S03E41 LEARNING FROM MY MISTAKES EXAMPLE 01
"A person who makes few mistakes makes little progress." - Bryant McGill. Well, I have certainly made a LOT of progress then. I hope to talk on this podcast about some of the more interesting mistakes I have made. Here's my first example of a mistake during a breast augmentation procedure.
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03E41 LEARNING FROM MY MISTAKES EXAMPLE 01
[00:00:00]
Sam Rhee: This podcast is an example of learning from my mistakes as a surgeon. It is also a remembrance of some of my mentors with whom I trained.
Mistakes happen in surgery. Surgeons are human beings. We obviously try to avoid mistakes, but there's not one surgeon in the world who has not committed errors, both major and minor.
Here is one mistake that I made as a fourth year medical student that has carried with me ever since in my surgical career.
Early as a fourth year medical student, I traveled to Atlanta for a month to do a sub internship in plastic surgery at Emory University. I was applying to plastic surgery training programs, and while Emory did not have a program where you could enter plastic surgery directly from medical school, they are among the, if not the top plastic surgery training program in the country and probably world.
Emory's Chairman of Plastic Surgery, Dr. John Bostwick was one of the preeminent breast reconstruction surgeons at the time. He pioneered the use of [00:01:00] the latissimus flap as well as immediate reconstruction after the treatment of breast cancer.
In addition, Dr. Boswick authored a historic book at the time, Aesthetic and Reconstructive Breast Surgery, and I was hoping if I did a great job, he might write me a letter of recommendation, which would help me apply to plastic surgery training programs.
Other Emory faculty members included Dr. Foad Nahai, one of the pioneers in the development of the musculocutaneous flap, who is one of the co-authors of the definitive textbook, Clinical Atlas of Muscle and Musculocutaneous Flaps. That was one expensive book, but me and all my other fellow residents bought it.
Dr. Grant Carlson, who was one of the few surgeons board certified in both plastic surgery and surgical oncology, was one of the only surgeons in the world well qualified to do both the breast cancer treatment as well as the breast reconstruction.
The Emory plastic surgery residents who were training in plastic surgery had all already completed full general surgery residencies.
And while new to plastic surgery, [00:02:00] they were experienced and seasoned surgeons to whom I looked up and admired.
It was truly an amazing month, and I watched and assisted the residents and surgeons who all worked harder than I thought possible. The residents, each would have an operating room and the senior surgeons would move from room to room, supervising each case. And sometimes scrubbing in a lot, and sometimes very little depending on the case's complexity.
Complex breast reconstruction cases required multiple hands on deck, while smaller cases were often completed with just a resident and sometimes a physician assistant, or sometimes just me, a medical student.
One day, Dr. Bostwick had a cosmetic surgery case, a breast augmentation. I had never assisted or even seen a breast augmentation case before. Cosmetic surgery was not a large part of my experience at my home medical school, so I chose that case and I was excited to watch and maybe even assist.
I watched in a corner while the case started, with a patient being smoothly placed under anesthesia. Incisions were made and the chest pockets where the implants were being placed were [00:03:00] created. The breast implants, which were saline in this case, were then inserted and filled. It's one of the more instantaneous changes you can see in plastic surgery where the breasts go from relatively flat to suddenly full and round.
I watched with amazement the first time, and trust me, you would too. It's still a dramatic transformation to see every time.
Dr. Bostwick had stepped in and helped with the pocket section, making sure the implants were in the correct position, then stepped out to the next operating room where another case was going on. I was left with a resident to close the small incisions, which were about an inch and a half long under the breast.
As medical students, there weren't many opportunities to suture, so this was really exciting that they let me scrub and help close.
As I was suturing the incision, I passed the needle back and forth through the tissue, and I'm not sure why I was passing the needle as deep as I did. You were only supposed to suture relatively superficially to close the skin and a little bit of the tissue underneath, but I remember taking a slightly bigger pass with [00:04:00] the needle once or twice, thinking I had to make sure the incision was tightly closed.
I was almost done with closing the incision when I saw a tiny amount of water welling up. I hesitated, not being sure what it was. Maybe it was the antibiotic irrigation fluid from rinsing the implant before we closed, or did I pass the needle too deep? I watched it for about 10 seconds and saw a tiny amount continue to ooze.
I had to tell the resident who was busy on the other side. He walked over to my side, watched a little bit, then called the physician assistant from the other room to come in. They weren't sure either if it was irrigation fluid or something much worse. Finally, the PA pressed on the breast after a minute and saw the water spurt out more briskly.
I wanted to die right then and there. We had to reopen the incision and Dr. Bostwick was called to come back into the room. Sure enough, I had punctured the implant. You could see two little needle holes where I went in and out. The resident later joked with me saying, man, you [00:05:00] really wanted to make sure you got that implant, didn't you?
Dr. Boswick came into the room, stood there, looked a little puzzled, then asked the OR staff for another implant. The resident and physician assistant removed the leaking implant and placed and filled the new implant. Dr. Boswick said nothing after that except asking the OR staff, "See if the company will cover the replacement implant."
Then he left the room. The resident closed the incision, and we were done. My awful mistake extended the case by about 30 minutes, but it felt like an eternity. I was physically and mentally wringing my hands, and I was sure I had blown my chance to get a letter of recommendation from Dr. Bostwick or anyone else at Emory.
The resident was trying to reassure me that, of course, it was a simple mistake, but I had seen others get chewed out much worse for much smaller mistakes in the OR. I felt like my plastic surgery career was finished before I'd even started. Maybe vascular surgery wasn't looking so bad as a specialty.
After the case, I ran [00:06:00] around and finally found Dr. Bostwick and apologized profusely. He was a tall, gentle, soft spoken man from a small town in Georgia named after his family. He was unlike so many of the surgeons I have ever met. I don't even remember what I said or what he said.
It was such a blur, but I know he smiled and tried to reassure me that it was okay. I do remember feeling a little bit better after that, although for sure up until that point it was one of the worst days of my life.
At the end of the month, I did ask for and get a letter of recommendation from Dr. Bostwick. He told me he would write me a strong letter and I trusted him to do so. I remember we talked and he told me, while Emory did not have a formal plastic surgery training program directly from medical school, there were a few residents who entered the Emory General Surgery Program, and after three years of training instead of the full five, they would admit them to the plastic surgery program early. He mentioned a superstar resident named Joseph Williams who did that and was about to enter the [00:07:00] Emory Plastic Surgery Program.
In retrospect, I think maybe Dr. Bostwick was obliquely offering me something like that. And because I wasn't socially aware and because I didn't think he would really consider a bonehead like me, I did not think he was serious. So instead, I replied with something about possibly looking to stay at my home institution, which had a guaranteed direct entry into plastic surgery from medical school.
I think he said he understood and he told me to wish Dr. Chiu well, who was the plastic surgery chairman at my medical school at the time.
I ended up matching at my home school for plastic surgery, and I have no doubt that Dr. Bostwick's letter of recommendation helped me tremendously.
I wonder if I had gone out on a limb and if I had told Dr. Boswick that I really loved Emory, which I did, and I was willing to take that chance and fully commit to their program, even though they didn't have a guaranteed spot in their program, what would his response have been?
It's possible he was testing me and that I would've been in his program.
I wish I had the chance [00:08:00] to ask him, but I will never know. Five years after that, Dr. Boswick died suddenly at the age of 57.
We were all told that it was a suicide, although I do not know any details. It was a tremendous shock to everyone who knew him as well as the entire plastic surgery community.
For someone who appeared triumphant in life, chairman of the best plastic surgery program in the country, well liked, respected, and admired by all. Someone who started in a small town, population 300 and rose to become a wealthy and successful plastic surgeon in one of the biggest cities in the United States.
It didn't, it didn't seem to make any sense to anyone.
It is very sobering and thinking of Dr. Bostwick is one reason why I ask myself every day, am I happy? Am I fulfilled by what I am doing? What is the definition of success? Every time I do a breast augmentation case, I think of Dr. Bostwick. I think of the shame and embarrassment I felt when I punctured that implant.
I think of [00:09:00] his kindness. I think of what I have learned and what I am still learning in many ways for my mistake. Thank you.
