A Doctor’s Diagnosis of Mistakes, Mysteries
COMPLICATIONS
A Surgeon’s Notes on
an Imperfect Science
By Atul Gawande
Metropolitan Books
288 pages; $24
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When a criminal or terrorist commits a heinous offense, there is usually a flock of “experts” who appear as if by magic with a flurry of explanations and pleas for understanding of root causes--political or psychological. But when a police officer, a social worker or a doctor makes a mistake, there is a tendency to demonize the errant party. This may be an appropriate response in the few cases when we are dealing with a truly bad apple, but in most cases, when we are dealing with people who did not intend to inflict harm, doesn’t it make more sense to examine what went wrong and why?
Mistakes, medical and surgical, form the leitmotif of Atul Gawande’s “Complications: A Surgeon’s Notes on an Imperfect Science.” Gawande, a surgical resident at a Boston hospital, is also a staff writer on medicine and science for the New Yorker. (Some of the 19 essays that make up this collection first appeared in slightly different form in that magazine and in Slate.) Writing directly from his own experience, seamlessly blending the anecdotal and the analytical, Gawande explores the gray areas--the difficulties, mysteries and conundrums--that make the practice of medicine so frustrating, frightening, exacting, exciting and rewarding.
In these essays we meet a woman who can’t stop blushing, a man who can’t stop eating, a pregnant woman whose very life is threatened by uncontrollable nausea and vomiting, a man in severe pain for no apparent reason. We learn of a once-competent orthopedic surgeon who refused even to acknowledge, let alone fix, the mistakes he had made on patients, and an anesthesiologist who helped reduce the rate of patient mortality twentyfold. We also watch Gawande in a variety of situations: all but botching an emergency tracheotomy; spotting just in time a tiny detail that stops him from cutting a patient’s bile duct during a gall bladder operation; and making an intuitive guess that saves a young woman’s life.
The essays are arranged in three sections. In the first section, “Fallibility,” Gawande looks at the kinds of mistakes doctors make, the reasons they make them and some of the ways that have been found of reducing errors to a minimum. Lawsuits, he argues convincingly, are “a remarkably ineffective remedy” because the threat of them prevents doctors from publicly acknowledging their mistakes.
“Mystery,” the second section, examines some areas in which science and medicine do not yet have all the answers, including pain that seems to have no direct bodily cause and nausea that doesn’t respond to treatment. And in the final section, Gawande shows us the extent to which “Uncertainty” remains a part of the process of diagnosis and treatment.
The decisiveness of surgeons was one of the things that attracted Gawande to this field: “There is a saying about surgeons, meant as a reproof: ‘Sometimes wrong; never in doubt.’ But this seemed to me their strength.” But such decisiveness comes from years of practice, and no aspiring surgical resident, however gifted, has this kind of confidence or skill. Gawande’s account of his own first attempt at inserting an intravenous line into a patient’s chest captures how scary and awkward these first steps can be. The size of the needle alarmed even him: “I couldn’t believe I was sticking it into someone’s chest.”
Yet it is necessary for young surgeons to learn their trade, even at the cost of some mistakes. Far less excusable are the mistakes that are made “When Good Doctors Go Bad,” the subject of another chapter that tells the stories of a surgeon who became dangerous and a psychiatrist who developed a program for treating this kind of pathological behavior.
Elsewhere, Gawande examines the impact of two relatively recent changes in the way medicine is practiced: the steep decline in the percentage of autopsies that are performed and the shift in the primary responsibility for medical decision-making from the doctor to the patient. Despite doctors’ confidence in their new diagnostic imaging machines and other tools, old-fashioned autopsies can still turn up surprising results. And although it may be good that patients and their families have the final say about treatment, there are times when patients have refused life-saving treatments simply because they were debilitated, panicked, confused and unable to understand what was being offered them.
Although Gawande’s overall view of his profession is consistent, balanced and constructive, the reader may detect a gradual shift in emphasis and attitude. At the outset, discussing the routine slip-ups caused by inexperience, fatigue, tension or inattention, he extols the value of sheer repetition: A good surgeon, he suggests, should aspire to the perfection of a super-efficient machine. He also bestows high praise on programs and systems that minimize the potential for errors. In the book’s latter part, he evinces a growing respect for the less mechanical, more human qualities of empathy, tact and sometimes even intuition. But whether he is describing a procedure, analyzing a problem or evoking an emotion, Gawande’s sharp eye, crisp prose and insightful understanding make his book as enjoyable as it is edifying.
