Failure in Surgery
Failure in surgery is not what we think it is. In most professions, failure is a metric, a necessary part of the iterative process. Engineering students who beta-test their ideas on YouTube don’t just avoid failure, they revel in it. But in our profession, the stakes are human. And so, instead of seeing failure as a necessary part of the learning process, we equate complications, mistakes, and missed expectations with personal defects. In surgery, failure feels personal.
French surgeon, René Leriche, famously said “Every surgeon carries within himself a small cemetary”.
We all have a secret place in our psyche where we’ve tucked away all the complications, mistakes, and missed expectations we’ve experienced throughout our career. As if that were not enough, many of us also carry the lingering shame of having to defend our decisions in front of a room of peers and mentors at M&M conference. It’s no wonder we tell ourselves that anything less than perfect is unacceptable. The problem with a perfectionistic mindset? Surgeons are humans, and humans are fallable. It is impossible to create perfect surgical outcomes for every patient, every time.
There’s good news. While we will all have complications, mistakes, and missed expectations in our careers, there is truly only one way to fail in surgery. And we have complete control over whether or not we fail in this way. The one way we fail in surgery is failing to serve the patient.
The surgery goes swimmingly, or we learn a lesson. The patient does amazing, or we gain a new understanding of a technique or postop care routine. We either succeed, or we learn.
When you stop equating failure with “mistakes, complications and missed expectations” and start equating failure with “failing to serve”, you open up a space to evaluate unfavorable surgeries without making them mean anything about you or your self-worth. That’s how we learn and grow in surgery. You have complete control over how you show up for patients, and if you show up in service every step of the way, you will succeed as a surgeon.
Intentions and thoughts of a service-minded surgeon:
I tell the truth about what happened in surgery.
I evaluate objectively.
I apply lessons I learn to the next case (if there is an actionable lesson).
I show up in service to the patient preop, in the OR, postop, and when complications, mistakes, and missed expectations happen.
I make the effect of my impact (the surgical result) none of my business. My business is to show up in service.
Complications, mistakes, and missed expectations are inevitable in surgery, but we decide whether or not we will learn from them. Part of showing up in service to patients is evaluating ourselves objectively. Here is a simple evaluation process you can use any time surgeries do not go as anticipated. *Bonus points if you do this evaluation process for every surgery.
What went well?
Begin by stabilizing your nervous system. Name specific actions you took that went well. Remind yourself that the surgery was indicated. You didn’t create the disease process or event that led the patient to surgery. Did you do a seamless initial dissection? What specific moves did you execute excellently?
What didn’t go as planned?
List facts without moralizing. Did you need more or different exposure during a critical step? How could you communicate better with the FA or resident providing that exposure? Did you do the right move wrong? Did you do a wrong move? What specifically didn’t go well?
What will you do differently next time?
Now that you’ve taken radical responsibility (responsibility is the “ability to respond”), what will you do different next time? What did you learn about your blindspots? Do you need to tweak your technique? Or do you need to tweak how you communicate with your support staff? Do you need to change anything preop or postop?
This is how outcomes improve, and how you stop carrying them as proof you are “not enough.”
A real example
Early in my career, I under-addressed a caudal septum and a patient continued to be unable to breathe well through one nostril postop. That review changed my practice: I began assessing the caudal septum in a different way and offering caudal septal reconstruction when indicated. A mistake transformed into a protocol because I was willing to look.
Guardrails around your service
Service is not self-erasure, people-pleasing, bending over backward, or being everything to everyone. You need boundaries to sustain your ability to show up in service. You can’t show up in service to patients who really need you unless you preserve your energy. Showing up in service to every request and desire of everyone is a path straight to burnout. Part of showing up in service to patients is protecting the asset: you.
Inbox requests to call patients are not demands. You decide if the patient truly needs a call from you (the surgeon), a member of the team, or if they need to come in to be seen. → “Happy to discuss. Please book a follow-up”, “Amy, please call this patient back and tell them____”.
After-hours access. You decide how much access patients have to you. If you are going to give out your cell phone, create boundaries around patient use → “Please only use this line for urgent clinical issues; all admin questions go through the office.”
Scheduling pressure. You do not need to say “yes” every time your office manager requests to add-on a patient → Set a rule for yourself to say “No” to non-urgent add-ons that compromise obligations to yourself or your family (getting to the gym, taking a walk, stopping at the grocery store after clinic, attending your kid’s swim lesson, etc.).
Take a look at the actions you plan to take, and set the dial to service. When service is your North Star, the “effect of your impact” (the uncontrollable parts of outcomes) stops defining you. Complications are still hard, but they are no longer identity-level verdicts.
Ready to practice this in community? Join Empowered Surgeons Group where we coach around complications, mistakes, and missed expectations regularly.
