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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.
Ask a lawyer if you should sue; the responce will be "Most Definitly".
Ask a doctor to operate; the responce will be "Most Definitly".
You can't judge a book by the way it wears its hair.
Back when I was in patient care, I really liked working with third- and fourth-year residents. They have a tremendous amount of knowledge but most of them haven't developed the arrogance and/or cynicism that a lot of docs get after a few years. I'd say an experience resident is in a better position to critique the medical field than just about anyone else, to tell the truth. The same is true in other biological fields (medicine is applied biology.) I'm in research these days, and let me tell you, it's the senior postdocs who really know what the hell is going on.
The correlation between ignorance of statistics and using "correlation is not causation" as an argument is close to 1.
Because it is the patient who is experiencing the pain involved, unless the physician can provide alternative pain management measures, and as long as the treatment desired is valid (no "Hit me on the head with that skillet" or "I demand you sacrifice a goat to Baal"), a patients wishes should be honored even if there are forseeable side effects to the treatment. Since the most oft used reasoning on limiting pain management is the possibility of addiction (which is not as great a risk as is currently taught in most institutions), the patients wishes should definitely be respected and the pain should be treated.
The book itself I have read some of - it makes a series of excellent points; one of which in the tagline - "notes on an imperfect science". We don't know very much about the human body compared to how much there is. All a doctor has to go on is a series of symptoms and an examination, followed by some lab tests. Most illnesses are diagnosed from the symptoms. Surprisingly few from the examination. Lab tests are mostly non-specific - they can confirm or refute your diagnosis, but a minority will actually make a diagnosis on their own.
The problem is that symptoms are very non-specific. Only a tiny minority of people with chest pain have a cardiac (or other "serious")cause for it. At the same time, a few people will have a serious disease but the symptoms are not typical of it. Do you investigate everyone for every disease? No, takes far too much resources with only a tiny return. What is done instead is the doctor listens to the story, examines the patient, and tests for the likely (in view of his findings) causative process, and also any serious (i.e. missing these would be bad shit) things which might give similar symptoms.
Everyone has an area of expertise - and also a finite amount of knowledge. Doctors cannot know everything, but will, if indicated, refer to another specialist with an appropriate area of interest, which will increase the chances of a diagnosis.
Bear in mind another few things - half of all people are below average intelligence; i.e. half of physicians are of below average ability; symptoms are often misleading, and tests and investigative surgery can cause their own problems, and you see my point - any area of medicine is a risk/benefit analysis. At the end of the day it's all probability - gambling with your life, in essence.
Doctors, usually, do try and make the best decision. It can't always be right. Incompetent and dangerous docs are one thing - they should be re-trained if possible, and struck off if not. The point made by the book is that all good doctors make mistakes as well. This is part of human nature, the problem is that the consequences can be grave.
The thing is, is it any different to be treated by the best surgeon in the world, with the lowest complication rate (there is no such thing as no complications), or the worst in the world, with the highest? If you get complications, you are still in the same boat. But what if you get no complications from the shit guy? What if he's competent, but that the unit he works in isn't, because it has less support staff than another unit?
One or both of them might be competent or not. But the fact that someone suffers a complication is a far more difficult question to deal with - it may be that no one is at fault. Some of these things simply just happen.
This idea was invented by Shampoo.
Of course, I was never told that. I was never offered that information, and if I had asked, the surgeon, the hospital, the medical community as a whole would have zipped their lips to protect one of their own.
In a word, 'Bollocks!'.
So.. Every user in a system needs to be told 'This is the sysadmin who accidentally deleted someone's files years ago, and didn't have things on backup', so they can use a different sysadmin?
You want to be told 'This taxi driver once had a car crash! I wouldn't use him if I were you'... This checkout attendant once shortchanged..
Where on earth do you get your clue from? If you want to be educated, go get a medical qualification. Start on proper courses to train you in exactly what being in the profession means..
Honestly, you're sounding like one of those 'holier than thou' people we so often see in politics. Of course they would never make a mistake, but everyone else needs to be open and honest, and let them know all their little failings..
The world is a big bad place. Bad things happen. Nothing is infallible. Some people actually spend many years training to try and help, and perhaps make a difference for the better..
When you can make a difference as profound as a doctor, carry the stress of the decisions day in and day out, and be perfect, then feel free to cast your stone.
My counter story is that each member of my immediate family have at some point had accidents that would have been fatal, if not for some person who trained and knew enough about the body to fix them, and they lived.
Would it have helped to know that these same doctors had lost patients on the table, or the ward days before? Not in the least.. If you go that route, you'll never havea doctor operate on you.. And thus, when it's needed, you'll be too paranoid to accept the risk, and just plain die of neglect.
Malk
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.
My mother came out of residency (as a psychiatrist) about 6 years ago. From what she has said, your first explanation is plenty on its own. Being in medicine constantly teaches you how human you are. You start out thinking you will be the perfect doc, and then you make a mistake. You decide you will never make a life-threatening mistake -- and then you do. You revise this and decide you will never make mistakes because of tiredness, or ignorance, or sheer gutwrenching stupidity -- and then you do all of these. Then, well, you will certainly never make the same mistake twice, right?
Eventually, if you're honest, you have to recognize that you're human, and sometimes you're going to screw up. I wonder if this is a process that psychiatrists navigate more easily than surgeons?
...he works at the same facility as my wife (who is also a doctor, but with a different specialty), and his book really does tell it like it is.
For those of you calling for doctors to be punished when they screw up : grow up, please. Life is never that simple. There are some bad doctors, but even the very best make mistakes, often for reasons beyond their control. If you read the book you'd understand a bit more about how seriously screwed up our medical system is.
Take the Residency system, for example. Simply, the Federal Government pays for a certain number of Residents (recently graduated MDs seeking speciality training in their chosen field) for each hospital. They are essentially 'free' labor for that hospital, so they are worked the hardest. The janitors earn more than they do, on an hourly basis (and even with the new hour restrictions coming in, $40K a year for an 80 hour week where you could kill people through tiredness isn't all that swell).
As the cheapest labor in the hospital, Residents spend a lot of time doing 'scut' work that should be done by porters or nurses, rather than doing what they're trained to do - you could do a lot of good if you spent that entire 80 hours a week being a doctor, but you'll be lucky if you spend half of that time actually using what you learned from med school. It's grossly inefficient, and since the alternative would cost hospitals money (they'd have to hire, and pay for, more porters or nurses) there's no incentive to change. That's just one of the many, many things that makes the delivery of medical services in this country so damn expensive and inefficient.
And that's not even mentioning the patients on State medical insurance who call out an *ambulance* in the middle of a *blizzard* because they have a freaking *sore throat*. My tax dollars at work. Gah.
Finally I visited one doctor who told me I needed to drink more water, have a humidifier in my room, and change my diet to largely plant based. In a few days my kidney problems ceased without any drug or surgical interventions.
Over the years since then, I've read, and noticed that the majority of health problems can be easily solved by the patient themselves. Just a little research from your local bookstore, or even the net can go a long way.
Doctors should really only be used to help diagnose your symptoms, and to treat those problems that you cannot yourself.
Instead, many of us see the latest drugs on TV and rush in to the doctor wanting him/her to prescribe them. All drugs are toxic and most have unintended side effects and consequences. If you dont believe me, check out side effects for a few popularly prescribed drugs that patients could easily be solving in more natural ways:
Zocor - http://www.medications.com/index.php?act=se&drug=Z ocor
Yasmin - http://www.medications.com/index.php?act=se&drug=Y asmin
Paxil - http://www.medications.com/index.php?act=se&drug=P axil
Levaquin - http://www.medications.com/index.php?act=se&drug=L evaquin
Sure, drugs have their place in certain circumstances, but doctors being in thrall of the pharmaceutical industry really set themselves up for lawsuits from uninformed patients who sometimes pressure them, and many times, medications are seen as the easy way out to shup-up a complaining patient and move on to the other one.
Fellow slashdotters who are ill, should talk to their doctors, and research natural alternatives from a variety of sources before submitting to surgery and medications. And if surgery and medications are unavoidable, get second and third opinions for convention and alternative physicians. You can save your life that way. Check out sites that expose certain health myths, such as The Physicians Committee for Responsible Medicine for more information.
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