Complications

Stella Daily writes "While the man (or woman) in the white coat no longer has the godlike status he once enjoyed, we still regard the doctors of the world as, perhaps, something more than human. We entrust them with our lives and with the lives of family members; we tell them things we would never tell anyone else. And when they fail, we are often severe in our punishments: multimillion-dollar lawsuits, lost licenses, and most of all, the cloud of public disapproval that follows a physician who has made a particularly well-publicized mistake, sometimes for the rest of his life." Stella's review continues below. Complications: A Surgeon's Notes on an Imperfect Science author Atul Gawande pages 269 publisher Metropolitan Books rating 10 reviewer Stella Daily ISBN 0805063196 summary What happens when humans do an inhumanly difficult job.

Complications is a look at the medical profession from the inside -- written by surgical resident Atul Gawande, it is a frank, thought-provoking commentary on what happens when fallible human beings do a job that requires infallibility. In its chapters, he reveals that doctors make mistakes more often than most of us think -- and that while there are bad doctors, the more usual case is the good doctor having a bad day, or the problem for which all the training in the world would not have been enough.

Gawande is refreshingly honest about the limitations of medicine and of how much doctors, despite years of training, do not know. Witness the titles of the three sections of the book: "Fallibility," "Mystery," and "Uncertainty." He shows us myriad facts and stories that seem designed to make us lose confidence in our physicians. The study that showed that a doctor's confidence in her diagnosis was not related to whether the diagnosis was correct. The colleagues who chose to remain silent when a well-known surgeon began to show signs of incompetence, choosing instead to quietly redirect patients to other doctors when possible. The studies that show that autopsies reveal misdiagnoses in between thirty and forty percent of cases. Yet Gawande suggests physicians are doing the best they can: given the complexity of the human body, the short amount of time they often have to make decisions, and a host of diseases, injuries, and conditions that mimic each other, it is a titanic task we ask of them. Often a doctor has little more than her intuition to go on; sometimes that intuition can result in messy complications, but just as often it results in a spectacular save.

Complications tackles other issues as well: How do we reconcile the needs of patients to have experienced hands performing procedures to the needs of physicians who must teach the procedure to residents so that a new generation of doctors will be able to perform it? What does a doctor do with a patient whose symptoms show no discernible cause? How much say should a patient have in his or her medical treatment? As Gawande describes, until quite recently, the answer was "none -- doctor knows best." But whose body is it, anyway? While the reader might find himself, as I did, indignantly reacting with, "Of course I should be able to decide what happens to me!" Gawande raises an important point. Sometimes a patient really is not in the best position to decide, as when a patient in pain demands the treatment that will alleviate her pain now but cause her serious trouble down the road, unable to consider anything but how much it hurts now. The doctor's dilemma of when to step in is one I do not envy, and one Gawande describes poignantly.

While you will pick up Complications for the ideas and questions it raises, it is the stories Gawande tells, and the polished magazine writer's style with which he tells them, that will make you unable to put it down. Whether it's the television anchorwoman who couldn't stop blushing, the star orthopedic surgeon who inexplicably began doing shoddy work that hurt more than it helped, or the beautiful young event planner who was saved from a deadly infection by Gawande's lucky guess, the stories are about fascinating human beings, and Gawande tells them with riveting language.

If Complications has a weakness, it is that the chapters sometimes seem disjointed, without adequate transition between them. In the acknowledgments, the reader learns that the book originated from several essays Gawande wrote for The New Yorker. When the book is considered as a collection of essays rather than a unified whole, the lack of continuity is not a problem, and even without knowing this, it is still a more than worthwhile read.

Complications is about, as its subtitle says, an imperfect science, but not just any imperfect science. Arguably more than any other field, medicine's failures are held under a microscope and second-guessed ad nauseam; we expect our doctors to be perfect, and when they are not, our disapproval can be severe indeed. While Complications may shock you with its admissions of how deep the errors run, in the end it will give you a better understanding of what it is to be a human being doing an inhumanly difficult job.

You can purchase Complications from bn.com. Slashdot welcomes readers' book reviews -- to see your own review here, read the book review guidelines, then visit the submission page.

Comments

Sleep!

[webword]

Probably the biggest problem in medicine today is lack of sleep of interns, nurses, and doctors. No joke. So many of these people lack sleep and it is killing us all.

Long Hours, Little Sleep

Sleep Deprived Medical Residents Ask for Limited Work Hours

Fatigue, Sleepiness, and Medical Errors

Doctors Are The Third Leading Cause of Death in the US, Causing 250,000 Deaths Every Year

Lack of Scientific Background and Hubris

[gmhowell]

I work in the medical industry, and my father has been a family practitioner for over 30 years. I have no doubt I've met and interacted with more doctors than the average person, and probably more than the average resident. With that disclaimer out of the way...

In my experience, there are two rather large things wrong with physicians that could be improved. Both of these would have a positive effect on outcomes. Neither are discussed much. It sounds like neither of these are touched on in the book.

First is a lack of scientific background. Now, I don't mean that some doc didn't have a BS in biology or whatever. They don't think like scientists. Far too often, physicians build up a mental table of symptoms. When a new patient presents with a condition, the table is consulted. This works fine in general, but falls apart miserably in corner cases. To solve those corner cases, some deductive (and inductive:) reasoning is called for. It is staggering the number of physicians who lack these skills. In some ways, newly minted MD's are better in this respect. They haven't had the time to develop a catalog, so they are reasoning through EVERYTHING. Sure, it makes them slower, but everything will be reasoned through. Docs with 5, 10, 20 years of experience have built a corpus of knowledge that they refuse to look beyond.

But all is not well with new docs. All physicians suffer from hubris. No kidding that this is one of the seven deadly sins. Most doctors are convinced of their own godhood. Check out Alec Baldwin's character in "Malice". Yes, it is a caricature. But there is also a grain of truth in his portrayal. For most doctors, questioning a diagnosis or treatment plan is a surefire way to piss them off. Being correct when they are wrong will drive them to either apoplepsy or catatonia. Is this something they come out of med school with? I think so. Older physicians seem to be better in this regard. There are two possible explanations that immediately come to mind. First is that they have experience to show their human failings. The other explanation is the makeup of the teachers and instructors in most universities today. Thirty years ago, they were staffed by former physicians, those who had had private practices, large patient caseloads, etc. Today, like much of academia, they are staffed by professional instructors. If you can't see the problem with this, I can't help you.

What's the solution? I really have no idea. Once the hubris disappears or is mitigated, it should be possible to learn the thought processes necessary to do good medicine. But how do you convince someone that they have too much pride? This is a real world problem for me, as my practice has several new doctors. They have potential. They can be great. But can they get past their own thoughts of superiority to recognize their weaknesses in certain areas?

Re: ..when a patient in pain ...

[rnicey]

Err, no. The most oft reasonings for limiting pain medication are:

1. It often interferes with blood pressure and other systems.
2. It most often interferes with diagnosis.
3. It very often makes anaesthesia more difficult in case of surgery.

Anyone who thinks that a screaming patient just rushed in from the ambulance should be given something like morphine just because they 'hurt real bad' without a proper exam and consultation is insane.

Enough!

[shagoth]

Ok, it's time for a physician to open his yap. There's plenty of hubris, and doctors are just mechanics and get paid too much/too little. Doctors should pay, blah, blah. And the like already spewed onto this thread. Here's my take.

First, I ran through the numbers a few weeks ago. Financially, if one became an RN (Registered Nurse) instead of a Physician Family Practitioner, you would be financially ahead of the physician by the time you account for deferred earnings and accrued educational debt until that physician had been out of residency for 10 years. That means that the nurse who began a career on graduation with a BS at 23 would be 41 before their counterpart that did premed and went to medical school would be financially even with them. Smart investing and good use of shift differentials as well as perhaps a masters degree in nursing could put them ahead indefinitely.

Further, medicine isn't recession proof. In the metro Seattle area, over 40 primary care doctors have become unemployed because the closure of a couple of large groups and layoffs by the big local HMO. Those guys don't just bounce into new jobs overnight.

The money in medicine is going elsewhere (lookup Tenet (NYSE: THC)). It's funneling into giant management corporations and insurance houses. Those of us out working with patients see very little of the money that comes in. Most family practices have overheads in the 50-60% range would greatly cuts the amount to the physician paid by the insurance. That combined with the endless gameplaying where insurance companies pay only a fraction of billed amounts.

As for the implication that doctors would rather operate than anything else is silly. I do office procedures, yes, but those are time consuming and pay relatively poorly. Besides, it's still possible to do the right thing without constantly thinking about the bottom line. I'm sure there are unscrupulous doctors out there, and frankly I've seen some questionable things done over the years but it's hardly the rule.

Most docs are out there humping it just ot make the debt service for their student loans. The days of fat cat doctors who made millions is long since over. I'd recommend getting ahold of a recent copy of Medical Economics to anyone who'd like to get a sense of what primary care physicians are up against. For those who intentionally decided on engineering instead of medicine, you made the right choice. A decent engineer makes as much or more than a family doc and has no call and minimal liability.

Re:From personal experience

[Desert Raven]

I'm curious if there's an additional negotiation AFTER that bill, perhaps there's an additional 80% 'hospital to insurance carrier' discount we don't hear about...

Yes, there is, though it's only about 50%.

A few years ago, I had to have surgery to repair a broken bone. The insurance company paid it, then a year later rescinded payment, So, the hospital sent me the bill. However, since it had already gone through the insurance system, it was the version of the bill that went to the insurance company. Right down at the bottom was a 50% discount for the insurance company.

This is also where I learned that the hospital administration was padding the bills. Had the anesthesiologist even given me half of the vials of medication on the bill, it would have killed me. Both the surgeon and anesthesiologist were well known to my wife and I, and flatly denied any knowledge of claiming that much medication on the bill. Seems this is the way the hospitals are "getting back" at the insurance companies for fixing prices so low on what the hospital is allowed to charge for a procedure.

Lessons learned? #1, Cash-paying customers are taking it in the shorts because of strong-arm tactics by the insurance companies. #2, if you need to pay cash on a hospital bill, especially for a surgery, have a medical professional review your bill before you pay it.

I ended up not paying the bill for two reasons. First, the insurance claim was legitimate, it wasn't my fault the hospital was stupid enough to give the money back without consulting me. Second, I told them that if I ever saw that bill again, I'd have them in court for fraud. I never heard from them again, and the charge was removed from my credit report.

Misunderstandings....

[Aesculapius]

There seems to be a lot of assumptions towards physician salaries, intentions, etc.

Salaries
The average physician makes about $150,000 per year. I know that seems like a lot. But think about this. The average physician has $150,000 in educational debt after they finish residency.....that's when they turn 30! So, you're thirty, have tons of debt, no savings, and you are just starting.
How does one determine how much a person should earn anyway? It seems to me there are 4 factors that SHOULD govern this process.
1. Physical exertion
2. Level of training/education
3. Level of responsibility
4. Contribution to society
It seems to me that for a physician 2-4 are very high.
Lastly, I can't stress this enough. PHYSICIANS ARE NOT INTO MEDICINE FOR THE MONEY!!!!! I couldn't have made it through medical school and residency if money was my motivation. Almost all physicians due this for some higher/noble purpose of helping others. It was that reason that let me get through not seeing my wife and new daughter in residency. It was that higher purpose that allowed me to be worked like a slave.

Responsibility
Bad things happend....that's life. I know that everyone has a story about a relative or friend that had a bad experience in medicine. Why do people automatically start looking for someone to blame? Doctors are able to predict a lot of things with the human body. There are a lot of things they cannot. There is a saying in medicine:it's half preventing fires and half putting them out. Unexpected things crop up all the time....it's unavoidable. Yes, sentinnel type of events like amputating the wrong leg have blame, but most bad things that happen could not have been predicted by anyone.
Flesh Mechanics
I hate this comparison. Why? Because it implies that the human body is just as simple as a car engine. It implies that every body is the same. Imagine you are a mechanic. You know that the car you are working on has an engine, electrical system, and exhaust. Now imagine that you kind of know how everything is connected but aren't sure because no 2 cars are the same. That's the way people are. EVERYONE is different. Reactions to medications are different....both good and bad. Reactions to surgery are different....both good and bad. All physicians have are statistics on how these things affect MOST people....not all. Ever hear of the uncertainty principle? Well, it's present in every aspect of medicine and no amount of research, knowledge or training will change that.

Many people have a problem with personal responsibility. It's your God given right to smoke, drink and do drugs. It's your God given right to drive without a seatbelt and participate in unprotected sex. But how do these behaviors magically become the doctors fault? A good example is the lawsuit against the tobacco industry. Yes, they hid research that suggested nicotine was addictive. Yes, they did not tell the public that tobacco was bad for you. There is one person that did.....the Surgeon General of the United States.....back in the 70's. So, it seems to me that if you started smoking after the 1970's, you knew the facts and CHOSE to ignore them. Why should you be entitled to any of that settlement. Yes, THEY were wrong but YOU made the choice and now have to live with that choice.

Physician Intentions
I know I touched on this earlier, but I cannot emphasize this enough. Every single doctor that I know (including myself) is in this field for the most noble reason I can think of....to help people. Most of us try to educate our patients so they can make informed decisions.....and they are YOUR decision. The "paternalistic model"(doing what the doctor says) of physician interaction ended in the 70's. We now live in a world where medical information is easily accessible by the public...and this is a good thing. What is frustrating is when the doctors information conflicts with the patient. I know many people feel this is just the doctor being arrogant because they "know best." Medicine rarely changes the way it treats a patient based on one study. Not all studies are good ones. All studies have limitations. Physicians know this and merely want to better educate you.

Litigation
This is a difficult topic....simply because I don't know the answer. Suing a doctor into oblivion isn't the answer. What does that get you? You have then successfully punished a doctor for all eternity and ruined his/her career and livelyhood (docs have families too) despite all the good he/she has done because of something he/she may not have done wrong. That hardly seems fair.
I have made mistakes.....none of which hurt anyone...but mistakes that I lost sleep over...not because I might get sued, but because something bad might have happend to a fellow human being.
I would also like to flip the coin here. Let's assume that I see you as a patient. Let's assume that you see me over the course of your life, follow my advice, and I treat appropriately your diseases appropriately. Let's say that all of that care EXTENDS your life by 10 years (I'm being conservative). How much is 10 years of your life worth? It seems to me that if you can sue me for taking 10 years of your life away for millions of dollars, why wouldn't giving you 10 years of life be worth millions of dollars? I am not trying to suggest that I bill that amount....that would be ridiculous.....I merely want to illustrate the point that legal action settlement are a little over the top.

Thanks for reading.....I just want everyone to know that the great majority of physicians care about you and about what you think.