Rosenfield Editorial Beyond the Checkli

Over the past few years, I have certainly been a zealot when it comes to promoting the perioperative checklist. As with religion, once you “see the light,” all you want to do is bask in it and encourage others to do the same. Paradoxi- cally, this mission has been a labor of love. The majority of my colleagues, of every surgical persua- sion, have not adopted checklists as earnestly as I have delivered the message. Looking back, I have heard “everything”: from understandable hin- drances caused by institutional barriers, to apathetic excuses immunized by the sanctum of private prac- tice.

Perhaps the only way to become a believer is to create your own operative checklist, conduct your own “controlled” experiment, and experience your own revelation: seeing is truly believing. 1 Clearly, there can never be a level I study to otherwise prove this outcome. No one would allow for random logistical errors and chart their con- sequences. As I reflect on my own 15-year checklist experience, my team would be quick to point out the innumerable instances in which the checklist has prevented “near-miss” events: errors that I have called errors of omission.

Decidedly, my checklist has become part of a larger personal philosophy; a singular expression of an overarching goal: put simply, to get better. This should come as no surprise to plastic sur- geons. It is in our DNA to strive to get better, all the time. This is what simultaneously drives us, haunts us, inspires us and, together, pushes our field forward. Our everyday practices are simply honing stones on which our skills should be sharp- ened. The key word is “should,” because it is in- sidiously easy to establish a standard of care that is too comfortable. In fact, we have only ourselves to move the target a little farther away every time we rashly think we have reached it.

Otherwise, a practice ceases to be a true “practice” and instead evolves into a mill. To this end, the surgeon must embed multiple prophylactic modalities, beyond my original “op- erating room checklist. ” For this purpose I now propose a more encompassing mandate: a “prac- tice checklist. ” This checklist extends the narrow scope of procedural mandates to encompass the holistic elements of managing the entire patient experi- ence, from the design of the incision to the lon- gevity of the outcome. This broader effort goes beyond reducing errors of omission to include those of commission.

Notably, these errors should not only encompass the usual litany of “physical” complications. As aesthetic surgeons, we must be willing to consider our “aesthetic” complications as well. To this end, the following list of surgical cri- teria and goals fittingly reads like entries within the Guinness Book of World Records: •The extent of surgery: the least. •The length of incision: the shortest. •The character and location of scars: the best. •The incidence of complications: the lowest. •The duration of recovery: the fastest. •The longevity of the outcome: the longest. •The reproducibility of the case: the greatest.

•The quality of the aesthetic result: the highest. How does one begin to address all the items on this fortified checklist? I propose—to borrow a term from Silicon Valley—a set of “change agents” to inspire and facilitate the endeavor: 1. Mentors: The moment you walk away from residency, you leave behind the last genuine method of peer review: someone who is lit- erally looking over your shoulder. To fill this void in private practice, it is a powerful asset to harbor a mentor in your practice: a col- league, a former teacher, a partner. I call my own mentor my “secret weapon. ”

The albeit From the University of California, San Francisco. Received for publication March 12, 2012; accepted April 23, 2012. Copyright ©2012 by the American Society of Plastic Surgeons DOI: 10. 1097/PRS. 0B013E318262F4B5 Disclosure: The author has no financial interest to declare in relation to the content of this Editorial. www. PRSJournal. com 969 honorable push to bring science to aesthetic surgery has inadvertently relegated the “ex- pert” to the bottom floor of the evidence pyramid. To whit, Niels Bohr elucidates this best: “An expert is a person who has made all the mistakes that can be made in a very narrow field.

” Does that not describe the untapped resource of our own plastic surgi- cal mentors? I would take the advice of my mentor over a published article any day. 2. Colleagues: “Exposing” yourself before your colleagues by way of presentation or publi- cation, as uncomfortable as it may be, nec- essarily fosters innovation. Both intellectual honesty and collegial feedback are the true catalysts to getting “better. ” Otherwise the term “evidence-based research” will risk be- coming just a slogan. 3. Residents: Equally so, engaging in the teach- ing of fresh minds can be a painless change agent to remaining fresh oneself.

Residents have the uncanny ability to get to the es- sence of what you know and, most valuably, what you do not. However, one must be open to receiving these, albeit unpolished, pearls of wisdom. 4. Patients: Perhaps the most unsung change agent is the patient. However, to benefit from this source, the surgeon must leave his or her ego by the examination door. That is, we must be willing to actively listen and learn from our patients. As the preeminent physi- cian Sir William Osler once admonished: “When all else fails, listen to the patient! ” I can ascribe many of my best “aha” moments in practice to doing just that. 5.

Surgeon: The full potential of the aforemen- tioned change agents are dependent on the ultimate power source: the surgeon. The ability to examine oneself honestly, criti- cally, and consistently is the essential stimu- lus. The most fruitful nutrient to feed such introspection is one’s own complications. The path to checking off the various items on the above-noted practice checklist is paved with these critical pauses between oper- ations. It is at these junctures that the sur- geon can analyze these less-than-perfect re- sults and tweak the surgical planning, techniques, and postoperative care. 6. Coaches: Both sports figures and concert musicians covet them.

Why not surgeons? After all, in training, we used to have pro- gram directors, attendings, and even chief residents watching over us. As I opined above, should we not be forever “in train- ing”? Atul Gawande, the surgeon-author, has recently proved the refreshing value of rein- stalling someone to “look over one’s shoul- der” while operating: a second pair of eyes and ears to observe, to judge, and to guide. Thus, I challenge all of us to sublimate any reflexive queasiness about such a notion.

Instead, let us inspire and harness the brain trust of our retired leaders to become per-haps the greatest untapped change agent of all: coaches. The greater goal is to challenge oneself to go beyond the checklisted pause: to embed change agents within one’s practice, which will act as pauses between operations. Only then can one en- sure a truly consistent personal mandate to get better: the practice checklist.

REFERENCE 1. Rosenfield LK, Chang DS. The error of omission: A simple checklist approach for improving operating room safety. Plast Reconstr Surg. 2009;123:399–402. Lorne Rosenfield, M. D. 1750 El Camino Real, Suite 405 Burlingame, Calif. 94010 DrR@DrRosenfield. com Plastic and Reconstructive Surgery •October 2012.

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