Managing Failure

Failure is the state when a desirable, or intended, objective is not met and is the opposite of success. When anyone talks or writes about failure it is always with the intention of avoiding it. It is obviously relative, can be biased based on the individual considering it, and depends considerably on the context in which it is used. It is difficult to define, but everyone understands what it is and recognises it when it happens. It is interesting to discuss it from the simplest situations of failure in surgery to the larger issue of failure of institutions.

Failure of Surgical Procedures: Of all instances of failure in medicine, this, arguably, is the easiest to remedy. I remember one of my mentors, Dr Ravikumar, a Paediatric Surgeon, telling me while discussing a surgical failure, ‘It is impossible for you to be the first one in the world to have met this problem during surgery. Many would have faced it, quite a few would have found successful solutions and at least some would have written about it. It is just that you need to read’. When faced with a surgical failure or complication, one needs to sit back and think about why it happened, discuss the problem openly with peers and delve further into the literature.

How do I personally avoid surgical failures? Two practices have helped me – First is Bob Acland’s dictum – ‘Preparation is the key to success. Before you start you must have done the procedure a few times in your mind’. Second, whenever you have to do a procedure which you have not done in the last 6 months, it is always worthwhile to read the steps or watch a video. This might appear to be superfluous advice, but nothing makes you more comfortable than the confidence of knowing that everything is well set for success, and knowing what you are in for when you pick up the knife. Commonly, we analyse our failures, but it is as important, and useful, for us to analyse our successes, the steps which led to the success and how to achieve it consistently.

It is also important to keep the memory of a failure very short. If we have a replant failure, we look for the earliest opportunity to do the next replant and succeed. There is an old tradition in the Air Force of the entire station flying immediately after an unfortunate crash. This is to boost the morale of a well-trained team and inspire confidence in the machine, after a rare and unfortunate failure of a routine procedure. Most of the time, it is led by the commanding officer himself, indicating that while the Squadron grieves for the departed comrade, life must go on and the Squadron must get back to the assigned task.

Failures during Training: Often we hear from people at the end of the training that they felt the lack of good teachers. It is wonderful if an eager student meets with an ideal mentor. Is there a shortage of mentors? With an experience of over 35 years in teaching, I have come to believe in what Gautama Buddha said 2,500 years ago that ‘When the student is ready the teacher will appear’. The saying also means that when we are ready to learn and grow, we will be ready to listen to and act upon knowledge we glean from the teacher who is already in front of us, and perhaps has always been there; only we were previously un-receptive to their offerings. I am convinced that there will always be someone who will spot and nurture a good student. A corollary of this quote, attributed to the Chinese philosopher Lao Tzu, that ‘When the student is truly ready, the teacher disappears’ is also true.

Failure to Thrive in Practice: An individual may sometimes become frustrated when he misses a job, or a promotion, which he rightfully deserves. It may seem as if people or the whole world is conspiring against him. This will happen sometime or other in everyone’s life. At that time, the first response of the individual is seething anger all around. This must be contained, since exhibiting it may lead to even more problems. It will be good if, at such a time of dismay, frustration and anger, there is a mentor to talk with, who can put things into perspective and guide us on the way forward. The need of the hour is the ability to see the bigger picture. At one such point of time in my career, I had the fortune of having Dr Lalita Kameswaran, the former Vice Chancellor of The Tamil Nadu Dr. M.G.R. Medical University, Chennai, as a mentor who assessed the situation and said, ‘Sabapathy, you are full of anger. Anger is a very powerful emotion. It must be constructively channelled, otherwise you will end up hurting yourself and your career. Put the thought of this issue aside and use the anger to work a little harder, at least half an hour extra every day. Most importantly, remember that what appears to be so important today, you will find to be totally irrelevant in the course of time. Any damage from a response to your anger now is likely to be to yourself. Just forget the past and get back to work’. That was a great piece of advice. Looking back, the issue which had me so fired up soon became irrelevant. This event also helped me learn the importance of looking at the bigger picture.

Starting, nurturing and thriving in practice needs a combination of professional skills, love for the job and positioning your skills in the right way and place, such that the needy may benefit from said skills. Currently, practising medicine has become a team game, and one must be a good team player. Even when all the desirable attributes are present, sometimes success eludes an individual. At that time, perhaps what is needed is to stay confident and to keep working without going off the track. Slackening the tempo of work, disregarding your values and underperforming due to self-pity can creep up slowly, leading you down a negative spiral.

Cricket legend Sachin Tendulkar scored his ninety-ninth century on 12 March 2011. After that, in every innings he played, he sought his hundredth hundred, and his fans worldwide were waiting to celebrate. But it took the champion batsman 370 days and 34 innings to create that history. On 16 March 2012, he scored that elusive hundredth century in Dhaka against Bangladesh. If the man revered as the ‘God of Cricket’, had to wait 34 innings to achieve his goal, we cannot expect a cakewalk in our endeavours.

Failure of Institutions: Individuals make institutions and when institutions fail it is because many individuals have collectively failed. Most surgical units peak and gradually slide downwards again. Rarely have we found them to survive at the same level of recognition beyond a few decades. Most have been created by a visionary whose ideas, skills and leadership qualities made the unit popular and productive.

However, decline is not inevitable. When Bob Acland visited our unit, he wrote in our visitor’s book about this and wished us ‘continued success’. This underlines the fact that continued success is neither automatic nor should be considered as an entitlement. It requires hard work. On further discussion, I enquired as to what he saw were the main reasons for the rise and fall of institutions. It is worth recalling the three points that he listed. The first was, ‘Celebrating Success’. While success needs to be celebrated, the founders and the next generation must understand that it is so easy to keep on explaining how the unit succeeded and fail to continue to put in the same groundwork in the unit. Second, ‘You may be training the world, and forget to train the people who will take over from you’. Identifying, nurturing and stabilising the next generation of surgeon leaders who will take over is a big challenge in itself. When that happens, units survive. The third was ‘Forgetting the core which brought you up to this level of success in the first place’. Perhaps the slide starts when people forget this. The core is good patient care. All units which have risen to a height have considered this a non-negotiable goal. Institutions fail when people who take over try to explain the loss of that value as inevitable, due to changing times and practices. Technology may help us to achieve our goals by a different path but the core value of patient satisfaction and putting the interest of the patient first and foremost must not change. History has shown that whenever that has happened, and physicians put their own interests first, and before those of the patients, even the most famous units faltered.

It all starts at the individual level, with small compromises by a few people that go unchecked. Not that these small, out of order, practices are not recognised by the people around—the tragedy is that many chose to remain silent and allow this to happen. At first, the defaults are all ‘small’, but many such, seemingly small, aberrations in practice add up and the system is derailed irrevocably. President Kennedy was fond of quoting Dante that ‘the hottest places in Hell are reserved for those who, in a time of great moral crisis, maintain their neutrality’. None of us can afford to be lookers-on, critics on the sidelines. One need not wait for occasions of great moral crisis to exhibit the courage of standing up. It has to be done the first time someone misses a ‘routine’ postoperative round or justifies an unacceptable mistake.

Failures are bound to occur, but it is the response that counts. At an individual level, what is needed is to stop and think what caused it, then correct the failing and keep going. This way, we stay right on the job. At an institutional level, it is the unwillingness of leadership to correct ‘small’ compromises, to grasp the opportunity to act, that allows a new norm, and allows the slide to start. At all times, we need people who will stand up if the core values are to be kept afloat. A single person alone can do this. As Andrew Jackson said, ‘One man with courage makes a majority’. Such people delay the failure of institutions indefinitely.