FAILURE AND RESCUE

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From the New Yorker, June 4, 2012http://www.newyorker.com/online/blogs/newsdesk/2012/06/atul-gawande-failure-and-rescue.htmlFAILUREAND RESCUEPosted by Atul GawandeThe following was delivered as the commencementaddress at Williams College on Sunday, June 3rd.We had a patient at my hospital this winter whose story has stuckwith 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 inher left eye. It tells you something about her that she was at work when ithappened—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 twentythousand Jewish refugees relocated to the Shanghai ghetto in Japanese-occupiedChina. She was a teen-age girl and spent eight years there, helping her familyjust to live and survive, until liberation in September, 1945. Denied a formaleducation, she worked as a seamstress upon admission to the United States. Sherose to head seamstress at Bloomingdale's in Chestnut Hill, outside Boston. Shemarried at twenty-three, had two sons, and was widowed at forty-four. Sheherself remained in remarkably good health.At eighty-seven, she still lived independently in a second-floorapartment in Norwood, Massachusetts. She drove a Honda Civic. She did all herown shopping and cooking. And she still worked—three and a half days a week atSears, doing office work, and her other weekdays volunteering at New EnglandSinai Rehabilitation Hospital.She was sitting at her desk at Sears when the vision in her lefteye went completely black. It came back after three minutes. She dismissed theepisode, but the next day the same thing happened again, only this time thevision didn’t come back. Her doctor sent her to our emergency room, where shewas suspected to have had a stroke caused by a severe atherosclerotic blockageof the carotid artery in her neck. She needed urgent surgery to open theblockage. She thought hard before agreeing to it. She had great fear of therisks and what they could take away from her life. But she had greater fear ofwhat her condition might take away. Being able to remain independent, work, andcontribute in some way was most important to her, and her best chance ofpreserving 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 complainedthat constipation was making her nauseated and uncomfortable. The team triedlaxatives, but they did nothing, and her belly only became more painful.A young resident was the one who, looking at her, felt thatsomething wasn’t right. In fact, this wasn’t constipation at all, but adisaster from a strange complication. Her stomach had twisted on itself, pulledup 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 rupturedinto her chest. This is catastrophic for anyone, let alone aneighty-seven-year-old woman. The textbooks describe an up to eighty-per-centfatality rate.Yet she did survive. In fact, she left the hospital with her sonwithin a week. And the more I reflect on the story of how that was madepossible, the more I think that the story is relevant to all of us, whateverour walks of life.When I was nearing the end of medical school, I decided to go intosurgery. I had become enthralled by surgeons, especially by their competence.The source of their success, I believed, was their physical skill—theirhand-eye coördination and fine-motor control. But it wasn’t, I learned inresidency training. Getting the physical skills is important, and they takesome time to practice and master, but they turn out to be no more difficult tolearn than those that Mrs. C. mastered as a seamstress. Instead, the criticalskills of the best surgeons I saw involved the ability to handle complexity anduncertainty. They had developed judgment, mastery of teamwork, and willingnessto accept responsibility for the consequences of their choices. In thisrespect, I realized, surgery turns out to be no different than a life inteaching, public service, business, or almost anything you may decide topursue. We all face complexity and uncertainty no matter where our path takesus. That means we all face the risk of failure. So along the way, we all areforced to develop these critical capacities—of judgment, teamwork, andacceptance of responsibility.In commencement addresses like this, people admonish us: takerisks; be willing to fail. But this has always puzzled me. Do you want asurgeon whose motto is “I like taking risks”? We do in fact want people to takerisks, to strive for difficult goals even when the possibility of failurelooms. Progress cannot happen otherwise. But how they do it is what seems tomatter. The key to reducing death after surgery was the introduction of ways toreduce 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 onlyconsider it as a last resort. Large numbers of patients developed seriousinfections afterward, bleeding, and other deadly problems we euphemisticallycalled “complications.” Now surgery has become so safe and routine that most isday surgery—you go home right afterward.But there continue to be huge differences between hospitals in theoutcomes of their care. Some places still have far higher death rates thanothers. And an interesting line of research has opened up asking why.Researchers at the University of Michigan discovered the answerrecently, and it has a twist I didn’t expect. I thought that the best placessimply did a better job at controlling and minimizing risks—that they did abetter job of preventing things from going wrong. But, to my surprise, they didn’t. Theircomplication rates after surgery were almost the same as others. Instead, whatthey proved to be really great at was rescuing people whenthey had a complication, preventing failures from becoming a catastrophe.Scientists have given a new name to the deaths that occur insurgery after something goes wrong—whether it is an infection or some bizarretwist 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 societalimprovement. We talk a lot about “risk management”—a nice hygienic phrase. Butin the end, risk is necessary. Things can and will go wrong. Yet some have abetter capacity to prepare for the possibility, to limit the damage, and tosometimes even retrieve success from failure.When things go wrong, there seem to be three main pitfalls toavoid, three ways to fail to rescue. You could choose a wrong plan, aninadequate plan, or no plan at all. Say you’re cooking and you inadvertentlyset a grease pan on fire. Throwing gasoline on the fire would be a completelywrong 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 ofthese elements came into play, leading to the death of eleven men and thespillage 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 wasimproperly designed, but the companies involved did nothing. Then, on theevening of April 20, 2010, during a routine test of the well, the rig crewdetected a serious abnormality in the pressure in the drill pipe. They watchedit and took more measurements, which revealed a number of other abnormalitiesthat signal a “kick”—an undetected pressure buildup. But it was two hoursbefore they recognized the seriousness of the situation—two hours without aplan of action.Then, when they did recognize the trouble, they sent the flowthrough a piece of equipment that can’t handle such pressures. The kickescalated to a blowout, and the mud-gas mix exploded. At that point, emergencycrews went into action. But for twelve minutes, no one sounded a general alarmto abandon the rig, leading directly to the loss of eleven lives in a secondexplosion.There was, as I said, every type of error. But the key one was thedelay in accepting that something serious was wrong. We see this in nationalpolicy, too. All policies court failure—our war in Iraq, for instance, or theeffort to stimulate our struggling economy. But when you refuse to evenacknowledge that things aren’t going as expected, failure can become ahumanitarian disaster. The sooner you’re able to see clearly that your besthopes and intentions have gone awry, the better. You have more room to pivotand adjust. You have more of a chance to rescue.But recognizing that your expectations are proving wrong—acceptingthat you need a new plan—is commonly the hardest thing to do. We have thisproblem called confidence. To take a risk, you must have confidence inyourself. In surgery, you learn early how essential that is. You are imperfect.Your knowledge is never complete. The science is never certain. Your skills arenever infallible. Yet you must act. You cannot let yourself become paralyzed byfear.Yet you cannot blind yourself to failure, either. Indeed, you mustprepare for it. For, strangely enough, only then is success possible. When Mrs.C.’s abdominal pain turned to catastrophe, for instance, my colleagues wereprepared. Now, they weren’t prepared for anything so odd as the idea that herstomach 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 aboutthe way her abdomen felt on his exam, the surgeon thought he was beingalarmist. She’d been doing great just the day before. And what could go wrongin someone’s belly after neck surgery? He’d never seen a serious belly problemin such circumstances.But the surgeon was humble enough to understand that he could. Younever really know what way trouble can strike. So he listened. He allowed theresident to order a scan. The team made sure it was expedited. When it showedthe queer twist, no one dismissed it. They got help from another surgeonimmediately. They had her on an operating table within two hours.Nothing went exactly perfectly. There was still a good deal offumbling around as they tried to sort out what was really going on and whatwould 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 aninadequate plan—perhaps even the completely wrong one. But they avoided theworst mistake—which was to have no plan at all. They’d acted early enough tobuy themselves time for trial and error, to figure out all the steps requiredto get her through this calamity. They gave her and themselves the chance torescue success from failure.I spoke to Mrs. C. a couple days ago, and she gave me permissionto tell you her story. She’s living with her son now. She turned eighty-eightthis past April. With her vision gone in her left eye, she can no longer workor 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 herfamily, especially her grandchildren. She’s even looking for ways to volunteeragain. “Life is not perfect, but it is good,” she said.As you embark on your path from here, you are going to takechances—on a relationship, a job, a new line of study. You will have greathopes. 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 thefield. I tried starting a rock band. You don’t want to know how awful the songsI wrote were. I wrote one song, for example, comparing my love for a girl tothe decline of Marxism. After this, I worked in government on health-carelegislation that not only went nowhere, it set the prospect of health reformback almost two decades.But the only failure is the failure to rescue something. I tookaway ideas and experiences and relationships with people that profoundlychanged 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 whathappens afterward that is defining. A failure often does not have to be afailure at all. However, you have to be ready for it—will you admit when thingsgo wrong? Will you take steps to set them right?—because the difference betweentriumph and defeat, you’ll find, isn’t about willingness to take risks. It’sabout mastery of rescue.Photograph courtesy Hulton Archive/Getty.Read more http://www.newyorker.com/online/blogs/newsdesk/2012/06/atul-gawande-failure-and-rescue.html#ixzz1wqH38SBrTweetShare