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Complications
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.
No man is perfect, and therefore, no doctor is perfect. Seek a second (or third) opinion.
Just my two cents
What is truely disturbing is that in this current litigious mentality of the US, doctors are more likely to address the symptoms rather than the source. Gives new meaning to 'take two asprin and call me in the morning'.
If we don't fight for ourselves no one will.
That's what doctors are, plain and simple. The day-to-day responsibility for not fucking your body up belongs to you. Decisions about your well-being and best interests are your responsibility. When it's time to have major work done, ask around, find someone who won't rip you off or "replace your muffler bearings" and who is at least minimally competent, and cross your fingers, knowing you're gonna get screwed anyway.
You don't have to be a doctor to have your life screwed up over one bad decision, btw. All you need are two fingerprints and a SS number.
In most cases the doctor you go to first is your family doctor. Unless it's some life-threatening thing they will recommend tests and medication, exercise, etc to see if the condition resolves. If the problem doesn't resolve then they may refer you to a surgeon. When you get to the surgeon they will do their own evaluation but most likely will agree with your family doctor that surgery is the right path. So a good part the reason that surgeons recommend surgery is that their referrals are from other doctors who believe their patients need surgery!
As for lawyers, very few would recommend that you sue for most disputes until you've tried a few letters or other ways of resolving the issue. The big liability cases get all the press because the numbers are so big (at least for the lawyers) but those are rare compared to everyday legal matters.
The same things that make humans fallible, also make us efficient and effective. The same "intuition" that may lead a doctor to be wrong, will many times lead them to be right. I would not want a computer diagnosing me. That human intuition may be able to quickly identify my problem, and fix it.
Think about this, if every person could write their own prescriptions (I'm NOT advocating this, just a thought experiment) they could probably treat their known illnesses well (assuming they are responsible, and a bit intelligent). It's not hard to find research data on different drugs. The information is relatively easy to come by. I could compare the different drugs used to treat my condition, evaluate the effectiveness with the risk, and make the decision. I realize that this is a huge oversimplification, but my point is that the biggest reason I go to the doctor is for his/her intuition in my diagnosis (and because I can't write my own preciptions).
Which is one of the two reasons that medical care in the US is so freaking expensive. The other being that drug companies are allowed to advertise prescriptions on TV, wasting millions on a nation of hypocondriacs that think "just one more pill will make everything okay". /rant
The Anti-Blog
You need to think of doctors as garage mechanics that specialize in specific areas of the car (hi, I'm a fuel-injectionologist but this surgery will require a sparkplugologist).
He/she does not have a complete manual of the 'car'. Constant updates to the 'manual' are occurring but they are often contradictory and not settled upon as fact. Also, due to the heavy specialization diagnosis can often be off because the mechanic/doctor has never seen the problem before and will try to fit the condition into the wrong pigeonhole.
Under these conditions, are you going to accept the word of the first doctor you see? You shouldn't. Depending on the seriousness of the condition, getting second and third opinions are lifesavers.
The fix is going to have to be a revolution in diagnostics, where vast comparative databases are at the doctor's fingertips, and the whole weight of medical wisdom is brought to bear on each person's case.
We will need doctor success rates for the purpose of identifying doctor mistakes quickly for correction not punishment, means to make sure people are not turned away because they will likely lower the doctor's 'batting average', truly incompetent dangerous doctors are weeded out less expensively, and an understanding by the general populace of the risky nature of any medical care.
________________________________________ History Must Not Fall Into The Wrong Hands ___________________________________
I expect a doctor to follow a similar process, maybe even more rigorously -- ater all, no one dies if my database does down in flames. However, there is the additional constraint of time, which may require parts of the process to be sacrificed. In my mind, competence is following this process and making sound judgements. Incompetence is hurrying so he can make his tee time.
Unfortunately, determining competence is complicated by the fact that it is fairly subjective. Someone has to look at all the facts and decide, did this guy screw up negligently? And that's the jury. Not that I think our court system is very good at getting to the truth and assigning proper damages.
I think that if something went wrong while in a doctor's care, if the doctor went to the patient, honestly explained the situation, and apologized sincerely, many (I won't say most) people would accept that. But hospitals are so terrified of lawsuits that they would never allow a doctor to do that, because it would be a huge liability, tantamount to a "confession" that could be used in court. And many doctors, I think, don't feel enough compassion for their patients to want to make that kind of gesture (maybe not, but that's my impression, given that doctors spend very little time with each patient).
So we're left with a situation that if anything goes wrong, we don't work it out mano a mano, but we go to court.
1. The psychiatrists are often idiots. It is amazing to discover the number of psychiatrists who went to med-school in the third world. Rough estimate: 75%. After three psychiatrists I couldn't understand, I ran into one who did speak English. Of course, he was also a wacko running what appeared to be a cult out of his office.
2. The psychiatrists are often wrong. The first psychiatrist I went to (for ADHD that had been thoroughly diagnosed by two separate psychologists before I was willing to pursue medication) decided after 15 minutes that I was bipolar. He then prescribed a mood stabiliser that made for the worst month of my life. I would sit there, all day, unable to feel anything. I was calm - but I was miserable, couldn't sleep, and developed carpal tunnel from the water retention that was a documented side effect of the drug he gave me. Turns out this drug was brand new, very expensive, and heavily advertised.
3. Let's say I am mis-medicated and develop manic tendencies, and go on a rampage. (A distinct possibility with some of the meds used.) Who goes to jail?
The doctor?
Hardly. I go to jail. The p-docs want total authority, but it is hilarious to watch the way they dodge responsibility.
The bottom line is, I refuse to surrender my control to any idiot with an MD. I now have a doctor who has finally figured out that (a) I have done my homework, (b) I am more aware of what's going on in my head than ANYONE else, and (c) he can prescribe medication, but he can't make me take it -- I'm adhd, not psychotic and not committable. I can be fairly functional with no meds at all so long as I don't go to school. So he has to convince me that the med he proposes is the best course of action. He is okay with this, and he has to be if he wants to continue getting my money.
The sad part is that, if I weren't so stinkin' stubborn and didn't read so much, I would have either roled over and played dead or given up on the whole process. The point of all this is not that all psychotropic meds are bad - in fact, getting the ADHD medicated has made a tremendous contribution to my welfare and the welfare of my family - but that you shouldn't trust someone just because he's a licensed physician.
"He who would learn astronomy, and other recondite arts, let him go elsewhere. " -- John Calvin, commenting on Genesis 1
Ok, you can give me a -5 for this, and I sincerely am not trying to be mean here, but...
They got lung cancer from cigarettes. Yes, the manufacturers lied about the complications, and they should pay for that. The fact of the matter is your grandparents chose to smoke, and it is very obvious that inhaling smoke is bad for you, even without a warning. I do not need a warnig label telling me that drinking gasoline is going to kill me, and I didn't need a warning on cigarettes to tell me that they weren't good for me either.
I'm sorry if I offended you, that was not my purpose. I understand your plight, but I do not think that was the point of this book.
Great Linux Site
Ok, here is how I feel on this subject. These are true facts from my own life.
:-)
1. My father was killed by a doctor. He had an aneurism behind his right knee he did not know about. He went to change a tire on my mom's car and when he squatted down his entire leg from the knee down turned white. He stood back up immediate, went inside, got my mom, and they went to the hospital. The surgeon on duty said he knew exactly where the problem was, didn't wait for x-rays, and operated in the groin section. First indication of a bad doctor. My mom, like my dad, believed doctors were gods. When the aneurism was not found they put my dad in Intensive Care (IC or ICU) and did the x-rays. Then the doctor botched the job by sewing my dad's main artery almost shut. He got gangrene and a blood clot detached. He had a stroke and died. My mom never sued. This is why I do not trust doctors and I always get three or four opinions. It is expensive but it is worth it. I don't want to wind up like my dad.
2. I have phlebitis. Major phlebitis. I, luckily, found a competent doctor who put me in the hospital. My blood was so thick they couldn't get any out to test how quickly it would coagulate. They thought I was going to die but I didn't. This was after seeing three other doctors.
3. A while later I was put on something called hydrochlorothiazide or HCT. It is a diuretic and has some other side effects. If you go to the Food and Drug Administration's website you can read up on just how bad this drug is if you get on it's bad side. One of those is that it makes you a bit dizzy as well as complacent. My great doctor I'd found turned out to like to fondle his male patients. I found another doctor.
4. The new doctor decided that since I am fairly well read and can think for myself that she would rather I just died - and told me to my face. She is no longer with the clinic I go to.
5. The next doctor I had I'd gone to twice when my leg with the phlebitis swelled back up. This was great cause for alarm with me. The doctor sent me to get a Venogram (sp?) done. The tests were inconclusive so he said "Take two aspirin and call me in the morning." (Honest to god! He actually said this to me!) I reminded him that I could not take aspirin since I am on Coumadin (a blood thinner) and I would die of internal bleeding (which he should have known about). He changed it to Tylenol. He's not working at the clinic any longer either.
My current doctor has been my doctor for the past two years and we have gotten along well.
Enough stories - here are my thoughts:
1. Doctors should have access to several databases. These should have diseases, muscle, nerve, bone, viruses, medicines, and other categories which I am probably leaving out.
1a. The databases should have symptoms, causes, effects, treatments, and most importantly, side effects, problems, reactions, and any other bad things that can happen from doing whatever it takes to fix the problem.
2. A drug interaction database. So doctors can know exactly what might interact with what and how to treat the problems that occur. (With hyperlinks to relevant information so they can verify the information for themselves if they need to do so.)
3. A database with methodologies on how to improve the human body so they don't have to just push pills on everyone. This should be open to the public as well (readonly status of course) so people can get on-line and find out how to keep themselves healthy.
4. Now, the important part: Make this available via wireless PDA to the doctor no matter where he is. So they can just plug in what is wrong and the AI breaks things down into percent chances (%c) of what is the matter. The reason this is so important is because I have seen (and I am sure so many others have) that your doctor only kind of knows you. If they are seeing over a hundred people a month they can not keep straight who's problems belong to whom. But a computer can. And it can recall that information and it can help the doctor to make the decisions he/she needs to make in order to help you out.
And that is the real problem here. Doctors become overwhelmed. Open your eyes and look at them. They are still doing everything with paper and pencil. Many times they can't even read their own writing. And charts? Do they have a nice bar chart that shows them how you are improving? No. They have to look at a bunch of separate papers, correlate all of that information into something useful, and then make a decision based on that information. If you think that's easy to do then have someone take twenty sheets of paper, write random numbers on them, shuffle them together, read each sheet of paper and add the numbers together in your head as you are going from one page to the next. Guaranteed that around pages eleven or twelve you will begin loosing what the number was because you also have to turn the pages, do the math, and continue going. But a PDA could do it in a few milli-seconds. Now try doing it with blood pressure, chloresterol, and other vital statistics. It's not possible. So they generalize. So long as you are up and breathing then you must be doing well. Here's a few pills, talk to you later.
It needs to stop. People cry "No! No! No! I don't want my personal information in a database!" Too bad - it already is there. What you should be crying about is the lack of proper security. We have credit cards - why not medical cards which have all of your information on the card? Can someone say flexible-CDs? Even if the card is only used as a key so only you can unlock the information - that would still be a great leap forwards for everyone. You go in, give them your card, your information is downloaded to their system, and your current information is available to the doctor. No more paying $50.00 or more to have your records transferred from place to place. Just so long as it is secure I'm all for it. Or put my information on a CD, have a good container for it (aluminum maybe?) and allow me to carry it from one place to the other. Or maybe we could go to memory sticks? These 256mb or more secure digital cards may just be the answer. Again - you carry it with you and the label says it all. "Medical Information"
Something to think about.
Someone put a black hole in my pocket and now I'm broke.