Excellence in Medicine through Rescue from Failure- Gawande

Below you will find excerpts from a commencement address given by Gawande re: excellence in medicine, from a perspective I had never heard before. 

"... the best surgeons I saw involved the ability to handle complexity and uncertainty. They had developed judgment, mastery of teamwork, and willingness to accept responsibility for the consequences of their choices.  

...I thought that the best places simply did a better job at controlling and minimizing risks—that they did a better job of preventing things from going wrong. But, to my surprise, they didn’t. Their complication rates after surgery were almost the same as others. Instead, what they proved to be really great at was rescuing people when they had a complication, preventing failures from becoming a catastrophe. 

....When things go wrong, there seem to be three main pitfalls to avoid, three ways to fail to rescue. You could choose a wrong plan, an inadequate plan, or no plan at all.  

...But recognizing that your expectations are proving wrong—accepting that you need a new plan—is commonly the hardest thing to do. We have this problem called confidence. To take a risk, you must have confidence in yourself. In surgery, you learn early how essential that is. You are imperfect. Your knowledge is never complete. The science is never certain. Your skills are never infallible. Yet you must act. You cannot let yourself become paralyzed by fear.  

Yet you cannot blind yourself to failure, either. Indeed, you must prepare for it. For, strangely enough, only then is success possible.  

...[The attending surgeon had] never seen a serious belly problem [after carotid artery surgery]. But the surgeon was humble enough to understand that he could.  

...So you will take risks, and you will have failures. But it’s what happens afterward that is defining. A failure often does not have to be a failure at all. However, you have to be ready for it—will you admit when things go wrong? Will you take steps to set them right?—because the difference between triumph and defeat, you’ll find, isn’t about willingness to take risks. It’s about mastery of rescue."

Choose a high risk clinical scenario and describe No plan, Inadequate plan, and Wrong plan scenarios. Then describe the Right plan. Try this exercise regularly and your patients and your hospital will benefit greatly from your preparedness. 

This connects to point #9 from our post on Clinical Reasoning - Progressive Problem Solving. Review that post to reinforce principles in Clinical Excellence. 

put in an example high risk case and connect to EN