor sent her to our emergency room, where she
was suspected to have had a stroke caused by a severe atherosclerotic blockage
of the carotid artery in her neck. She needed urgent surgery to open the
blockage. She thought hard before agreeing to it. She had great fear of the
risks and what they could take away from her life. But she had greater fear of
what her condition might take away. Being able to remain independent, work, and
contribute in some way was most important to her, and her best chance of
preserving this was to act.
The operation went remarkably well. There were no problems at all.
She was weak afterward, but the next day she ate, got out of bed, felt fine.
The day after that, she seemed ready to leave the hospital. But she complained
that constipation was making her nauseated and uncomfortable. The team tried
laxatives, but they did nothing, and her belly only became more painful.
A young resident was the one who, looking at her, felt that
something wasn’t right. In fact, this wasn’t constipation at all, but a
disaster from a strange complication. Her stomach had twisted on itself, pulled
up into her chest, and become trapped—a condition known as a gastric volvulus.
Worse, an ulcer seemed to have formed in the lining of her stomach and ruptured
into her chest. This is catastrophic for anyone, let alone an
eighty-seven-year-old woman. The textbooks describe an up to eighty-per-cent
fatality rate.
Yet she did survive. In fact, she left the hospital with her son
within a week. And the more I reflect on the story of how that was made
possible, the more I think that the story is relevant to all of us, whatever
our walks of life.
When I was nearing the end of medical school, I decided to go into
surgery. I had become enthralled by surgeons, especially by their competence.
The source of their success, I believed, was their physical skill—their
hand-eye coördination and fine-motor control. But it wasn’t, I learned in
residency training. Getting the physical skills is important, and they take
some time to practice and master, but they turn out to be no more difficult to
learn than those that Mrs. C. mastered as a seamstress. Instead, the critical
skills of the best surgeons I saw involved the ability to handle complexity and
uncertainty. They had developed judgment, mastery of teamwork, and willingness
to accept responsibility for the consequences of their choices. In this
respect, I realized, surgery turns out to be no different than a life in
teaching, public service, business, or almost anything you may decide to
pursue. We all face complexity and uncertainty no matter where our path takes
us. That means we all face the risk of failure. So along the way, we all are
forced to develop these critical capacities—of judgment, teamwork, and
acceptance of responsibility.
In commencement addresses like this, people admonish us: take
risks; be willing to fail. But this has always puzzled me. Do you want a
surgeon whose motto is “I like taking risks”? We do in fact want people to take
risks, to strive for difficult goals even when the possibility of failure
looms. Progress cannot happen otherwise. But how they do it is what seems to
matter. The key to reducing death after surgery was the introduction of ways to
reduce the risk of things going wrong—through specialization, better planning,
and technology. They have produced a remarkable transformation in the field.
Not that long ago, surgery was so inherently dangerous that you would only
consider it as a last resort. Large numbers of patients developed serious
infections afterward, bleeding, and other deadly problems we euphemistically
called “complications.” Now surgery has become so safe and routine that most is
day surgery—you go home right afterward.
But there continue to be huge differences between hospitals in the
outcomes of their care. Some places still have far higher death rates than
others. And an interesting line of research has opened up asking why.
Researchers at the University of Michigan discovered the answer
recently, and it has a twist I didn’t expect. I thought that the best places
simply did a better job at controlling and minimizing risks—that they did a
better job of preventing things from going wrong. But, to my surprise, they didn’t. Their
complication rates after surgery were almost the same as others. Instead, what
they proved to be really great at was rescuing people when
they had a complication, preventing failures from becoming a catastrophe.
Scientists have given a new name to the deaths that occur in
surgery after something goes wrong—whether it is an infection or some bizarre
twist of the stomach. They call them a “failure to rescue.” More than anything,
this is what distinguished the great from the mediocre. They didn’t fail less.
They rescued more.
This may in fact be the real story of human and societal
improvement. We talk a lot about “risk management”—a nice hygienic phrase. But
in the end, risk is necessary. Things can and will go wrong. Yet some have a
better capacity to prepare for the possibility, to limit the damage, and to
sometimes even retrieve success from failure.
When things go wrong, there seem to be three main pitfalls to
avoid, three ways to fail to rescue. You could choose a wrong plan, an
inadequate plan, or no plan at all. Say you’re cooking and you inadvertently
set a grease pan on fire. Throwing gasoline on the fire would be a completely
wrong plan. Trying to blow the fire out would be inadequate. And ignoring it—“Fire?
What fire?”—would be no plan at all.
In the BP oil disaster in the Gulf of Mexico two years ago, all of
these elements came into play, leading to the death of eleven men and the
spillage of five million barrels of oil over three months. According to the official investigation,
there had been early signs that the drill pipe was having problems and was
improperly designed, but the companies involved did nothing. Then, on the
evening of April 20, 2010, during a routine test of the well, the rig crew
detected a serious abnormality in the pressure in the drill pipe. They watched
it and took more measurements, which revealed a number of other abnormalities
that signal a “kick”—an undetected pressure buildup. But it was two hours
before they recognized the seriousness of the situation—two hours without a
plan of action.
Then, when they did recognize the trouble, they sent the flow
through a piece of equipment that can’t handle such pressures. The kick
escalated to a blowout, and the mud-gas mix exploded. At that point, emergency
crews went into action. But for twelve minutes, no one sounded a general alarm
to abandon the rig, leading directly to the loss of eleven lives in a second
explosion.
There was, as I said, every type of error. But the key one was the
delay in accepting that something serious was wrong. We see this in national
policy, too. All policies court failure—our war in Iraq, for instance, or the
effort to stimulate our struggling economy. But when you refuse to even
acknowledge that things aren’t going as expected, failure can become a
humanitarian disaster. The sooner you’re able to see clearly that your best
hopes and intentions have gone awry, the better. You have more room to pivot
and adjust. You have more of a chance to rescue.
But recognizing that your expectations are proving wrong—accepting
that you need a new plan—is commonly the hardest thing to do. We have this
problem called confidence. To take a risk, you must have confidence in
yourself. In surgery, you learn early how essential that is. You are imperfect.
Your knowledge is never complete. The science is never certain. Your skills are
never infallible. Yet you must act. You cannot let yourself become paralyzed by
fear.
Yet you cannot blind yourself to failure, either. Indeed, you must
prepare for it. For, strangely enough, only then is success possible. When Mrs.
C.’s abdominal pain turned to catastrophe, for instance, my colleagues were
prepared. Now, they weren’t prepared for anything so odd as the idea that her
stomach would have wound on itself like a balloon twisted too tight. In fact,
when the surgical resident told Mrs. C.’s surgeon that he was concerned about
the way her abdomen felt on his exam, the surgeon thought he was being
alarmist. She’d been doing great just the day before. And what could go wrong
in someone’s belly after neck surgery? He’d never seen a serious belly problem
in such circumstances.
But the surgeon was humble enough to understand that he could. You
never really know what way trouble can strike. So he listened. He allowed the
resident to order a scan. The team made sure it was expedited. When it showed
the queer twist, no one dismissed it. They got help from another surgeon
immediately. They had her on an operating table within two hours.
Nothing went exactly perfectly. There was still a good deal of
fumbling around as they tried to sort out what was really going on and what
would need to be done. For a time, they hoped for a small, short procedure,
using just a scope and avoiding a big operation. It would have been an
inadequate plan—perhaps even the completely wrong one. But they avoided the
worst mistake—which was to have no plan at all. They’d acted early enough to
buy themselves time for trial and error, to figure out all the steps required
to get her through this calamity. They gave her and themselves the chance to
rescue success from failure.
I spoke to Mrs. C. a couple days ago, and she gave me permission
to tell you her story. She’s living with her son now. She turned eighty-eight
this past April. With her vision gone in her left eye, she can no longer work
or drive, and she misses both greatly. “I’m not the same person I used to be,”
she told me. She doesn’t like being dependent on others, even for just a ride.
But she has otherwise returned to leading a life of her own. She enjoys her
family, especially her grandchildren. She’s even looking for ways to volunteer
again. “Life is not perfect, but it is good,” she said.
As you embark on your path from here, you are going to take
chances—on a relationship, a job, a new line of study. You will have great
hopes. But things won’t always go right.
When I graduated from college, I went abroad to study philosophy.
I hoped to become a philosopher, but I proved to be profoundly mediocre in the
field. I tried starting a rock band. You don’t want to know how awful the songs
I wrote were. I wrote one song, for example, comparing my love for a girl to
the decline of Marxism. After this, I worked in government on health-care
legislation that not only went nowhere, it set the prospect of health reform
back almost two decades.
But the only failure is the failure to rescue something. I took
away ideas and experiences and relationships with people that profoundly
changed what I was able to do when I finally found the place that was for me,
which was in medicine.
So you will take risks, and you will have failures. But it’s what
happens afterward that is defining. A failure often does not have to be a
failure at all. However, you have to be ready for it—will you admit when things
go wrong? Will you take steps to set them right?—because the difference between
triumph and defeat, you’ll find, isn’t about willingness to take risks. It’s
about mastery of rescue.
Photograph courtesy Hulton Archive/Getty.
