The Four P's that Make a Microsurgeon: Perfectionist, Pragmatist, Persistent, and Paranoid

Old microsurgeons think only about the past because they have no future, the young ones think only about the future because they have no past; but the best use the present by relying on the past to make the future—unknown

Once upon a time a struggling young plastic surgeon would be advised that the successful development of a private practice depended on “ability, affability, and availability”—not necessarily in that order. Expressing some frustration with this reality, long ago I somewhat condescendingly added “appearance” as the fourth “A.”[1] This seemed to be of paramount importance then, since the proper attire, fast cars, that big house in the right neighborhood, an enticing medical spa, and splashy billboards all were condoned as necessary evils designed to attract prospective clientele. Just add social media and a flashy Web site, and this perception may still be true today, with “ability” still being pushed aside for the sake instead of economic security.

Yet another pathway more risky—with compromise unacceptable and antagonism inevitable—could then and now still be taken. Reconstructive microsurgery can be that treacherous road where seemingly insolvable challenges are routinely encountered, innovation need be a constant companion, and the thrill of success becomes an aphrodisiac. Its reward is often personal satisfaction, but always knowing that the quality of life for so many, or even life itself, is only better—thereby fulfilling to the n^th degree what traditionally has been the purpose of our calling.

For the elder microsurgeon, as I have become, a reflection back in time can now safely be observed to see how all this transpired, to perhaps vicariously help others understand what traits, whether innate or learned, need to be mastered. For fear of being too simplistic, these essential attributes without a doubt must include unmitigated perfectionism, pragmatism, persistence, and a little touch of paranoia. Remembering the four “A's” intended to guide the young plastic surgeon,[1] a plausible pneumonic for the budding microsurgeon would make these the unavoidable four “P's,” again not necessarily in any order.

Per•fec•tion•ist: (pẽr-fek′shə-ist) n. a person who strives for perfection, or extreme degree of excellence according to a given standard. [2]

I was often admonished as a resident that “perfection is the enemy of good,” as sometimes—perhaps more often than not—striving for better than good can result in a bad outcome if not executed properly. But isn't perfection also the enemy of bad?

Perhaps the “lure of perfection” is what separates our specialty from all others, as we always strive to seek a better solution.[3] Is it not true that all will be naught if but for one misplaced microsuture? Indeed, as Goldwyn has attributed to Michelangelo, “trivials make perfection, but perfection is not trivial[4].”

Prag•ma•tist: (prag′mə-tiz′t), n. a practical person. [2]

A pragmatist always shows good judgment. Good judgment is based on our life experiences, which may be a result of bad judgment. All surgeons by their nature abhor impracticality and its corollary, the waste of precious time and energy. Deep down, we usually realize that the best long-term exercise from the outset may be to chose a free flap, regardless of complexity.[5] Nevertheless, a futile exercise should be abandoned before being commenced. A failing exercise should be discarded before the patient's welfare is irretrievably harmed. As Vasconez also points out, not every replant can be saved.[5] Nor every tissue transfer salvaged after a microanastomotic catastrophe. Maturity brings an understanding of our limitations, and a realization that we are no more than human beings.

Per•sis•tent: (pẽr-sis′tənt), adj. refusing to relent, continuing to endure, persevering. [2]

Like the loneliness of the long-distance runner, perseverance along the seemingly endless trail to success in microsurgery may often be without support of other believers, be they peers, the hospital administration, or insurance carriers. Long-term delayed gratification must be accepted to be a prerequisite, as skills are honed, knowledge accrued, and judgment acquired.[6] Nothing of consequence when executed even properly adheres to any game plan perfectly; complications are inevitable, especially in microsurgery, where they seem to be inversely proportional to the degree of magnification. How problems are solved as they are encountered, and the flexibility to accomplish this adroitly, separates the neophyte from the master—the latter who will use every skill available in seeking their resolution.

Par•a•noid: (par′ə-noid′), adj. a mental disorder characterized by systematized delusions, as of grandeur, or, especially, of persecution. [2]

Paranoia, I have been told, is an essential character trait to allow the satisfactory completion of any residency program. It probably is also a useful survival mechanism to be retained for the rest of one's career.[7] After all, anything less than perfection has to be our fault and will always raise the omnipresent issue of liability for which no one else could be culpable. Vasconez's Fourth law[5] accurately summarizes this dictum: “it always happens to me.” “It” must always be interpreted to be an untoward event. Is there any other? Our universal insecurity may or may not be a personality disorder, as do we not constantly challenge our results (and that of others), at least with our rationale being that we empirically seek how to do it better the next time? As Pogo said, “we have met the enemy, and they is us.”[8]

So just what makes microsurgeons a little different? Outsiders might agree that paranoia is rampant. Aren't “they” always out to get us? But doesn't paranoia in part drive our absolute need for perfection in an imperfect world? And persistence create our capability to achieve that perfection in spite of otherwise insurmountable odds? Yet eventually do we not learn to be pragmatic enough to know when perfection is unobtainable or even a futile goal? Is it just a coincidence that these four “P's” are so interwoven, inseparable, and immutable? It can be no accident that these traits so well recapitulate the epitome of a microsurgeon. How we maintain these characteristics in a state of equilibrium in a sea of turmoil separates those successful at this calling from those who will never be. Our differences and yet our similarities with our other colleagues, whether they be aesthetic or reconstructive, have made our past bright, and so too will be our future.

Notes

Presented at the 16th World Congress of the International Confederation for Plastic, Reconstructive, and Aesthetic Surgery, Vancouver, Canada, May 25, 2011.

• References

• 1 Hallock GG. The ascent of the plastic surgeon. Plast Reconstr Surg 1986; 78: 541
• 2 Webster's New World Dictionary of the American Language. Cleveland, New York: The World Publishing Company; 1960
• 3 Masters LW. The lure of perfection. Plast Reconstr Surg 1981; 67: 511-513
• 4 Goldwyn RM. Are you an insider or an outsider?. Plast Reconstr Surg 1990; 86: 1176-1177
• 5 Vasconez L. 2005 Jurkiewicz Lecture. Ann Plast Surg 2006; 56: 1-8
• 6 Rohrich RJ. The carrot or the carrot seed?. Plast Reconstr Surg 2004; 113: 1787-1788
• 7 Goldwyn RM. What everyone should have. Plast Reconstr Surg 1997; 99: 1408-1409
• 8 Kelly W. Pogo: We Have Met the Enemy and He Is Us. Delran: Simon and Schuster; 1972