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.

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Comments

Re:A surgical resident?

[Daniel Dvorkin]

The book was good, but was written by a surgical resident. It's akin to a graduate student writing a book deploring academia for what its worth. There's less credibility there.

A resident is the equivalent of a senior postdoc, not a grad student. One year of internship plus several years of residency for most fields -- even general surgery requires a four-year residency in most cases, IIRC. And I can almost guarantee he's not a first-year resident, because there's no way in hell he had time to write a book during internship. He's probably not a second-year either. If he's a third- or fourth-year, then he is eminently qualified to write such a book.

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.

..when a patient in pain ...

[burgburgburg]

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.

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.