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"Perfect is the enemy of the good"


Sometimes, this doctor learned, doing everything for your patient may not serve him well.


The Way I See It

"Perfect is the enemy of good"

Sometimes, this doctor learned, doing everything for your patient may not serve him well.

By Fernando Ugarte, MD
General Surgeon/Marysville, KS

We physicians like to feel that we can be invincible. Accepting shortcomings is not the way we've been trained. We feel we must solve every problem, avoid every complication, and save every life—and that anything short of such outcomes reveals a defect in ourselves that we simply cannot accept.

To counter that notion, my chief at the University of Chicago School of Medicine, George Block, declared to us that "Perfect is the enemy of good." At the time, I could not understand why a superb, skillful master surgeon would use that phrase. Only after many years of practice have I begun to appreciate what he meant. A recent case brought home the truth of his message.

A gentleman who had been shot in the abdomen by a fellow hunter was brought to our emergency room. Within minutes he was in profound hemorrhagic shock, his abdomen distended with blood and carrying at least 300 pellet fragments. I advised an immediate laparotomy.

The patient was from out of town. We couldn't locate his wife, but luckily we reached a brother-in-law. I explained that unless we explored this patient immediately, he was likely to die. The brother-in-law, who was a police officer, understood the seriousness of gunshot wounds and agreed that we should proceed. I documented in my notes that I was operating in grave circumstances without a proper consent to do what I felt was a life-saving procedure.

The laparotomy was a challenge: to stop hemorrhaging from major vessels and close multiple holes in several abdominal viscera. I had to do a diverting colostomy and a Rouxen-Y diversion of the patient's biliary system. The hemorrhage finally stopped, and his vital signs stabilized.

In the back of my mind, however, was the nagging thought that I hadn't solved all of this patient's problems. There was a possible pancreatic injury that I could not deal with because of other massive injuries. I realized that he might have to be re-explored later.

The patient was then transferred to a big-city trauma center by helicopter. I called the surgeons there and gave a full report of the case. I never heard back, although I called their hospital and offices several times. Had I not done enough? Had I done something wrong? I did keep in touch with the nurses, and learned that the patient required a couple of reoperations but eventually went home.

In the following months, I kept thinking that if I had done the perfect operation, this patient would not have needed further surgery. This thought kept haunting me until a year and a half later, when I received a nice card from the patient's wife. She thanked me for saving her husband's life and was glad that I had cared for him. His colostomy was going to be closed, and he would soon be attending a daughter's wedding.

I felt a great relief and finally realized that I had done the good and necessary operation. All along I should have realized that trying to do the perfect job—prolonging the operating time, and exposing the intra-abdominal organs to further trauma—would not have saved this patient's life and could in fact have been dangerous. I also came to accept that in the rural hospital where I practice, it was necessary to leave additional care of the patient to others and that the lack of reply from the surgeons did not mean that I hadn't done a good job.

The letter from the patient's wife enabled me to be grateful for my abilities and proud of myself. While we may fail on occasion, if we do our best and accept our professional shortcomings we can be good physicians. But we do not have to be perfect.



Fernando Ugarte. "Perfect is the enemy of the good". Medical Economics 2001;2:99.

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