The Sandbox Rules for Plastic Surgery

Use good judgment in making decisions. Good judgment is gained from experience. Experience is gained from making mistakes. Mistakes come from using bad judgment in making decisions.

—Anonymous

I have observed my children grow by how they play and interact with each other and their friends from the time they were in the sandbox to playing soccer, gymnastics, and dancing, as well as other sports and activities. There is a remarkable parallel that one draws from watching your children grow and having educated residents for more than two decades. Children, and residents, tend to learn from each other, teach each other, and help develop who they are, both internally and externally.

Life, as with plastic surgery, is an accumulative endeavor gathered from what we have learned from our life experiences as well as whether there have been mistakes or mishaps. These are invaluable yet painful reminders of who we are, who we will ultimately become, and how we treat each other. Therefore, the natural extension of our life rules is what we have learned in kindergarten or even before that–-what I call the “sandbox rules.” Many of these rules are applicable to what we do in life, in medicine in general and as we grow and develop in plastic surgery in particular. Adhering to these rules will help keep us out of harm’s way in life; after all, life is hard enough. When things are going well, why rock the boat? Some of life’s sandbox rules follow.

1. Share your toys (be compassionate with your patients).
One of life’s lessons that begins in the sandbox is to share. Sharing initially involves toys, such as the bucket and shovel, the toy train, or the mold that makes circus animals with damp sand. Later, sharing takes on broader applications, such as sharing the same space with others, to enjoy their company in close proximity. Still later, higher-order sharing takes place when children begin to show each other how to do things, how to make stuff, how to do something different. Lastly, sharing involves the giving of compassion to friends in the sandbox who get hurt, upset, or frustrated. It is the same in plastic surgery. We learn to share and use the same surgical instruments in the operating room. We learn quickly how to share the same small space together, standing foot to foot for hours on end in surgery, rubbing shoulders on rounds. In time, if we write about our experiences, we share with the plastic surgery community at large by publishing our results, in the hope that we can share beneficial information to help our colleagues improve their own procedures and practices. Doing this also helps provide better outcomes and safety for our patients. Most importantly, we begin to share our expertise and common humanity with our patients in our face-to-face encounters with them. The confidence, calm, and hope we confer to them are of utmost importance to our profession.

2. Put things back in their place/clean up your mess (do not leave a mess/live and operate carefully).
One of the songs many children learn early in life is the “Clean-Up Song”:
Clean up, clean up
Everybody, everywhere
Clean up, clean up
Everybody do your share
It is important to learn that toys need to be placed back where they belong when playtime is over. Picking up after yourself can be made into a game: who can pick up their things the fastest, or the neatest, or the most quietly? Although toys can be strewn across the sandbox while you are playing, at the end of the day things cannot be left in a mess. In time, children often begin to learn their own sense of order and play with things in a tidy fashion. One of the things my son learned when playing with his toy cars was to place them in neat, even rows, side by side. I did not have to teach him this; he just began doing it on his own. If I changed the order or moved a car, he would get upset! The same is the case with plastic surgery. We need to learn how to operate carefully and safely. We must learn and refine techniques that maximize our skills and optimize patient care and safety. We operate with care and conduct our operations and training in a neat and organized fashion, not letting the operative field become cluttered. Of all the surgical specialties, we make the most of completing our operations with meticulous and aesthetically pleasing closings and results. The intraoperative result needs to be the best it can be before you leave the operating room.

3. Say you are sorry if you make a mistake or if there is a problem with your patient or your family.
We all make mistakes. The sandbox makes an excellent training ground to learn how to apologize and ask for forgiveness. Any mistake in the sandbox, such as throwing sand, grabbing someone else’s toy, or having a fit, is easy to apologize for and forgive. Mistakes or offenses are quickly forgotten, but the skill of learning how to apologize becomes deeply ingrained in a person’s character. When we grow up and enter residency or our own practice, it is just as important to say “I’m sorry,” even if the stakes are higher and have more lasting consequences. Nevertheless, it is okay to say you are sorry.¹ Doing so shows your humanity and your character. Not doing so shows your arrogance or callousness. Being able to say you are sorry to your family is equally important.

4. Play fair.
Learning the value of playing fair starts in the sandbox and becomes increasingly more important as we mature. It is good to take turns with toys, to share, to play in a friendly way, and to find out that we are not the only person in the sandbox and that we need to treat others with honor and respect. If we learn these lessons early on, it makes applying them easier when we are adults. It is an old maxim but always bears repeating: Treat each other as you want to be treated, whether you are a patient or physician.

5. Wash your hands.
I sometimes marvel that anyone can survive to more than 4 or 5 years old, considering how many germs there are out there waiting to destroy us. It is simply remarkable what we are exposed to as children and adults. I shudder to think about my children rummaging around in the sandbox or in the flower beds, covered in grime and saturated in “nature.” Every time I came in from playing outside, my mom made me wash my hands. With soap. It is a simple practice in medicine and life, with wonderful, clear-cut benefits. It keeps you clean also when you see your patients and operate. If we would merely wash our hands between patient visits in the clinic, our nosocomial infection rate would plummet.^2,3

6. Take a nap every afternoon.
Children need naps outside of their regular sleep during the night. Study after study concludes that children need an abundance of sleep. I noticed with my children that their nap patterns began to change at around the age of 2 and then again at 4. Before the age of 2, they would take a mid-morning nap and a mid-afternoon nap, and still get 10 to 11 hours of sleep at night. At age 2, however, the mid-morning nap became hit or miss, but they would still regularly sleep in the mid-afternoon. After age 4, even the afternoon nap became less predictable.
Sleep is such a wonderful invention. It helps us to repair physically and sort things out mentally, and it calms us emotionally. In medical school and residency, I would take the occasional cat nap when I could. Even a 20-minute “power nap” would enable my system to “reboot,” as it were, and I would feel much better. To the degree possible, we should still try to take a midday nap, especially given the typically hectic and exhausting schedule of the plastic surgeon. Sufficient nightly sleep helps as well, although I must confess I rarely sleep more than 4 hours per night. Also, regular times of personal retreat and renewal are very important.

7. Hold hands when you cross the street.
It is interesting to see that children are willing to hold hands with each other; they are not nearly as self-conscious as adults. Children are not afraid to go together, play together, and learn together. In time, they become less dependent emotionally on their family and friends. However, as they gain independence incrementally, they need to develop the ability to cooperate and work with colleagues. We do not have to go it alone; in fact, we should not try to go alone. When I was a resident, it was always a good idea to double-check a challenging case with my chief. I learned more in hands-on groups in the laboratory and clinic than I did going it alone. As surgeons, we have to make difficult decisions on our own, but to the degree possible, try to get good advice before making major decisions, both in plastic surgery and in life. I enjoy and often take for granted the company of my partners as I seek advice on a difficult case. I receive weekly e-mails from colleagues, friends, and past residents who seek my advice on patient care. These e-mails show me that they are practicing safe, competent, and caring medicine.

8. Dare to wonder why.
I remember my children asking me not long ago, “Why, daddy?” Five hundred times a day. Children’s minds are sponges, and they possess a sense of wonder and interest in everything. Sometimes, I would watch my children remain absorbed for an hour at a time, fascinated by the intricacy of a flower or a toy. At other times, their concentration seemed woefully fragmented; they bounced around from one thing to the next, interested in all of them but too excited to sit still for more than a minute at a time. Children learn. They figure things out, and because everything is new, they never tire when confronted with something different. They often create meaning and piece information together in totally unexpected ways, contrary to “conventional wisdom.” For plastic surgeons, it is okay to think out of the box; in fact, it should be mandatory. That is the spirit of learning and doing new things. We need to relearn how to look at things and observe things carefully.⁴ We may find that, on careful study, something is not the way we thought it was. A new opportunity for growth and investigation begins with such a discovery. If we question what we do, we learn new things and do not repeat things that have no meaning or no rationale.

9. Have a balanced life.
Children have fun. They eat and sleep and play and learn; all of it is one big event to them. They do not really begin to compartmentalize their lives until they are much older. Because of this, having fun, learning, “doing” things, completing chores, and so forth are all just part of life. This sense of balance is one of the first things that gets jettisoned when you enter medical school and especially residency. Studies come first. Fun, relaxation, care of the body, relationships—these essential elements of a healthy, balanced life are often minimized. It is important to have fun and to have balance. Try to reprioritize your life to allocate time and energy to do the fun and important things again. Do it every day. This is the most difficult thing I have learned and am learning to do: balance life. It is a daily struggle for me, as my love for plastic surgery seems to overpower me.

10. Always read “Dick and Jane” books.
See Spot Run. Sally, Dick, and Jane were and still are real youngsters to many of us; they played amusing pranks, dressed up in father’s and mother’s clothes, played with their toys, visited grandmother and grandfather on the farm, romped with their pets, made fascinating discoveries during a spring walk in the woods, and did many of the other things that we healthy, wide-awake youngsters delighted in doing, and children today still love doing. More importantly, they taught us to read and they made us want more stories—furthering our interest in reading. The pictures were bright and colorful, the stories fun and familiar. At every turn, they encouraged children to learn how to see, listen, touch, and feel. Almost magically, these simple books taught me some truly remarkable, important life lessons. The same mindset and behaviors should constantly be practiced by plastic surgeons. We see, touch, listen, and feel. Profound mysteries often lie hidden under the surface of simple things.

11. Give back to plastic surgery and to your community.
Children are often self-absorbed, which is only natural. Life revolves around them; they are interested in their needs and wants. Certainly, they learn about the needs of others and develop the ability to put others’ needs above their own, but much of life is self-focused. Only later does a person develop a sense of community and a desire to give back to their community. Looking back on my life, I realize that I have been given so very much by my family, friends, community, and people I do not even know who went before me. Coming to understand this is humbling, and empowering. I desire to give back to those who helped me in my life. It is good to give back in terms of giving time, skill, and money. Doing so shows that your sandbox education is complete. I have learned and continue to learn important life lessons, and now my role is to help others learn as well, as I continue the journey of life in the sandbox.

You have to do your own growing no matter how tall your grandfather was.

—Abraham Lincoln