Boxing, a Surgical Hero (Marc de Leval), and Finding Opportunity in an Incoming Punch

Incoming punches

Nothing could be better than having your world suddenly fall apart (!?) – at least when seen through the lens of opportunity. This concept became apparent to me while pursuing an ill-advised hobby of amateur boxing in Toronto (a poor choice for a congenital heart surgeon who relied on his hands and his brain for a living…!).

Poor choices aside, I learned about threats and opportunity from my boxing coach in Toronto (Mario Lechowski). During a sparring session, he showed me that he could make himself invulnerable in the ring by covering up. Indeed, I could swing away and my punches had no significant effect. We changed roles and I ‘covered up’ and I felt some confidence growing because I could deny him any opportunity to hit me. While I was enjoying my newfound sense of safety in the ring, diabolically, he said ‘OK, now try to hit me’. POW! I saw stars….. What happened?

It was only at the moment that Mario saw my punch coming at him that the opportunities arose for a counterpunch. In contrast to my reflexive panic when a punch was coming towards me, he simply slipped his head slightly out of the way and coolly assessed the opportunities that he knew would open up the minute that I started my attack. Jab, cross, hook, uppercut. The key was maintaining calm in the face of an incoming punch. He simply identified the opportunity that he knew would become apparent - and counterpunched.

We can all be a bit more like Mario when life comes at us with a punch. Our reflexive reaction is to get excited, franticly try to block the punch, or duck wildly. Outside the ring, when life throws a punch we complain to our colleagues, say things that don’t serve us in the long run, whine that life is unfair, lose sleep, overeat, write an angry email – you know the routine. All bad.

Imagine the power if you could welcome the punches from life – and look at the incoming punches with a mind as cold as ice, spot the unexpected opportunities (that are ALWAYS present), slip, pivot, and counterpunch. Life’s punches can be transformed from threats into…opportunities.

How about an example in congenital heart surgery?

Marc de Leval was one of my surgical heroes and I was lucky to meet him when he was a visiting professor at the Hospital for Sick Children (Toronto) in 1996. He had recently published one of the most influential manuscripts in our specialty (that certainly changed my life forever) entitled “Analysis of a cluster of surgical failures - Application to a series of neonatal arterial switch operations” (https://pubmed.ncbi.nlm.nih.gov/8127123/)

Immediately striking in the title are the words ‘surgical failures’. Professor de Leval describes how he had been enjoying ‘initial euphoria’ with one mortality among his first 52 arterial switches performed when he ran into a cluster of mortalities where 7 out of 15 patients died. It is important to appreciate the context of the arterial switch in this era (1994). Bravado expressed on the podium at international meetings was the norm – and publicly reporting a cluster of ‘surgical failures’ required incredible academic honesty. Furthermore, Professor de Level outlined how he addressed his own concerns about surgical performance with visits to observe other surgeons and then he underwent voluntary retraining (see Figure 4 above). As an attentive cardiac surgery fellow, I was blown away by his incredible moral integrity as a surgeon.

This experience with a cluster of cases led Professor de Leval to initiate analysis of human factors in the conduct of congenital heart surgery. In 2000, he published his analysis of 243 arterial switch procedures performed by 21 surgeons while being observed by a team of human factor investigators. Errors were classified into minor and major events. Interestingly, the major events could be identified and commonly neutralized by the surgical teams to diminish the effect on mortality. The minor events, however, were not considered important in isolation, but in aggregate had a very strong detrimental effect on outcomes. It was apparent that a ‘tight ship’ in an operating room fairs better than a ‘loose ship’. An important lesson for all surgeons because the choice to run a tight ship is a decision within control of the surgeon – there is no such thing as a small detail in the operating room. (https://pubmed.ncbi.nlm.nih.gov/10733754/)

Marc de Level deserved a great deal of credit for coolly transforming a “cluster of surgical failures” into a pivotal set of studies that advanced our understanding of human factors in the operating room. It is also worth noting that he subsequently performed 120 consecutive arterial switch procedures with only 3 deaths which remains an impressive feat. Thus, he transformed our specialty and continued to provide excellent surgical care. Truly a model surgeon.

Sadly, Professor de Level passed away on June 26, 2022. Nevertheless, his legacy lives on. We should all work to master his ability to calmly look at punches from life and turn them into opportunities to improve care for our patients.

Three important messages:

1. When life is ‘covered up’’ without threats coming at you, opportunities may be present but they are hard to see and limited in number

2. When life throws the punch at you, your natural inclination will be to panic and retreat. Instead, keep a cool head and start sizing up the unexpected opportunities that always become apparent.

3. A counterpunch in life offers rich options that aren’t otherwise present. Be nimble. Be flexible. Slip, pivot, and take your shot > POW!

….ALL threats are opportunities!