Complications : A Surgeon's Notes on an Imperfect Science , by Atul Gawande

Book Review

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Complications : A Surgeon's Notes on an Imperfect Science , by Atul Gawande
Hardcover - 271 pages
First Edition, April 2002
Published by Metropolitan Books
a division of Henry Holt and Company
ISBN 0-8050-6319-6 / 0805063196

We're angry when a surgeon makes a preventable error. Even a malpractice suit doesn't seem to be sufficient. We want the bad doctor to be thrown out of the profession.

We've got it all wrong, says Boston's resident surgeon, Atul Gawande. The problem of bad doctors who make mistakes is a minor factor. The major problem is that good doctors make mistakes. All doctors make mistakes. We're going to have to reform standard procedures, and resist our impulse to punish surgeons for being fallible humans.

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When some manufacturers of anesthesiology equipment used dials that turned clockwise to turn up the gas or oxygen, and other manufacturers used dials that turned counterclockwise to turn up the gas or oxygen, human error on the part of anesthesiologists killed a number of patients. When the equipment dials were standardized among all manufacturers (and it was an engineer, not a doctor, who recommended it), the number of patients who died during surgery dropped.

Likewise, when the nationwide procedure was for an anesthesiologist to rely on a stethoscope to determine how well a patient was breathing, a number of patients died during surgery, or suffered brain damage, due to insufficiency of oxygen. When it became the standard for hospitals to have the expensive equipment to monitor the patients' oxygenation, that problem was fixed.

These two reforms were fought for, and won, by Dr. Ellison Pierce, when he was elected vice president of the American Society of Anesthesiologists in 1982. A study found that these two reforms alone resulted instantly in a 95 percent decrease in the number of surgery patients who died from what is called human error on the part of the anesthesiologist. [pages 64-68] Clearly, the approach of punishing people was ineffective; what was effective was to fix the system.

More recently, we have continued to hear new reports of orthopedic surgeons operating on the wrong arm or leg. Our response is typically, "How could an M.D. confuse right and left?" However, it wasn't until 1998 that the American Academy of Orthopedic Surgeons called for it to be standard practice to use a marker to label the body part, and to do so before the patient or the surgeon go to the operating room. [69] In retrospect, everyone will ask, "Why didn't I think of that?"

Beyond adopting new standards and procedures, there continue to be errors that result from doctors losing their concentration, or making bad decisions. Dr. Gawande tells the story of the time he had to perform an emergency tracheotomy (placement of a breathing tube into an incision in the neck) on a car accident victim brought in by an ambulance. While first trying a tube in the patient's mouth and throat, to see if it restored breathing, he should have immediately told the staff to get out the tracheotomy kit, in case he needed it. He waited until he needed it before he called for it. Then he waited until he had a problem with the "trache" before he called for the assistance of another doctor who had much more experienced with the procedure, and was available elsewhere in the hospital. Before he even began, he should have put out a call to see if the other doctor was available. With seconds to spare, it was the other doctor who saved the patient's life. [48-54]

Excerpt from Complications, by Atul Gawande, page 57

The important question isn't how to keep bad physicians from harming patients; it's how to keep good physicians from harming patients.

Medical malpractice suits are a remarkable ineffective remedy. Troyen Brennan, a Harvard professor of law and public health, points out that research has consistently failed to find evidence that litigation reduced medical error rates. In part, it may be because the weapon is so imprecise.... [O]nly a small minority among the patients who did sue had in fact been the victims of negilegent care. And a patient's likelihood of winning a suit depended primarily on how poor his or her outcome was, regardless of whether that outcome was caused by disease or unavoidable risks of care.

A deeper problem with medical malpractice suits is that by demonizing errors they prevent doctors from acknowleding and discussing them publicly. The tort system makes adversaries of patient and physician, and pushes each to offer a heavily slanted version of events. When things go wrong, it's almost impossible for a physician to talk to a patient honestly about mistakes. Hospital lawyers warn doctors that, although they must, of course, tell patients about injuries that occur, they are never to intimate that they were at fault, lest the "confession" wind up in court as damning evidence in a black-and-white morality tale. At most, a doctor might say, "I'm sorry that things didn't go as well as we had hoped."

Very helpful here is a mandatory weekly meeting held in every academic hospital in the U.S. It is called the Morbidity and Mortality Conference, nicknamed M & M. The doctors and their supervisors frankly discuss their own mistakes, with the intention of becoming conscious of what should be done better the next time. Because there are no patients, lawyers or reporters present, the doctors are frank with themselves and each other. In fact, most states have laws exempting the M & M from legal discovery. [57-62]

Inviting ever more constructive self-criticism is a vastly better way to protect patients than a pervasiveness of lawsuits. Generally, I might add, in any industry which employs fallible human beings, a policy of punishing errors is the surest way to prevent an open discussion of how best to prevent errors. Unfortunately, as Gawande points out, we tend to feel that it's "paradoxical" [62] to resolve that we won't make errors in the first place, and at the same time, have weekly scheduled meetings about our errors, the very existence of which meetings implies that some of these errors, which we resolve not to make, are going to be inevitable. We can resolve the apparent paradox by recognizing what British psychologist James Reason calls "latent errors." [63] All complex human systems include errors just waiting to happen.

Table of Contents
Complications : A Surgeon's Notes on an Imperfect Science , by Atul Gawande
Author's Note1
Part I -- Infallability 
Education of a Knife11
The Computer and the Hernia Factory35
When Doctors Make Mistakes47
Nine Thousand Surgeons75
When Good Doctors Go Bad88
Part II -- Mystery 
Full Moon Friday the Thirteenth109
The Pain Perplex115
A Queasy Feeling130
Crimson Tide146
The Man Who Couldn't Stop Eating162
Part III -- Uncertainty 
Final Cut187
The Dead Baby Mystery202
Whose Body Is It, Anyway?208
The Case of the Red Leg228
Notes on Sources253
Acknowledgments 265

We don't see bimodal distribution pointing to the existence of "good" and "bad" doctors. What we actual have is a normal bell-shaped distribution of the number of times doctors make serious errors or bad decisions. The bad doctors, then, are those who are located at the "bad" tail of the normal distribution. Gawande held several conversations with one of them, former orthopedic surgeon Hank Goodman, whom a hospital eventually fired.

Discussing one of several cases that went wrong, "Goodman told me that he should have done ... a total hip replacement. But it had already been a strenuous day, and he couldn't endure the prospect of a longer oparation. He made due with pins." [91] The author explains, "Medicine requires the fortitude to take what comes; your schedule may be packed, the hours late, your child waiting for you to pick him up after swimming practice, but if a problem arises you have to do what is necessary. Time after time, Goodman failed to do so."[93-94]

Here I would have liked Gawande to acknowledge that we have a social planning problem, directly or indirectly an economic problem. If, for example, society had twice as many orthopedic surgeons, then each of them would carry half the load, and perhaps Dr. Goodman wouldn't have been so fatigued that he decided to "made due with pins." For that matter, another problem mentioned above, the pre-1982 problem of anesthesiologists failing to have on hand the expensive equipment necessary to monitor a patient's breathing (one device that measures blood oxygen levels, and a second device that measures carbox dioxide exhaled) was also indicative of an economic problem. The author doesn't render an opinion on the controversial issues of politics and economics. I would have thought that the connection is a natural one.

Complications is a deeply humanistic book about surgical problems, free from any tendency to cover up embarrassing facts. Asserting that good doctors make serious mistakes, Gawande describes several that he has made, and those of his friends, whose real names are given. This honesty combines with easy readability to result in what will be certainly recognized as one of the best nonfiction books of the year.

Reviewed by Mike Lepore for

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Complications : A Surgeon's Notes on an Imperfect Science
by Atul Gawande - ISBN 0-8050-6319-6 / 0805063196

Book Description from the Publisher

A brilliant and courageous doctor reveals, in gripping accounts of true cases, the power and limits of modern medicine.

Sometimes in medicine the only way to know what is truly going on in a patient is to operate, to look inside with one's own eyes. This book is exploratory surgery on medicine itself, laying bare a science not in its idealized form but as it actually is -- complicated, perplexing, and profoundly human.

Atul Gawande offers an unflinching view from the scalpel's edge, where science is ambiguous, information is limited, the stakes are high, yet decisions must be made. In dramatic and revealing stories of patients and doctors, he explores how deadly mistakes occur and why good surgeons go bad. He shows what happens when medicine comes up against the inexplicable: an architect with incapacitating back pain for which there is no physical cause; a young woman with nausea that won't go away; a television newscaster whose blushing is so severe that she cannot do her job. And in a richly detailed portrait of both the people and the science, Gawande also ponders the human factor that makes saving lives possible.

At once tough-minded and humane, Complications is a new kind of medical writing, nuanced and lucid, unafraid to confront the conflicts and uncertainties that lie at the heart of modern medicine, yet always alive to the possibilities of wisdom in this extraordinary endeavor.

About the Author

Atul Gawande is a surgical resident at a hospital in Boston and a staff writer on medicine and science for The New Yorker magazine. He received his M.D. from Harvard Medical School and an M.P.H. from the Harvard School of Public Health. His writing also appeared in The Best American Science and Nature Writing 2000. Gawande lives with his wife and three children in Newton, Massachusetts.


"Complications is a book about medicine that reads like a thriller. Every subject Atul Gawande touches is probed and dissected and turned inside out with such deftness and feeling and counterintuitive insight that the reader is left breathless."

-- Malcolm Gladwell, author of The Tipping Point : How Little Things Can Make a Big Difference

"No one writes about medicine as a human subject as well as Atul Gawande. His stories are scary, funny, absorbing, and always touched with both a tender conscientiousness and an alert, hyper-intelligent skepticism. He captures, as no one else has, the doubleness of doctoring: what it feels like to see other people as fascinating, intricate, easily breakable machines and, at the same time, as mirror images of one's own self. Complications is a uniquely soulful book about the science of mending bodies."

-- Adam Gopnik, author of Paris to the Moon

"Complications is a literary version of an informed consent form. It's refreshingly honest, if not always reassuring. Some people still prefer to think of surgeons as infallible gods. But Atul Gawande is a rare and wonderful storyteller who portrays his profession with bravery and humanity."

-- Ellen Goodman, Pulitzer prize winning columnist, and coauthor of
I Know Just What You Mean : The Power of Friendship in Women's Lives

"Gawande's prose, much like the scalpel he wields, is precise, daring but never reckless. But it is after he exposes what lies beneath that we see the full measure of Gawande's gift: his compassion, his honesty, and a trademark hypervigilance paired with scholarship. Much like reading George Orwell, the reader emerges entertained, enlightened, transformed and immensely satisfied."

-- Abrahan Verghese, author of My Own Country : A Doctor's Story and The Tennis Partner

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Complications : A Surgeon's Notes on an Imperfect Science
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