s a pediatric surgeon who operates on sick children, I’m hardly one to forswear risk taking and innovation. But as I prepared to lead an FDA-approved study on a new surgery to treat sleep apnea in children with Down syndrome, I found myself wondering if our disruption-intoxicated culture places too much emphasis on innovation and not enough on the less glamorous preparatory work that must be undertaken to innovate responsibly.
Some people shrink from risk taking, which can limit their potential. Others make the opposite mistake: They jump headlong into risk without carefully thinking it through. So-called biohackers inject themselves with untested gene therapies. Thrill-seekers on YouTube sneak into construction sites and climb the steel skeletons of tall buildings apparently without having undertaken planning or practice runs.
Collectively, we rush to embrace new technologies that transform vital areas of our lives (think social media) without making much effort to study their potential effects. The general ethic seems to be “Try it now, and if unanticipated problems occur, pick up the pieces later.”
In his 2011 book “Thinking, Fast and Slow,” psychologist Daniel Kahneman distinguished between the gut feeling that impels you to leap into novelty and risk taking and the less glamorous process of reflection, preparation, and practice. The first he calls “thinking fast,” the second “thinking slow.” Our culture of innovation today is all about thinking fast. I think we sometimes need to take a deep breath and inhale a big dose of “slow.”
The failure to think slow can have devastating results. Here’s an example from my field of pediatric airway surgery. In 2011, Dr. Paolo Macchiarini, an Italian surgeon, reported confidently on the world’s first transplant of a synthetic trachea, performed at Sweden’s famed Karolinska University Hospital. Over a five-year period, Macchiarini went on to implant the synthetic trachea in nine desperately ill patients. Seven died, and the other two had to have the artificial tracheas replaced by conventional transplants. The cause of this disaster: an impetuous rush to innovate.
According to a BBC report, an independent commission “found that the scientific foundation for the new operation was weak, and condemned the failure to carry out risk analyses before the patients received their operations.”
Children with Down syndrome often have sleep apnea that is so severe that these nighttime interruptions in breathing can strain their already weakened hearts; cause severe mood swings, anger management issues, and attention issues at school and at home; and lower IQ and cognitive ability. When I first got the idea of stopping sleep apnea by cutting open a child’s neck and attaching a pacemaker directly to the nerve that controls the tongue, I was keenly aware of the good the surgery might do. I was also aware of the great risks, so I slowed myself down.
I researched the surgery, contacted several of the “fast” thinkers who had had come up with the idea, and asked for their advice. I went into the anatomy lab and practiced portions of the painstaking surgery on cadavers again and again and again. During one session, my hand slipped just a few millimeters and I was horrified to see my scalpel slice the pearly white hypoglossal nerve in two. An image flashed before my eyes of my patient waking with a tongue he or she couldn’t control and so couldn’t eat or drink or talk normally because of me. So I redoubled my practice. I also had lengthy conversations with the parents of the first child on whom I would perform the surgery, candidly discussing the risks and assessing whether the surgery truly made sense.
After weeks of practice, I finally felt I was proficient enough to safely pull off the surgery. The parents of my patient decided to run the risks attendant in being “first,” and today they’re glad they did: The surgery was a success. Since then, the operation has been a success for more than 15 other children.
Being the first is heady stuff. These days, everyone seems to strive for it. Neil Armstrong stepped on the moon, and now Elon Musk wants to usher us to Mars. We watch in wonder as his rocket thrusters fall gracefully back to earth and land smoothly to carry another rocket another day, forgetting how many of those thrusters fire-balled unsuccessfully out of the sky before. We forget that when John F. Kennedy boldly proclaimed, “We choose to go the Moon,” that it took eight long years of training, trial, and error between his famous speech in 1961 and the stunning achievement of the first Moon landing on July 20, 1969, when Neil Armstrong stepped off the lunar module’s ladder and took that memorable “small step.”
In a culture that rewards being the first and pushing aside the risk, I am learning that it’s sometimes necessary, and even helpful, to question yourself and your motivations, to think slow, to have doubts and experience fear, and then to do the necessary work to learn and prepare.
In surgery, as in life, everything goes fine until it doesn’t. Practice, simulation, and thinking slow are what prepare us for that known unknown before taking a small step forward.
Christopher Hartnick, M.D., is a professor at Harvard Medical School and director of pediatric otolaryngology at the Massachusetts Eye and Ear Infirmary.