Learning something new is an important part of life (and a fun one I might add). We spend so much of our time focused on certain aspects of our learning, but I often wonder if we’re focused on the wrong aspects. For example, take a look at a recent success of your own. Maybe you sculpted a new statue or created a new culinary dish. Perhaps you’re a clinician and obtained a good outcome for your patient. It feels great to have a success.

But do we really learn from our successes? I’ll posit to you that, as difficult as it is, we actually learn more from our failures than successes.

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“We actually learn more from our failures than successes”

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Here’s one example. Each week during our resident academics, my residents and I review their surgical cases from the week. They show the pre- and postoperative radiographs, relate some of the patient history, and we discuss the particulars of the procedures: how they were done, how did it go, what was successful and what wasn’t.

Typically, in the case where the procedure was completed flawlessly with an excellent result, we sit there looking at the image with nothing to say!

“Looks good”, one of the residents might say.

“Yup. Looks good,” I might add.

The resident who did the case will beam happily for a moment, proud of his or her work (and rightly so). What do you think happens next? You guessed it.

Nothing.

There’s very little to discuss, and the learning stops there (in fact, it never started). We move on to the next case.

This is very different from the case where something didn’t go according to plan or the result wasn’t 100% optimal. In these situations, there’s so much to discuss, and the residents’ (and my) learning are accelerated. We might discuss what went wrong and why, how that error could have been avoided, and what could be done next time to improve the outcome. This is where the learning occurs.

Ray Kroc, of McDonald’s fame, used to say, “If you’re green you’re growing. If you’re ripe you rot.” Oddly, this is one of the strongest memories from my youth as a McDonald’s worker. Yes, I worked there for eight years while going to high school and college. In order to learn, we must live within that green zone.

Oftentimes, during these surgical discussions, I’ll take the devil’s advocate position and ask, “So what could have been done differently or better?” I’ll sometimes ask this even in the cases where everything went well. Many times, I’ll receive a blank stare from the residents, which shows me they hadn’t considered that anything could have been done better.

This, fair reader, is where all of us go wrong. We focus on the wrong aspect of our experiences.

Take the medical literature as another example. It is well known that there is a publication bias rampant throughout published literature. This bias is created when the outcome of a study influences a journal’s decision whether or not to publish the study. This bias most often falls toward the side of the positive study (the one with “significant” results). Studies with no or poor results are often relegated to unpublished status or the grey literature (documents produced outside of the normal publication routes).

In the foot and ankle literature, it’s almost comically funny to note the number of studies that report positive or successful results. It’s so common that I can predict before reading an article that a particular procedure will be considered successful by the authors.

Here’s a quick example of one. In the most recent Journal of Foot and Ankle Surgery, the 3^rd study listed on their web page is by Prissel and colleagues¹ reporting on the outcomes of direct plantar approach to plantar plate repairs. I’m reading the article as I write this editorial. As of the moment of accessing the article, I hadn’t read it yet (you’ll have to trust me on this), and I assumed the result reported on this surgical procedure would be positive. Here are the reported results:

The authors conclude, “Our modified Foot Function Index results demonstrated that this approach provides excellent postoperative pain relief, improvement of associated disability, and improvement in activity limitations”¹.

Now, I don’t dispute or criticize the study itself (this isn’t a journal club where we pick apart studies for methodological problems). I actually find this to be a potentially useful study that may provide assistance for those of us figuring out the best approach to plantar plate issues. However, this does bring up a couple of interesting points.

First, what are the chances that this study would have been published if the results were a failure rate of 87.1% instead of a success rate of 87.1%? Likely a lot lower. The literature, especially that discussing procedures, is replete with this type of result.

But more important, there’s a more significant number that gets to the point of our conversation today: 12.9%. That’s the number of poorly aligned toes after the surgery. For that matter, the 7.6% recurrence and 2.8% revision rate are also important. These numbers imply that there’s something we don’t know about this surgical procedure. Here is the opportunity for improvement.

If 12.9% of patients had a poorly aligned toe, that means there’s something incomplete about the procedure. There must be a better way to do some aspect of it. Perhaps there’s another reason for the failures? Maybe the initial recovery needs to be conducted differently? Maybe certain splinting methods would help? Perhaps there’s some deficiency in the procedure execution.

I’m looking here into the rhetorical dark corner, under the rug so to speak. This is where medical science has an opportunity to step forward. The history of science is full of individuals who looked at what came before them, saw a deficiency of some type, and asked the right question. If Einstein thought Newton had all the answers, we wouldn’t have general or special relativity. If our other great physicists thought Einstein had it completely right, then we wouldn’t have quantum mechanics and the standard model of particle physics (much less TV, radio, phones, and a host of other technologies).

Successful athletes and business people have this in common. They focus little time on the parts they do well and spend much more time on their deficiencies. This is the way students are taught to study: track the info you know and quiz yourself on what you don’t know.

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“Successful athletes and business people have this in common. They focus little time on the parts they do well and spend much more time on their deficiencies.”

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In fact, it’s well known in educational circles that passive study techniques, such as passively reading, leads to an unrealistic and false sense of the amount of knowledge one has. The reason testing is so successful as a study method is because it provides us a realistic view of what we know and what we don’t know. Focusing on the “don’t knows” then allows us to move forward.

Similarly, each of us should focus on our failures and areas of ignorance rather than what we did successfully. Maintaining what we do well and focusing our attention on what can be done better is the key to truly advancing our individual and collective knowledge. For medicine in general, I suggest the creation of a new journal called The Journal of Failures (or something a little more positive perhaps) where the emphasis is not on the successful procedure but rather the failures. For the rest of us, we should remain cognizant of the importance of our successes and embrace our failures for what they are: our best opportunity to grow.