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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.
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.
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.
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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