For the week of Sept 25 - Oct 1, 2002

book review:

Gawande reveals 
the perplexing 
world of medicine

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By ADAM TANOUS
Express Arts Editor

It is not a particularly profound revelation to note that our relationship with the world of medicine is a troubled one.

Complications: A Surgeon’s Notes on an Imperfect Science By Atul Gawande. 269 pp. Henry Holt and Co. $24.

Despite the nearly exponential growth in medical knowledge and care—in fields of genetics, molecular biology and a whole host of other technical advances—there seems to be a considerable amount of discontent among patients.

Then along comes a surgical resident named Atul Gawande with his book "Complications: A Surgeon’s Notes on an Imperfect Science." And what Gawande leaves us with is the lasting and important thought that medicine is very much a human endeavor—a fact that is responsible for both its triumphs and failures.

In his introduction, Gawande writes: "Medicine is, I have found, a strange and in many ways disturbing business. The stakes are high, the liberties taken tremendous. We drug people, put needles and tubes into them, manipulate their chemistry, biology, and physics, lay them unconscious and open their bodies up to the world. We do so out of an abiding confidence in our know-how as a profession. What you find when you get in close, however—close enough to see the furrowed brows, the doubts and missteps, the failures as well as the successes—is how messy, uncertain, and also surprising medicine turns out to be."

Atul Gawande. Photo by Graham Gordon Ramsay

Such an admission from a Harvard-trained doctor, ostensibly one of the best, might be at first blush unsettling to readers and patients. Yet, it is Gawande’s honesty in discussing cases, his and colleagues’, that is ultimately reassuring. What resonates at the core of the book, and at the core of medicine in general, is a basic humility. It is a humility that allows a doctor to move past the shortcomings of the profession, to remain inquisitive, to question each move—always with the patient’s interests foremost in mind.

Gawande divides his book into three sections: the fallibility of doctors, the mysteries of medicine, and the uncertainty that is and likely will remain at the center of the field.

The first goes into great detail as to how mistakes in medicine are made. These are systematic errors and individual ones. The former are often identifiable and fixable; the latter are distressing but inevitable. "You have a cough that won’t go away—and then? It’s not science you call upon but a doctor. A doctor with good days and bad days. A doctor with a weird laugh and a bad haircut. A doctor with three other patients to see and, inevitably, gaps in what he knows and skills he’s still trying to learn," Gawande writes.

He goes on to point out, "If error were due to a subset of dangerous doctors, you might expect malpractice cases to be concentrated among a small group, but in fact they follow a uniform, bell-shaped distribution. Most surgeons are sued at least once in the course of their careers. Studies of specific types of error, too, have found that repeat offenders are not the problem." These are sobering facts, but critical ones because they dispel our misconceptions about medicine and its practitioners.

Gawande also discusses the inherent conflict in medicine: that of the desire to give patients the best possible care while at the same time allowing young doctors to gain experience. Without the latter, of course, the profession would come to a grinding halt. As he points out, surgeons "believe in practice, not talent …what’s most important to them is finding people who are conscientious, industrious, and boneheaded enough to stick at practicing this one difficult thing day and night for years on end."

Perhaps the most intriguing section of the book has to do with decision-making in medicine. A decade ago, patients simply did what doctors told them was the best course. Now patients are much more actively involved in decision making. It is a problematic development: "People are rightly suspicious of those claiming to know better than they do what’s best for them. But a good physician cannot simply stand aside when patients make bad or self-defeating decisions—decisions that go against their deepest goals," Gawande writes. To what extent can or should a doctor venture from the technical into the personal aspects of a given medical decision? It is a question doctors wrestle with case by case.

"Complications" is an engaging, well-written book. To read it is to meet the people a surgical resident meets, to understand the decisions they and their patients face and the difficulty in getting the right outcome.

 

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