Complications: A Surgeon's Notes on an Imperfect Science - Hardcover

Gawande, Atul

Hardcover

ISBN 10: 0805063196 ISBN 13: 9780805063196

Publisher: Metropolitan Books, 2002

Synopsis

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 also shows us 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. Gawande offers a richly detailed portrait of the people and the science, even as he tackles the paradoxes and imperfections inherent in caring for human lives.

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.

Complications is a 2002 National Book Award Finalist for Nonfiction.

About this title

About the Author

Atul Gawande is the author of several bestselling books: Complications, a finalist for the National Book Award; Better; The Checklist Manifesto, and Being Mortal. He is also a surgeon at Brigham and Women's Hospital in Boston, a staff writer for The New Yorker, and a professor at Harvard Medical School and the Harvard School of Public Health. He has won the Lewis Thomas Prize for Writing about Science, a MacArthur Fellowship, and two National Magazine Awards. In his work in public health, he is Founder and Chair of Ariadne Labs, a joint center for health systems innovation, and Lifebox, a nonprofit organization making surgery safer globally. He is also chair of Haven, where he was CEO from 2018-2020. He and his wife have three children and live in Newton, Massachusetts.

Reviews

Atul Gawande's voice has become familiar through the articles he has published in the New Yorker over the past several years. With these and other pieces collected in Complications: A Surgeon's Notes on an Imperfect Science, his varied interests and anecdotes cohere into a fascinating meditation on medicine as a human endeavor -- a meditation not only on the state of medicine today, with its controversies, jumps in knowledge and practice, and very real limitations, but also in some ways on the intrinsic complexities and paradoxes of the profession. Gawande writes about the whole enterprise of learning surgery -- and by extension, of learning any kind of medicine -- by practicing, in both senses, on human beings. And so the discussion extends from his own experience in learning how to put in a central line to the question of why and how repetition -- practice and more practice -- brings expertise and smoothness, and then beyond to the moral dilemma of teaching medicine to new learners: "This is the uncomfortable truth about teaching. By traditional ethics and public insistence (not to mention court rulings), a patient's right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden, behind drapes and anesthesia and the elisions of language." After this introductory section about his own initiation into surgical technique, Gawande brings home the idea that everyone in medicine always needs to face questions of judgment, competence, and decision making. He looks at whether computers can read electrocardiograms more reliably than cardiologists and whether a team of nonsurgeons who perform only hernia operations, day in and day out, will do better by their patients than highly trained general surgeons. And then, inevitably, he takes on the issue of medical mistakes, both the error in judgment or technique by the otherwise reliable doctor and what happens to a doctor who makes mistake after mistake. He argues not only that uncertainty and some possibility of error come with the territory but also that many mistakes can be caught and prevented by applying lessons learned from other professions and other ways of thinking. But after all the discussion of how changing complex systems can reduce human error, Gawande, in telling the story of his own inability to obtain an airway in a trauma patient, is left with the truth that medicine remains a human endeavor, with responsibility and even blame to be assigned accordingly: "Good doctoring is all about making the most of the hand you're dealt, and I failed to do so. . . . Whatever the limits of the M&M [morbidity and mortality conference], its fierce ethic of personal responsibility for errors is a formidable virtue. No matter what measures are taken, doctors will sometimes falter, and it isn't reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it." In his discussion of mysterious syndromes, of severe blushing, chronic pain, obesity, and nausea, Gawande confronts issues both at the limits of medical understanding and also, not coincidentally, at the intersection of mind and body. The sufferers he describes -- a woman who wants to be a TV anchorwoman but endures debilitating blushes, an architect with years of chronic back pain, a construction contractor who weighs 194 kg (428 lb) -- speak vividly through his clear and sympathetic writing, showing and telling how their lives have been damaged and circumscribed and even defined by these medical conditions. And yet there is always the nagging question of whether they are somehow "complicit" in their own destruction, whether the blushing problem is some compound of self-consciousness and vanity, whether the pain is "all in his head," whether the weight represents moral weakness. And in following some of these people through surgery -- an endoscopic thoracic sympathectomy to cure the blushing, a Roux-en-Y gastric bypass for the weight -- Gawande leads us to a fascinating surgical perspective. It is almost as if the more this surgeon becomes practiced and comfortable with the astonishing intimacies of surgical technique, with all possible invasions and manipulations of the human body, the more intrigued he becomes by the intricacies of the mind and the spirit and their power over the body and its progress, in sickness and in health. A beautifully written essay on autopsies includes an unforgettable image of a surgeon watching the much less gentle and elegant cutting done on the body after death: "Surgeons get used to the opening of bodies. . . . Nevertheless, I couldn't help wincing as she did her work: she was holding the scalpel like a pen, which forced her to cut slowly and jaggedly with the tip of the blade. Surgeons are taught to stand straight and parallel to their incision, hold the knife between the thumb and four fingers, like a violin bow, and draw the belly of the blade through the skin in a single, smooth slice to the exact depth desired. The assistant was practically sawing her way through my patient." The point of the essay is the necessity of autopsy and the high likelihood of discovering a different cause of death than had been assumed -- a misdiagnosis or complicating condition -- and by extension, the continuing presence of uncertainty even when decisions must be made and action taken and even though human beings cannot be completely understood by algorithm and experience. In the closing essay, Gawande confronts intuition -- what it is, how it works, and how it plays out in medical practice -- by taking us through the remarkable story of his "great improbable save," a 23-year-old woman who came in with what looked like a cellulitis of her leg and who turned out to have necrotizing fasciitis -- a diagnosis Gawande raised early in the course of her illness partly because he happened to have seen another case of it recently. When you are through with your initiation, when the systems work to support your practice, how do you finally make your decisions? When does inconsistency in how patients with the same problem are treated reflect problems in the system or bad doctoring, and when does it reflect tiny but real differences in human presentation or in instinct and choice on the part of well-trained experts and a willingness to live with the necessary degrees of fallibility, mystery, and uncertainty? Given the nature of the questions, of course, and the nature of the problems, there can be no resolution and no answers, but this book is a wonderful tribute to the complexity itself and to the intellectual, personal, and professional consequences of taking it on. Perri Klass, M.D.
Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

Medicine reveals itself as a fascinatingly complex and "fundamentally human endeavor" in this distinguished debut essay collection by a surgical resident and staff writer for the New Yorker. Gawande, a former Rhodes scholar and Harvard Medical School graduate, illuminates "the moments in which medicine actually happens," and describes his profession as an "enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line." Gawande's background in philosophy and ethics is evident throughout these pieces, which range from edgy accounts of medical traumas to sobering analyses of doctors' anxieties and burnout. With humor, sensitivity and critical intelligence, he explores the pros and cons of new technologies, including a controversial factory model for routine surgeries that delivers superior success rates while dramatically cutting costs. He also describes treatment of such challenging conditions as morbid obesity, chronic pain and necrotizing fasciitis the often-fatal condition caused by dreaded "flesh-eating bacteria" and probes the agonizing process by which physicians balance knowledge and intuition to make seemingly impossible decisions. What draws practitioners to this challenging profession, he concludes, is the promise of "the alterable moment the fragile but crystalline opportunity for one's know-how, ability or just gut instinct to change the course of another's life for the better." These exquisitely crafted essays, in which medical subjects segue into explorations of much larger themes, place Gawande among the best in the field. National author tour.

Copyright 2002 Cahners Business Information, Inc.

New Yorker readers will recognize writer-physician Gawande because of his article on the TV anchorwoman with an almost career-ending blushing problem. He exhibits the same smooth, engaging style and choice of unusual subjects in the 13 pieces in this collection, many of which amount to medical detective stories. Typical of those is the last piece, about a young woman who had, it seemed, a simple rash on her leg. But Gawande had earlier seen a patient with necrotizing fasciitis, the flesh-eating bacteria of tabloid fame, and had an uncomfortable hunch that he pursued with his fellow surgeons and a dermatologist. The rest of the tale illustrates the emotions and reactions of the patient and her father as well as the role of the hunch in science. Several entries deal with medical ethics, considering doctors who "go bad" and the long-time failure of doctors and their organizations to police the profession, and whenever Gawande depicts the regular morbidity and mortality conferences in hospitals, he is downright riveting. William Beatty
Copyright © American Library Association. All rights reserved

Excerpt. © Reprinted by permission. All rights reserved.

Complications

A Surgeon's Notes on an Imperfect ScienceBy Gawande, Atul

Metropolitan Books

Copyright ©2002 Gawande, Atul
All right reserved.
ISBN: 0805063196
When you are in the operating room for the first time and see the surgeon press his scalpel to someone's body, you either shudder in horror or gape in awe. I gaped. It wasn't the blood and guts that enthralled me. It was the idea that a mere person would ever have the confidence to wield that scalpel. I wondered how the surgeon knew that all the steps would go as planned, that bleeding would be controlled and organs would not be injured. He didn't, but still he cut.

Later, I was allowed to make an incision myself. The surgeon drew a six-inch dotted line across the patient's abdomen and then, to my surprise, had the nurse hand me the knife. It was, I remember, still warm. I put the blade to the skin and cut. The experience was odd and addictive, mixing exhilaration, anxiety, a righteous faith that operating was somehow beneficial, and the slightly nauseating discovery that it took more force than I realized. The moment made me want to be a surgeon -- someone with the assurance to proceed as if cutting were routine.


Continues...

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Edition details

• Publisher: Metropolitan Books
• Publication date: 2002
• Language: English
• ISBN 10: 0805063196
• ISBN 13: 9780805063196
• Binding: Hardcover
• Edition number: 1
• Number of pages: 269