Flying and Falling

What can the myth of Icarus teach us about making, and living with mistakes?

 

The story of Icarus has provided inspiration for many artists—poets and painters alike—as they have tried to understand what it is to fail in human endeavour. It provides a way in to thinking about how we should respond to mistakes in healthcare.

Icarus and his father, Daedalus, are imprisoned on the island of Crete. Daedalus plots an escape using wings he has made from feathers stuck together with wax. He tells Icarus to make sure he doesn’t fly too close to the sun. Then they set off. Ovid takes up the story:

When now the boy, whose childish thoughts aspire
To loftier aims, and make him ramble high’r,
Grown wild, and wanton, more embolden’d flies
Far from his guide, and soars among the skies.

The soft’ning wax, that felt a nearer sun,
Dissolv’d apace, and soon began to run.
The youth in vain his melting pinions shakes,
His feathers gone, no longer air he takes:

Oh! Father, father, as he strove to cry,
Down to the sea he tumbled from on high,
And found his Fate

Ovid, Metamorphosis

Sooner or later, all doctors have that experience of falling. The clammy realisation that something you’ve done, or something you haven’t done, is going to have a major impact. The pit of your stomach drops away into a void. Time slows—like walking through treacle—and at the same time runs away as the brain fails to comprehend the emerging reality. Part of you holds on to the idea that maybe, just maybe, you’ve misunderstood. Maybe it’s not as bad as you think. Maybe it will all be alright. And no-one will notice. While a bigger part of you is mired in the dawning realisation of just how bad this may be. Bad for the patient, but also bad for you.

Mistakes in clinical practice can have terrible consequences for patients; but they deeply effect all those involved. The term second victim has been used to describe the repercussions for doctors, nurses and other clinicians. Some have suggested that pilots—with skin in the game— are more careful than doctors, because they literally crash alongside their passengers. But many studies have shown a widespread tendency for clinicians to crash metaphorically, through alcoholism, drug abuse, divorce and mental illness; in those who leave the profession; and in those who commit suicide. Margaret Murphy, whose son Kevin died after medical error, has suggested that shared abandonment better encapsulates the way that patients, clinicians and families all suffer.

But he–his damaged purpose drags him down-
Too far from his half-brothers on the shore,
Hardly conceivable, is left to drown

Michael Hamburger, Lines on Brueghel’s “Icarus”

A painting by Chagall catches Icarus in freeze frame, mid dive, while the whole world watches: a slow motion car crash with rubber necking drivers straining to see every step of the unfolding tragedy. Susan Scott talked to surgeons who had made mistakes and asked them about the impact of those mistakes on them, as human beings. The surgeons described sleep disturbance and extreme fatigue, along with anger, extreme sadness and intrusive memories. They had lost confidence, feared for their reputations and experienced doubt about their future careers. Often, they had lost the ability to be satisfied by their work and avoided the clinical area as much as they could. Initial questions of “How could this happen?” and “What did I miss?” gave way to “How much trouble am I in?” and “Will I ever be trusted again?” It becomes difficult to see any future that is not entirely defined by what has happened. Sometimes to see any future at all.

In the picture above, Bruegel shows us a different view. For the wider world, Icarus’ fall is a foot-note at the edge of the frame; his fault (with the judges) a failure to point his toes as he enters the water. The ploughman has his own furrow to plough, precisely parallel, and keeps his eyes on the ground. The shepherd hears wings but sees no danger for his sheep. Even the falconer on the shore thinks only of regaining his startled bird’s jesses. The affairs of the world sail steadily on, unruffled.

In Breughel’s Icarus, for instance: how everything turns away
Quite leisurely from the disaster; the ploughman may
Have heard the splash, the forsaken cry,
But for him it was not an important failure; the sun shone
As it had to on the white legs disappearing into the green
Water; and the expensive delicate ship that must have seen
Something amazing, a boy falling out of the sky,
had somewhere to get to and sailed calmly on.

WH Auden, Musée des Beaux Arts

Jason Han and others have written about the ways in which cognitive biases—the hardwiring of our brains—adversely effect our ability to gain a proper perspective on mistakes, reducing doctors’ willingness to be open and honest in the aftermath of error. Fundamental attribution error describes the tendency to put ourselves centre stage, ignoring the impact of others and of the complex systems within which we work. There has been a growing awareness of the importance of a systems based approach to learning from error, but this hasn’t taken away our natural instinct to blame (and shame) ourselves.

At the same time, forecasting error makes us fear the worst when something goes wrong: overestimating the scale and duration of harm, while underestimating the physical and psychological resilience of those affected. Very often, the consequences of a mistake will be very much less than we initially suppose. The world will go on much as it did before.

According to Brueghel
when Icarus fell
it was spring

a farmer was ploughing
his field
the whole pageantry

of the year was
awake tingling
near

the edge of the sea
concerned
with itself

sweating in the sun
that melted
the wings’ wax

unsignificantly

William Carlos Williams, Landscape with fall of Icarus

We also have a tendency to re-write the past in the light of a subsequent mistake. When something goes wrong, we re-examine everything that came before. Hindsight bias causes us to see a clear, linear path leading inexorably towards failure. The story of Icarus has become a shorthand for arrogance and self-conceit before an inevitable downfall. The moral is: be cautious, stay on the ground, and fear failure. The concept of hubris is woven into the very fabric of western ideas of our place in the world.

Seth Godin, in ‘The Icarus Deception’, argues that this is based on a fundamental misreading of the myth which continues to have a detrimental effect on our approach to creativity and innovation in our lives. Icarus was warned about straying too high, but also about flying too low.

                                           My boy, take care
To wing your course along the middle air;
If low, the surges wet your flagging plumes;
If high, the sun the melting wax consumes:
Steer between both

Ovid, Metamorphosis

Before he fell, Icarus was doing something that no human had ever done before. In a series of pictures, Matisse shows him swooping through a blue sky, soaring amongst the stars, his wildly beating heart vividly alive. The moral isn’t stay on the ground: it’s learn, then fly better.

Everyone forgets that Icarus also flew.
It’s the same when love comes to an end,
or the marriage fails and people say
they knew it was a mistake, that everybody
said it would never work…
I believe Icarus was not failing as he fell,
but just coming to the end of his triumph.

Jack Gilbert, Failing and Flying

Failure is an inescapable part of the practice of medicine by universally flawed human beings. We are beholden to our calling to avoid mistakes whenever we can, to be honest and open when they do happen, to learn and to avoid repeating them. But, for the sake of our future patients, our families and ourselves, we urgently need to find perspectives in which neither our future, nor our past, is defined by our failure.