OPINION
DOCTORS ' Lounge
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Failure, A History
Mary G. Barry, MD Louisville Medicine Editor editor @ glms. org
Learning to practice medicine is an exercise in failure. Over and over, we don’ t know the answer, from the first cut in Gross Anatomy to the final oral exam as seniors on the surgery service. Our guesses at the answer progressively improve, but medical school for many of us was best described by Sir Winston Churchill:“ Success is stumbling from failure to failure with no loss of enthusiasm.”
Internship is a trial not by fire, but by fear. For the first time we are making minute to minute decisions that could hurt or kill somebody. Medicine eternally has guarded against that by the chain of command. The shaman has his apprentices just as the Attending has an entourage. But at 0300 when only real Coca Cola can sustain you, it is your decision whether to go with your own brain and gut, or call for your higher power. The price of asking for help can mean losing the chance to trust your own eyes, ears and heart. But in not asking for help, you can lose your patient. That is why the practice of medicine is so collaborative: you do what you know, you ask when you don’ t know, and over time your repertoire of disease pattern recognition grows by leaps and bounds. You spend that year
34 LOUISVILLE MEDICINE testing your diagnostic skills to the limit, then expanding that limit, again and again.
Through residency you gain enough confidence to be cocky, but inevitably get shot down at Morning Report. You face the wrath of the subspecialists when you have been admitting for GI and failed to do the Trail Test with your waterlogged cirrhotic( inside you grumble, at least he can breathe now, whaddya want?). But we learn that with increased responsibility comes increased guilt. I don’ t know a good doctor who cannot instantly come up with 10 or 20 epic mistakes and when they tell someone about them, the shadow of that guilt is almost visible in the room.
Failure of medical knowledge is thus essential to scientific learning. We are spurred by the sting of not knowing, and inspired by the hope of helping someone better the next time.
But it’ s not just knowledge. It’ s the personal failures of not trying hard enough, of not being kind enough, of not listening well enough, of needless hurry, of not truly seeing the person in front of us at that moment, that plague us all. We fail to comfort, or fail to teach, or fail to grasp the real worry behind the stated chief complaint. These are part and parcel of modern medical life, beset as we are by the slings and arrows from everybody in the whole damn world who is not a doctor but trying to make our lives miserable in a myriad of ways. Nonetheless, as we navigate the intricate waterways of what gets paid for how, by whom and how many forms do I fill out and how much do I have to type of which buzzphrases just to get my guy a CT scan? And on and on – you get out of breath just describing it.
What interests me is that this culture of trial and failure bolstered by the relative protection of the medical hierarchy does not translate well into other realms, except the armed services. Businesses where competition is the norm for advancement pay a lot of attention to failed initiatives, lessons learned can propel or sink a career.
But the fight to get into the premier universities has so poisoned the well of ordinary teenagerhood that colleges these days have had to develop whole programs on failure. Students who achieve admission are models of perfection in every endeavor and have managed to stand out from their peers in some admirable, individual way. Their failures have been rare. But college life brings all kinds of opportunities to screw up, and about 10 years ago colleges began to find that distraught students sought coun-