Failure: the great teacher

Editor- `One learns nothing from success, only from failure.` Yes, I
agree, but we are no longer allowed to learn from our mistakes. Our
patients have had their expectations raised to an impossibly high level by
politicians and this is why they are no longer universally grateful.
Doctors have difficulty with failure because they care. We, as a
profession, have never guaranteed perfection. Audit repeatedly shows that
this is not possible and never will be. Indeed we are now encouraged to
try to explain every possible complication of treatment to our patients.
We are also obliged, quite reasonably, to reveal our results for major
complex procedures. In spite of this we still receive complaints and
letters from solicitors when things go wrong. As a trainee surgeon I was
taught to do my best to `mend` people and not to expect to cure everyone.
The
medical profession is not failing the public. It is political whims, often
embodied in charters, that fail the public in raising expectations to
impossibly high levels. Surgery has always been and will remain a great
leveller. Surgeons have to cope with failure, and the surgeon who has
no failures or complications is just not doing the work. We have lived
with ignorance, weakness and failure, and will have to continue to do so
as long as we continue to practise.

H J R Evans
Consultant General and Vascular Surgeon
Prince Philip Hospital
Bryngwynmawr
Llanelli
Carmarthenshire

You seem to be correct about this idea having occurred to someone
before. I recently ran accross this quote attributed to Longfellow:
"Sometimes we may learn more from a man's errors than from his virtues."
Is it clear that we can generalize from this study of GPs reactions to
patient complaints? What are (or were) the morbidity and mortality
conference and the clinicopathologic conference, if not traditions in
medical education and practice founded on the principle that failure
offers an opportunity for learning and improvement?

Berwick's classic paper "Continuous improvement as an ideal in health
care" (NEJM New England Journal of Medicine. 320(1):53-6, 1989)
emphasized the importance of creating a context that enables us to
acknowledge failure and create improvements. Others have demonstrated
that such an approach can indeed improve practices over time (Malenka DJ.
O'Connor GT The Northern New England Cardiovascular Disease Study Group: a
regional collaborative effort for continuous quality improvement in
cardiovascular disease. Joint Commission Journal on Quality Improvement.
24(10):594-600, 1998.

On the other hand, I think it was JFK who said something like
"success has a hundred fathers but failure is an orphan." One impediment
to progress is the assumption that errors in medicine are individual
failures - the implication being that if we root out those rotten apples,
the rest of us will be OK. But Leape (A systems analysis approach to
medical error. Journal of Evaluation in Clinical Practice. 3(3):213-22,
1997) has emphasized "that most errors result from defects in the systems
in which we work. These are failures in the design of processes, tasks,
training, and conditions of work that make errors more likely." If so,
then the "rotten apples" approach to error in medicine is doomed not to
improve practice, but merely gives us another reason to feel bad about
ourselves.

The Kipling poem is called "If." You will find it in any anthology of
Kipling, and in many anthologies of English poetry. There is an anthology
called "The Nation's Favourite
Poems" published by BBC Books in 1996 (ISBN 0 563 38782 3). "If" was the
favourite. Second was Alfred, Lord Tennyson's "The Lady of Shalott" and
third Walter De La Mare's "The Listeners." Kipling has two other poems in
the anthology, but T S Eliot has the most (5) and W B Yeats the next most
(4), illustrating to my mind the good taste of BBC listeners.

Richard Smith

Editor
BMJ