Customer Reviews

Complications: A Surgeon's Notes on an Imperfect Science

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Dr. Gawande's essays are thoughtful and very well written, and it blows my mind that he was able to be such a prolific writer while doing a residency (let alone a surgical residency). I read these essays one at a time originally when they appeared in the New Yorker during my pre-med and med school days, and I enjoyed rereading them recently, now that I'm a resident myself. It is always refreshing to see honesty when it comes to the imperfections of the medical profession. His stories about dealing with his own children's medical problems are very compelling, struggling with when to relinquish control to other doctors and when to step in and advocate. I also currently find myself much more interested in the cognitive science of decision making, having to make potentially life-altering decisions in a split second, balancing multiple confounding variables along with personal styles, experiences and instincts. Another topic given well deserved scrutiny is the phenomenon of physician burnout and how the profession deals with, and often fails to deal with, "good doctors gone bad."

Dr. Gawande comes across as the type of person I wouldn't expect to enjoy working with the typical surgeon colleagues. In fact, I would love to see him address this topic in his future writings. It would take a writer of his skill to explore the stereotypical personalities and cultures of the different specialties. No one wants to over-generalize, but medical students from various schools will have very similar descriptions of the types of O.B. residents versus psychiatrists versus pediatricians versus orthopedists that they worked with. The broad, simplified version of this is along the lines seen on the TV show Scrubs, with surgeons being the jocks and internists being the geeks. That is too generalized but not entirely untrue. It's an interesting question, what perpetuates these sub-cultures, whether it is the type of person drawn to a specialty or whether people pick their careers based on who they want their colleagues to be.

In the end, even with all the discussions of mistakes, burnout, and imperfections, I found this book to be affirming about the medical profession. Affirming both as a physician and as a sometimes patient or family member of a patient. Medicine doesn't always work like it should, and doctors should not be placed on pedestals. There are real problems in the system, but there are also plenty of very dedicated, hard-working, medical professionals doing their best to overcome those problems, working to provide the best care possible to their patients, to make the best decisions possible given the limitations of our knowledge. In times of crisis, you just have to take a deep breath and then put your faith in the system.

"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.

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.

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.

I read this book while convalescing from surgery,therefore with recent 'experience" from both sides of the blade. I was amazed at the impressive insight and expressiveness of this surgical resident who only starting his medical career. His descriptions of various controversial medical themes and dilemas evoked many of my own experiences,emotions and my own impressions of how it is that we solve our daily medical mysteries that rarely conform to the textbooks. I've recommended this book to my son who is contemplating a career in medicine, I think he'll understand better what he might be getting himself into. I am anxious to follow any subsequent writings of this writer to see what I think will be an interesting evolution as he becomes first an attending physician and then deals with many more challenging experiences that will leave him even more perplexed,doubting,dispirited,uncertain but at the same time elated by his many clinical triumphs.

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.

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?

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.

Jordan Wilson

Medical Student
UMD School of Medicine

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.

People often take medical care for granted, but anyone who lives through an injury or illness (their own or a loved one's) experiences the complex set of issues discussed in Atul Gawande's fascinating book.

"Complications" is presented in three sections, abstractly named Infallibility, Mystery, and Uncertainty.

INFALLIBILITY

We've all read other books about medical education and training, but Gawande states the realities chillingly: "Like the tennis player and the oboist and the guy who fixes hard drives, we need practice to get good at what we do. There is one difference in medicine, though: it is people we practice upon."

From the inexperience of the intern to the ubiquitous medical error to the burned-out doctor gone careless, medical care is saddled with the variability of all human endeavors. In the second chapter of this section Gawande outlines two examples of reducing that variability -- what he calls "the quest for machinelike perfection in the delivery of care."

A Swedish study, led by an expert in artificial intelligence, fed EKGs and the multitude of factors involved in their interpretation into a computer and trained it to do 20 percent better than a cardiologist in determining whether a patient had had a heart attack.

The second example involves a medical center outside Toronto -- the Shouldice Hospital -- where hernia repair is the only operation performed. Due to "routinization and repetition," variations are ironed out of the process and near perfection is attained.

A particularly interesting chapter details how patient safety was deliberately engineered into the delivery of anesthesia, dropping the death rate to 20 percent of what it had been in only a decade.

MYSTERY

The second section of "Complications" explores several conditions that are particularly fraught with intangibles: chronic pain, nausea and vomiting, blushing, and obesity. These conditions and their possible treatments (gastric stapling and bypass, in the case of obesity) are explored with humility and respect.

UNCERTAINTY

The several issues covered in the final section highlight the frequent difficulty of knowing the best thing to do. Gawande explores the modern concept of patient autonomy in decision-making, a welcome turnaround from the paternalism of earlier times. These chapters detail cases where the best decision is by no means clear, even with a second and third opinion. Decision theory, he points out, is a good predictor in the aggregate, but of little use in the individual case.

Gawande's essays (some of which were previously published) are loosely linked in theme, but together they give a fascinating look at the realities of medical care and decision making. Though some treatments and statistics may have changed in the six years since "Complications" was published, the underlying realities are enduring.

The most telling metaphor in Gawande's book is that of the hurricane and the ice cube: science, he says, can give a good statistical prediction of what a hurricane will do. But it can state with 100% certainty that an ice cube thrown into a fire will melt. Medicine, he shows us, is more the hurricane than the ice cube.

Linda Bulger, 2008