Continuous performance improvement | Marta Crispens, MD
The patient described here is fictitious, but is based on situations that we have all experienced.
Mrs. Smith is a delightful, 48-year old woman with stage IIIc high grade serous carcinoma of the ovary. She undergoes an optimal cytoreductive surgery, including modified posterior pelvic exenteration with low colon anastomosis. She is slender and healthy. The surgery goes well, except for some challenges with the colon anastomosis. In the end, it is airtight, and all seems well. She is discharged from the hospital quickly, but returns within 24 hours with a pelvic abscess due to a leak from her anastomosis.
Five months, multiple attempts at percutaneous drainage, weeks of antibiotics, a 13-hour operation, and an enterocuteous fistula later, she is discharged home again on TPN. It has reached the point that you dread going to her room, because you know that you will only have more bad news for her. Every time you see him, the husband fixes you with an angry stare. What we do is hard. It can eat your soul. You can tell yourself, “I did not give her the bad cancer,” as you turn and walk away, but it isn’t a satisfactory answer.
Peyton Manning, who played in the NFL for 18 seasons with the Indianapolis Colts and the Denver Broncos, is considered one of the greatest quarterbacks of all time. He holds the NFL record for passing yards, touchdown passes, career wins, AP MVP awards, and Pro Bowl appearances. He led his teams to two Super Bowl wins. Yet, Peyton Manning threw interceptions and lost games. How was he able to come back game after game and continue to play at such a high level, despite bad throws and bad games?
In sports psychology, it is recognized that fear of failure leads to poor performance. Successful athletes know that they will fail. They use their failures to identify their weaknesses and improve their performance. Peyton Manning was well known for his intense game preparation. He would spend hours watching game films, critiquing his own performance. He would then spend more hours out on the field, practicing with his teammates until they had the plays right. And then the next game, he would start the process over again—continuous performance improvement.
We are all going to have bad outcomes, but we cannot be consumed by them. Bad outcomes are not a judgment on us as people or as doctors. Self-abuse only interferes with your motivation and future performance. After the fact, we need to make an honest, dispassionate analysis of the situation. What can we do better the next time?
So you go back into that room, every day. And you tell the patient and her husband the truth, even though it is painful to them and to you. Then, you and your team non-judgmentally analyze the situation—what did we do right? What could we have done better? And every day, you are a better doctor for her and every other patient you care for. You identify your weaknesses and fix them, honing your skills day by day.
“True victory is victory over oneself.”
Morihei Ueshiba, O’Sensei
The Founder of Aikido
Marta Ann Crispens, MD, FACOG, is an Associate Professor and Director, Division of Gynecologic Oncology, in the Department of Ob/Gyn and Chair of the Vanderbilt-Ingram Cancer Center Scientific Review Committee at Vanderbilt University Medical Center in Nashville, TN.