As surgeons, we have journeyed through undergraduate education, medical school, residency, and/or fellowships and have had a great deal of success in order to become who we are and what we do today. We strive for success and attempt to minimize failures. On a larger scale, society has taught us that failure is negative, to be mitigated and that we should work hard to avoid it. Even in our letter grading system which we are exposed to at an early age, F is the only letter that corresponds to the first letter of what it stands for—“Failure.” Avoidance and prevention of getting a F, becomes ingrained in us and the negative connotation develops that failure is bad.
Over my 25 year career, I have participated in many case conferences at multiple institutions. These conferences have been filled with presentations of extraordinary successes rather than presentations of failures (except when we are forced to do so, as in Mortality and Morbidity conference). As surgeons, we love to show our great successes and often minimize, hide or strategically forget our failures. We love commenting, most often to the person sitting next to us, on what the presenting surgeon missed or could have done better. We all do it to some degree with some being much more vocal than others. The bias toward successful outcome presentations is rampant in our conferences and literature. In fact, a vast majority of medical journal publications focus on successful outcomes of surgeries rather than descriptions of failed outcomes. It has been estimated that in 2007, 85.9% of medical journal publications were on positive outcomes across most medical disciplines and countries.1
What is the role of failure if we ignore, hide or de-emphasis it? As surgeons we all have complications or have had surgeries go awry resulting in a failed. As a young attending, I was keen on publishing our results of a pedicled vascularized bone graft for scaphoid nonunion. The early data was overwhelmingly positive and successful2 and I was certain that our larger series would echo the same outcomes. Much to my dismay, after evaluating the data, our results were worse than our prior publications.3 The initial urge to scrap the project was overwhelming. Guidance from key mentors, told me that failure is just as important as success, especially if you can make positive lasting changes from failure. After critical evaluation of the data and the characteristics of the failed pedicled vascularize bone grafts, we were humbled to learn that a large structural vascularized bone graft was needed to correct the scaphoid deformity and address avascular necrosis which could not be provided by the pedicled vascularized bone graft. The ultimate result of our failures was an innovation of the use of a structural medial femoral condyle vascularized bone graft for scaphoid nonunions associated with avascular necrosis and carpal collapse.4 Success through failure.
It is how we accept and deal with surgical failures, and in particular how we analyze our own failures that enable positive change. A paradigm shift is needed: failure is a powerful tool that affords opportunity to hone and improve our outcomes and patients wellbeing. Learning from failure is a much more powerful and lasting lesson than gained from constant success. It allows for insight, innovation, and creativity. While failures are discouraging and painful for both the surgeon and patient, positive application of failure can unlock great potential. Success is good, but “Success through Failure” is awesome, inspirational and evolutionary.
1. Mlinarić A, Horvat M, Šupak Smolčić V. Dealing with the positive publication bias: why you should really publish your negative results. Biochem Med (Zagreb). 2017;27:447–452.
2. Steinmann SP, Bishop AT, Berger RA. Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg Am. 2002;27:391–401.
3. Chang MA, Bishop AT, Moran SL, et al. The outcomes and complications of 1,2-intercompartmental supraretinacular artery pedicled vascularized bone grafting of scaphoid nonunions. J Hand Surg Am. 2006;31:387–396.
4. Jones DB Jr, Bürger H, Bishop AT, et al. Treatment of scaphoid waist nonunions with an avascular proximal pole and carpal collapse. A comparison of two vascularized bone grafts. J Bone Joint Surg Am. 2008;90:2616–2625.