"Complications", by Dr. Atul Gawande is a very gutsy and honest discussion about medicine in general, and surgeons in particular. The book is also unique, for unlike others of its type it is written by a surgeon that is starting his career, and not looking back upon it. I would imagine that the book caused some consternation amongst his peers. The book does nothing to minimize the skills and accomplishments of the men and women who can reach in to the body and do some pretty spectacular work. The book does portray them as human beings that come with all the normal traits that any of us do. The pressure they must deal with is that when they make a mistake, it can irreparably harm or cause the death of the patient they are trying to help.
The vast majority of careers that people practice does not involve decisions that can cause the outcomes I mention above. And few occupations require of their practitioners near perfection, that if not delivered has a major legal industry prepared to hammer them with lawsuits. Incompetent or negligent doctors should be punished and removed from practice, but what about a human error, or a doctor that makes every single decision that is correct and appropriate for the patient he or she sees, and misses the 1 in 250,000 cases where doing everything correctly can cause a patient to die. The final chapter of this book deals with exactly those type of odds. Whether those odds are beaten often depends on the instincts of the physician. And these intuitive feelings they may or may not act upon are certainly helped by experience, but younger doctors without the years that familiarity brings can often make a decision largely because they are so new. Dr. Gawande makes clear that all the sophisticated technology available does not replace the one on one interaction with the patient.
If we ever need a surgeon we want a person we perceive as experienced, a person we are literally willing to risk our health and our lives with. The problem is that virtually no one wants to be part of a new surgeon learning his craft even with very experienced surgeons standing right at the table, watching and even directing the path the surgery takes. Dr. Gawande also shares his feelings when his children are ill and the contradictions he deals with as a parent, even as he is often on the other side with people judging him and his youth.
The statistics say that a surgeon will make a given mistake once every 200 times he or she performs a surgery that is described in the book, and that is also fairly common. If the mistake is made the results range from terrible to potentially terminal. The author does a great job of sharing what it feels like to be told that you will make the mistake, that doing the task 99.5% of the time without error can still cost a life.
A person who decides to become a general surgeon will study and practice until their mid 30's before they are able to operate on their own. That type of commitment is rare, and recent articles have said that less men and women are willing to devote that much of their lives before beginning their chosen career.
We want these people to be perfect when it is either we, or someone we care about that is to be operated on. They are not perfect, although those that are excellent can statistically come very near perfection. I would trust Dr. Gawande for he is a man that is clearly skilled, but is also acutely aware of how fine a line he walks every moment of his day.
on April 10, 2002
There are other writing doctors around, but there's nobody like Atul Gawande. I'd first got to know his voice, his distinctive approach -- immense vivid medical detail combined with an almost philosophical interest in the systemic or ethical dimensions of the problems he explores--in the pages of The New Yorker. But there's a lot here that never appeared in that magazine, and, besides, the whole really is greater than the sum of its part. His arguments -- about the fallibility of medicine, about judgment under conditions of uncertainty, etc. -- run through the chapters like sinews. "Complications" is a genuine page turner, but you come away not only entertained, but enlightened, too. I've recommended it to a lot of my friends, and nobody's been disappointed yet.
on April 3, 2002
This book is basically a collection of essays Gawande has published in the <i>New Yorker</i>, where he is a staff writer, along with a few from <i>Slate</i>. His writing style is similar to that of Malcolm Gladwell, Jerome Groopman, and other <i>New Yorker</i> authors of the David Remnick era - intelligent and clear.
Gawande is a surgical resident, so he is experienced enough to have insight into the medical profession and practices of surgeons, but still new enough in the field to bring a keen critical mind and the clarity of a relative outsider's perspective. Also, his compassion is one of his distinct qualities and shines through in the writing.
If you are a regular New Yorker reader, you probably have already read all of these essays. The brilliant essay about why doctors make mistakes is included, as well as memorable essays about when good doctors go bad, and how the practice of autopsy goes in and out of fashion. The only one that was new to me was the one about a surgeons' convention, which was entertaining but not crucial reading. It is nice to have them all in once place, but unless you are a completist or a rabid Gawande fan, I'd recommend getting it from the library or waiting for the paperback.
Rarely do I think a book is so important and so good that it should be read by everyone. Atul Gawande has written such a book.
America has the best health care in the world and yet our health care system is a mess. High insurance rates and malpractice suits make for a situation where patients often cannot get the help they need and many doctors are afraid of taking risks because of the chance of being sued. With a willingness to realize certain things and make some changes, America could turn it's medical services into a true blessing for all of its citizens.
What is the most important realization? That doctors are human beings and even the best of them are going to make mistakes from time to time. This is probably the most important point Gawande makes in his book. It is a sad state of affairs when every single doctor in this nation expects to be the defendant in a major lawsuit at least once in their careers. How many possible brilliant doctors has this single fact driven from the profession? It is one thing when a doctor makes an error through maliciousness but a doctor who makes an honest mistake should not have to fear career destruction. If something could be done about all this litigation, it would likely be easier to drive truly bad doctors from the profession because doctors and hospitals would be more like to start admitting when things go haywire and actually make a concerted effort to try to make things better.
Though his insights into what it's like to be a doctor are incredibly valuable, I find his views on the psychology of being a patient interesting as well. His articles on the mystery of pain, the horrors of nausea & blushing (yes, blushing) and the results of a patient who has undergone gastric bypass surgery for obesity are eye-openers. He also has a very good chapter on the ethics of medical decision-making between a patient and doctor. Those people in the camp that all medical decision should be left up to the patient need to understand that, in many cases, the patient simply doesn't want to make that decision.
I had read much of the material that is in this book before as Gawande has published in various magazines. But I kept an eye out for this and I am glad to see it all gathered together in a single volume. It has been awhile since I've been so impressed by a book.
on May 25, 2002
There is a lot to like in this self-portrait of a physician. OK, now here's a guy who has a long list of life's best ticket punches. He grew up as the privileged son of a double-doctor couple in a verdant, genteel Ohio college town. He went to Stanford, then Oxford, then Harvard. Now, he's in residency, training to be a surgeon, a more prestigious medical specialty than either of his parents had. He is a published author, both in the medical research literature and in the popular press. I know about him because I've read his articles in the New Yorker.
But the self-portrait that emerges is one of a humble, compassionate and well-rounded human being who just happens to have a first-class analytical mind and formidable skill with a pen. He admits to having no particular talent as a surgeon, just a dogged determination to master a complex set of skills. He makes mistakes, but he has some lucky breaks, too. He has a national reputation because of his New Yorker articles, but he wanders anonymously through his professional conference, acting like a first-year graduate student, feeling bemused and bewildered and lucky to be there. He finds time in his busy life to visit his patients at home because he wants to know if the surgery he performed on them did any good.
Dr. Gawande sounds like the kind of doctor I would like to have. In one beautiful sentence that soars off the page near the end of his book, he states his credo as a physician: to have that one "crystalline" moment in another person's life when his intervention alters its course for the better. I was awed and humbled by that sentence because I know that I can't state my professional goal so succintly or so poetically. Since the sentence was at the very end of the book, Dr. Gawande had deftly preceded it with the weight of evidence necessary for a merely rational person to figure out that the odds were stacked against him. As he says in many ways throughout the book, medical knowledge and clinical skill are always imperfect, so such moments are rare and fleeting.
But when I thought about Dr. Gawande's sentence more deeply, I found it disturbing. A generation ago, the ideal doctor was a Dr. Welby-like character, who delivered you and your sister and your mother and knew that all of you had a sweet tooth. Maybe managed care has damaged our health-care system so profoundly that all we get now is one moment with a doctor. If we're extremely lucky, that doctor may be a Harvard-educated surgeon like Dr. Gawande, who is not yet cynical about his job and is having a good day.
One of Dr. Gawande's own cases illustrates a big problem with his credo. A woman shows up in a surgeon's office after a mammogram revealed suspicious microcalcifications in her left breast. She was upset because the surgeon recommended a biopsy. This was the fourth time that her breast would be biopsied and it was already disfigured from the previous attempts. And all of those earlier biopsies had come back benign. "I'm not getting another goddamed biopsy," she said. Every time I come in here, you people find these specks and want to operate.
Dr. Gawande's response was to try to persuade the patient to change her mind because the abnormal mammogram could be an early symptom of cancer. But rather than discus with her the large body of literature that shows that the history of breast cancer surgery is a history of overtreatment, that there are many biases built into the culture of medicine and surgery that predispose to overtreatment, and that patient pressure has forced doctors to scale back their mutilating therapies, Dr. Gawande offers a cheap rhetorical trick. A good doctor, he says, will let the woman get dressed and invite her into his office, where they will sit side by side in comfortable chairs. He will say: Every time you come in here, we find something. And every time we do a biopsy, it's benign. As Dr. Gawande writes, these sentences show empathy because they convey to the patient that she's been heard. But the only thing the doctor actually did was repeat what she said.
So maybe that crystalline moment isn't enough time for a genuine conversation. If Dr. Gawande can't pull it off, with his obvious communication and people skills, then who can?
on March 30, 2008
I am a great fan of Dr Gawande.
Since the first time I read his essay in the New England journal of medicine, I have expected more from him.I have read most of his pieces from the New yorker.
I think he is amazingly talented and that he will only turn out more and better books.
As a layman, I would give this a 5 stars: for once Dr Gawande has been able to describe in a medical person's perspective that would register with a layman.without the glamour and jazz.
Our fears,doubts and tribulations.
For medical personnel: this would be a 3 stars: not because it is subpar, but because he tends to simplify this a little more than I would like him too. He lost me through 3/5 ths of the book when he hit the Bariatric surgery part. I had to struggle to get back in again.
I would have liked him to tackle the other part of patient care that we, being PC, tend to avoid: difficult patients, people who live of the system, a lazy and inefficient system which chews residents and fellows and makes a mockery of ideal medicine.Of a profit driven insurance system and a medicare/ medicaid system which promotes mediocrity.
But maybe that is another book.
a must read for pre meds and parents of pre meds.
on December 11, 2002
I found Complications by Atul Gawande to be an exciting read from cover to cover. It is filled with a variety of topics centering around medicine's fallibility, mystery, and uncertainty, as perceived by Gawande who is himself a surgeon. Gawande's mastery of language makes each chapter come to life by developing the situation and revealing topics often ignored by the medical community. He also does a great job of leaving his own bias or opinions out of the chapters. This undirected, yet thought-provoking prose was ideal for our small-group discussion class which read his book. We found many topics to discuss and ethical issues to ponder. Although our time was limited as a class, I believe we could have spent much more time digging deeper into the issues Gawande addressed. Issues that we especially enjoyed pondering included the idea of "practicing" medicine on patients as part of the educational process, the robot feel of sub-specialty medicine vs. primary care medicine, and the stories of patients living with medical problems such as the "man who couldn't stop eating." Overall, I highly recommend this collection of short stories both because it is a delight to read, and because it raises some very interesting ideas that I hope to further investigate.
UMD School of Medicine
on November 15, 2002
Even in a wonderfully literate magazine such as The New Yorker, Dr. Atul Gawande's articles have always stood out. Dr. Gawande is a staff writer for the magazine and he writes about issues he can deeply relate to-the science and complexities of medicine. Complications: A Surgeon's Notes On An Imperfect Science is a compilation of many of Gawande's essays, a few of which have appeared before in the New Yorker. Many of the essays, however, are new.
It is immediately apparent upon reading the book what an extremely humble person Dr. Gawande is. Even as a resident surgeon in a prestigious hospital in Boston, he retains a special capacity to see the human side of the person laid out on the operating table. Dr. Gawande is able to distance himself from his profession and analyze its faults and shortcomings (including his own).
Complications, nominated for the National Book Award this year, is divided into three categories. In the first, Dr. Gawande focuses on the fallibility of surgeons. In one of the most honest statements in the book (and there are many!) he says, "Medicine is, I have found, a strange and in many ways disturbing business. The stakes are high, the liberties taken tremendous. We drug people, put needles and tubes into them, manipulate their chemistry, biology, and physics, lay them unconscious and open their bodies up to the world. We do so out of an abiding confidence in our know-how as a profession. What you find when you get in close, however-close enough to see the furrowed brows, the doubts and missteps, the failures as well as the successes-is how messy, uncertain, and also how surprising medicine turns out to be." Surgeons, it turns out, are only human, and they do make mistakes on the job. All have to learn on the operating floor. It is a fine line between learning and the betterment of all patients with no harm caused.
The second part of Complications deals with the mysteries surrounding some of the most common of physical ailments-pain, blushing, obesity, morning sickness to name a few. It is in these pages that I was struck by how keen Dr. Gawande is to keep track of his patients. He continues to be in their lives long after the surgery has been done.
Dr. Gawande addresses the uncertainties that plague medical decisions in the last part of his book. How much rights do patients have when the doctor knows "what is good for them". The book features a brilliant discussion of patient autonomy. "The new orthodoxy about patient autonomy has a hard time acknowledging an awkward truth: patients frequently don't want the freedom that we've given them. That is, they're glad to have their autonomy respected, but the exercise of that autonomy means being able to relinquish it." In one of many personal examples in the book, the author himself admits to letting his doctors decide how to care for his premature baby when she was gasping for breath. Sometimes laying the entire decision burden of patient care on the patient can be too emotionally exhausting.
Apart from Dr. Gawande's precise writing (the book reads like a thriller!), I was struck by his strong feelings for the socio-economic underprivileged. He does not neglect to make the case that in a medical setting where learning needs to be done it is often at the expense of the underprivileged or the uninformed. The doctor's child gets special treatment, but the truck driver's child doesn't.
Complications is the kind of wonderful book that makes me feel better prepared the next time I or one of my own is lined up on the operating table. I have been given a view into how the system works. I know I can keep myself informed and hope for the best. If I am lucky, my surgeon will be like Dr. Atul Gawande, capable, sincere, and a person who knows how to "preserve kindness."
Being in the medical field, I found myself pretty engrossed in Atul Gawande's COMPLICATIONS. But even if you're not in medicine, there's no reason you shouldn't pick up the book. Focusing on both sides of the scalpel (those that get cut as well as those that do the cutting), the vignettes sketched out here are hit upon with compassion, thoughtfulness, and razor-sharp telling ("We have taken [medicine] to be both more perfect than it is and less extraordinary than it can be.")
Gawande holds back nothing in his narrative. One chapter will discuss the evolution of a surgeon and how perilous and dangerous it can be ("Everyone wants a surgeon with experience, but how does a new surgeon become the veteran?"), while the next will look at how effective specialized medicine is (a hospital that does ONLY hernia operations and how incredibly successful those surgeons are).
The most frightening portion of the book -- for me -- was the discussion on dangerous doctors (chapter 5: When Good Doctors Go Bad). When MD's get older and can't function as well, or get burned out, or simply can't keep up with new medical technology, there's no system in place to remove them. The AMA, local affiliate groups, none have the sole power to remove a doctor until it is often too late for the patients (Gawande's examples are horrifying, showing us an orthopedist who had more law suits pending against him than patients in his practice, and still he practiced and operated).
The big flaw with this "novel" is that it isn't novel at all. It is a compilation of short stories without a core. Whipping back and forth between medical superstitions in one chapter to the study of subjective pain the next, there's no rhyme or reason to the placement of chapters within the book. This isn't all bad, though, just something the reader should be aware of before digging in.
Regardless, it is an eye-opener to those in the medical profession and those who are patients within it. Gawande is as sharp with his pen as he is with his scalpel. And he spares no one; from the physicians within his own cadre, to the misconceptions patients hold for their care givers.
Complications should be required reading by all physicians, past, present and, especially, future simply because it is brutally honest and keeps its perspective tightly woven toward patient care.
on April 23, 2002
Yes, this is a book by a surgeon, and there are certain, um, "graphic" descriptions in this book. But it's well worth your while to read them, even if they make you feel goosy, in order to learn from this incredibly talented writer, surgeon, and ethicist.
Some ethical questions:
- Should a doctor act on hunches?
- What if the action might be risky?
- Should a teaching hospital let a junior doctor operate on YOU?
- Will the hospital even tell you if this happens?
A big one:
- Is it ever right to ignore a patient's plea to "Please don't put me on a machine"?
You may think you know the answer to the last one, but after you read his description of an actual patient who said this, you'll be much less sure.
And what about when a doctor is sure of his diagnosis - is the doctor right? How often? Well, it happens that there _is_ a way to find out, and it was commonly used 50 years ago. We just don't like to use it much, anymore. It's called an autopsy. But in the few cases where it is still used, there are surprises.
What an incredibly informative book. Read it. Get past the blood, you'll be glad you did. You'll see your doctor, and medicine, and your own body, in a whole new light.