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9 of 11 people found the following review helpful
5.0 out of 5 stars The hurricane and the ice cube, February 16, 2008
This review is from: Complications: A Surgeon's Notes on an Imperfect Science (Paperback)
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
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Showing 1-8 of 8 posts in this discussion
Initial post: Feb 17, 2008 11:49:20 AM PST
Last edited by the author on Feb 17, 2008 11:49:56 AM PST
How frightening is this?: << 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." >>

I recall one time when my daughter was questioning her doctor and he was reluctant to answer. When I attempted to throw him a lifeline by saying: "That's why they call it the PRACTICE of Medicine," he frowned at me. It appears I was pretty "spot on." ... one of those times I didn't want to be right, though.

Linda, this is a wonderful, in-depth review of a book that we all should read, especially with our health care system being in such bad condition. I'm going to recommend this to a friend for whom I've been editing court documents for a pending medical malpractice case. His battle has been a long, drawn-out one and he's always seeking fresh, new sources. Perhaps something in this book will be useful to him.

Thanks for finding yet another off-beat book to share with us. Your pen just keeps getting hotter and hotter! :)

Posted on Feb 17, 2008 2:26:05 PM PST
Linda Bulger says:
Betty, I'm glad you found this review interesting. Dr. Gawande has a more recent book in print too, but I wanted to review this one first.

Some of his stories really make you think.

Posted on Feb 17, 2008 2:36:07 PM PST
EXCELLENT review, Linda!

In reply to an earlier post on Feb 17, 2008 2:57:34 PM PST
Andre 2015 says:
Very nice review Linda. I won't start telling about what happened to me when I woke up from a coma and the three treating doctors had three different diagnoses....and opinions about what was best for me (or was it their pockets)
Anyway, I'm ver yhappy to decide for myself who is going to treat me and for that I really want to look the man in the eye.
Very interesting book!

Posted on Feb 18, 2008 6:08:54 AM PST
Now this, Lindalee, is a superb topic and review! I am so proud of you! I could be your father (but I think I'm too young).

Love ------- Metamorpho ;)

Posted on Feb 18, 2008 9:52:32 AM PST
Linda Bulger says:
Ha! my father! You're DEFINITELY too young, believe me, Meta.

Thanks for visiting, all of you. Coma, Andre? that doesn't sound good. Scary.

Posted on Feb 18, 2008 10:01:43 AM PST
What an incredible review, Linda! Your last paragraph is a gripping closer. I am in awe! Talk about practice made perfect. Do you remember writing about Betty urging you to review, your reluctance--and now! Wow!
Judy

Posted on Feb 18, 2008 2:23:29 PM PST
Linda Bulger says:
Oh yes, Judy, I remember writing that. Betty was so persuasive, always polite about it but very persistent. I was so shy about it! Now look what a "rambler" I turned out to be.

I'm lucky that I really enjoy my reading; it's so much easier for me to write a convincing review when the book really engages me.

Thanks for all your support, friend!
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