#19 Can Doctors Avoid Complications?
A Review of Complications by Atul Gawande MD
During medical school and years of general surgery residency, when the rest of us were struggling to show up with clean clothes and combed hair, Atul Gawande was keeping a journal and crafting the tales of his experiences and special interests. The essays he wrote were published in The New Yorker and later in 2002, compiled into the book Complications: A Surgeon’s Notes on an Imperfect Science, the first of Gawande’s many books. As the son of two physicians, he saw the pleasures and pitfalls of the practice of medicine from an early age. Lucky for us, he has shared his prodigious talents as an author, surgeon, professor of public health studies, and entrepreneur.
Even twenty years after its debut, Complications is still an excellent read.
Gawande divides the book into three sections that correspond with the general topics of his essays and anecdotes. The first section, titled “Fallibility” includes several personal experiences and insights from the early days of his residency. Fallibility means the tendency to make a mistake or to be wrong. It is something that can happen everywhere, including in medicine. Some fallibility arises from there being a learning curve for every skill, particularly those in surgery. Gawande’s own experience of central line insertion is highlighted in an early chapter. Subclavian central line insertion is difficult to do correctly the first time (particularly before the advent of bedside ultrasound). For a physician to learn how to do a central line, he or she must have a first patient to try it on. Gawande missed his first three times and worked himself into quite a funk before a supportive senior resident talked him through a successful attempt. He discusses the concerns that arise as to which patients receive care from the inexperienced versus the experienced practitioners. Regarding the training of physicians he writes, “We want perfection without practice. Yet everyone is harmed if no one is trained for the future.” ( p. 24)
Fallibility occurs in even the most experienced doctors and Gawande reports in the chapter “When Good Doctors go Bad” on one orthopedic surgeon who became so careless that he was no longer allowed to practice. Unfortunately, his colleagues let him continue for quite a while even when they had concerns about multiple complications. He explains the uncertainty of medicine and how it can take a long time to see a pattern of truly irresponsible behavior as opposed to just having more complicated cases. Gawande makes the point that discipline of physicians works best when it done by a group outside the peer group or employer because it is more objective.
Gawande candidly shares a painful personal experience with a difficult patient airway and the deadly delay he caused while performing an emergency tracheostomy. He found himself full of guilt and shame as he sat through a discussion of the case in a weekly Morbidity and Mortality (M & M) conference at his hospital. He observed, “In fact, the M & M's ethos can seem paradoxical. On the one hand, it reinforces the very American idea that error is intolerable. On the other hand, the very existence of the M & M, its place on the weekly schedule, amounts to an acknowledgement that mistakes are an inevitable part of medicine.” (page 62)
The second section of the book entitled “Mystery” relates several stories of unusual signs and symptoms that are not easily explained or treated. Gawande includes events such as blushing, nausea, and pain. In each of these cases, the doctors could not explain why the patient had the condition. Much of the time, the patient just wanted the doctors to believe them and take their problem seriously. The patients were more willing to accept that there was no conclusive medical explanation than the doctors. The physicians had trouble accepting that the diagnoses remain elusive. Both lay people and physicians will enjoy Gawande’s telling of the medical mysteries.
The final section, “Uncertainty,” addresses the problem doctors have when it comes to making an important decision like making the right diagnosis or making choices on a course of treatment. He discusses the declining use of the autopsy. The autopsy is one way for physicians to determine what was actually wrong with the patient. It is the final way to get rid of uncertainty and to instruct the doctors how to recognize such conditions in the future. He laments that autopsies are done less and less either because physicians no longer request them, the costs involved or the family of the deceased are opposed to the procedure.
Another recurring point of discussion is the decision-making power of the patient. Gawande notes that patients have become more pro-active in their desire for decision-making ability, but they are much more ambivalent about actually exercising it. In situations of great uncertainty, patients do not feel comfortable or emotionally able to make the tough decisions. Some do not think they can handle the responsibility if it turns out to be the wrong decision.
Gawande notes that doctors prefer to make the tough decisions. One of the skills the author had to learn as a resident was how to persuade patients to make the decision, he thinks is best. He clearly developed a classical paternalistic approach to the physician-patient relationship as the son of two physicians and a general surgeon in training. Nearly twenty years later, as our patients go online to read reams of medical information and misinformation, the ongoing challenge for physicians is to determine what the patient wants and to collaborate on the plan.
Physicians and future patients will enjoy reading Complications and will likely themselves nodding in agreement with many of Gawande’s observations. At the time of publication in 2002, the essays may have felt to the lay public to be shockingly honest and insightful “behind the scenes” accounts of what actually was happening in the American medical system. We know all too well of what Gawande speaks and like me, may reflect on the mistakes we have made along the way. The perfectionist tendencies we curate so skillfully will often leave us feeling inadequate and unworthy. As human physicians, we are susceptible to mistakes and uncertainty while considering the many tests and treatment options that lay before us.
He writes, “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.” ( p.73) As an emergency physician faced with high impact decisions and tons of uncertainty, I identified strongly with Gawande’s feelings of guilt and remorse over the mistakes that he made. The spotlight he has shone on medical errors through his many essays and books has surely opened up this discussion and reduced the incidence of mistakes.
As just one notable quote from the book illustrates, Gawande exposes himself and his medical colleagues as not quite the scientific and infallible beings glorified in the movies and on television.
“The fact is that virtually everyone who cares for hospital patients will make serious mistakes, and even commit acts of negligence, every year. For this reason, doctors are seldom outraged when the press reports yet another medical horror story. They usually have a different reaction: That could be me. The important question isn’t how to keep bad physicians from harming patients; it’s how to keep good physicians from harming patients.” (page 56)
Yes, indeed.
This review first appeared in The DO Magazine
