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

Re:in all truth

[chrisseaton]

Will people please stop the "my two cents" rubbish? It's an overused phrase and doesn't actually convey any useful information.

Re:in all truth

[unicron]

Yes, completely unlike the tome of wisdom and insight your reply was.

Re:in all truth

[Henry V .009]

Hell, I'll go to bat any day for someone who wants to remove some piece of overused cruft from the English language.

A Sympathy for the Doctor?

[BlackHawk]

I have not read the book. I'm planning on it, when finances permit me to spend something on myself again that isn't required for my profession (we've all just come through the annual gift-giving frenzy).

There's a saying: You can find "sympathy" in the dictionary between "shit" and "syphilis". That pretty well sums up my feelings about sympathy in general. Unfortunately, it also sums up my feelings about the medical industry, of which, like it or not, doctors are a part.

Now, Americans live in a country where crisis medicine (medical procedures used to treat catastrophic and sudden bodily failures, like injuries due to vehicular accidents or sudden onset of acute illnesses, like appendicitis) is king, and is very well developed. Why? Several reasons.

• -It's sexy. The procedures are flashy, the results are often dramatic, the doctor is directly responsible for the save if it occurs, and provides the doctor with the most hands-on approach to the save.
• -It's mandated. That's right, mandated. A doctor can't work with a patient for months or years to slowly correct a problem, or prevent it, because the HMO won't pay for it. But they will pay for a surgery.
• -It's a quick fix. And I don't think I have to elaborate on how much we Americans love quick fixes. We love them so much that we won't consider anything else, unless none exist.

Unfortunately, the very nature of quick fixes is that they are prone to mistake. So, we see doctors make mistakes. No reasonable person would fail to cut someone slack for making an honest mistake. Of course, that's the rub. Most people aren't all that reasonable, period, much less so when they're in pain.

But the flip-side to that is what I'm going to focus on, and it's a point alluded to in the review above. When doctors make mistakes that aren't honest. Maybe they were being sloppy. Maybe they were in too much of a hurry, not for good reasons, but for a golf game. Or maybe he just had to get to the bank. In the cases of the most notorious failings, like Dr. David C. Arndt (mentioned in the linked story), national coverage guarantees that he won't work in this, or any, town again. But what about the ones who don't make the headlines?

In 1994, I had surgery to repair a hernia. It was a dime-sized hole in my left lower abdominal wall. The surgeon that my GP sent me to declined to do the surgery laproscopically, even though it was acknowledged as a method of reducing the recovery time. "We've had problems with the procedure," he told me. So I had the old method used, an anterior incision that was 4.5" long and had a piece of nylon mesh sewn in to close the hole. The surgeon prescribed codeine for the pain. Not co-tylenol, just codeine. When my wife went to the pharmacy, the clerk told her that no one had prescribed that alone in over 15 years. I later found out that the surgeon definitely had had trouble with the laproscopic procedure: he had been the surgeon working the procedure when he clipped the artery of a patient, nearly killing him on the table. 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.

There is where the doctors fail in a way that could be avoided. Be honest! Be open! Educate me in the why's and wherefore's of your past mistake, and I'll be much more likely to give you credence in the future. But if you keep it quiet, and I find out later, then you're toast. I'll sing like a bird to anyone who will listen, and that's when the power of "word of mouth" advertising really shines.

Sympathy for their mistakes? Sure, if it's warranted. I'll cut that much slack for anyone. But if you hide it all from me, I'm going to assume you don't want me to know, and I'm by nature a very suspicious person...