This is a fabulous book, and you should read it.
OK, now that we've summarized, let's talk in a little more detail. Atul Gawande is a surgical resident and medical writer who has shared his thoughts on medicine as a science in this intriguing book. He is one of those rare people within any discipline that has a big-picture view and can actually communicate it. And it is worth noting that within medicine, such people are exceedingly rare. They are bred out in the training process. Dr. Gawande is very special.
On the surface, "Complications" is a quick but fascinating read. It is a serious of cases that Gawande has encountered. The reader gets the back story, the details of the treatment, and the followup on the outcome. Especially interesting is his inclusion of some intimate descriptions of medical procedures such as hernia surgery, insertion of a central line, and "stomach stapling." At some level, these things are a little gruesome to non-doctors, but horribly fascinating too.
But there is much more to this book than a simple peek into the ER or the operating theater. "Complications" is about the reality of medicine-- as a human discipline practiced by, you guessed it, humans. He talks about perplexing cases that even the smartest doctors choked on explaining. He talks about medical mysteries that are still far from solved, such as the mechanisms of feeling pain and hunger. He talks about the importance of "gut feel" as opposed to a purely rational approach to diagnosis and treatment-- as well as the large number of mistakes that every doctor can expect to make, no matter how talented they are.
Yes, that's right. Doctors make mistakes, all the time. And they even talk about them in a special weekly session called "M&M" (mortality and morbidity), held at all hospitals and perhaps large private practices too. The whole thing is highly ritualized, rather like a religious ceremony. It is part of the indoctrination of a doctor to understand the solemnity and importance of M&M.
But all of this is within the priesthood. To patients, doctors project a different image-- one of calm assurance, benign omnipotence, complete surety. Don't worry, everything will be fine. I can fix it.
One of the most important issues Gawande addresses is this image of perfection. Of course, patients need their doctors to appear certain of a diagnosis, certain that a treatment will work, confident that the surgery will go well. But underneath, the doctors aren't sure. They only know things by percentages-- 90% of patients will respond to this drug, 75% of people with this signature on their MRI have cancer. And they have no idea when that random hand will strike, making them screw up a perfectly standard surgical procedure (this will happen. It just does).
Somewhat indirectly, Gawande is saying, why can't we acknowledge that doctors are human? Sure, they have to ease patients' fears and project a positive attitude so that patients will also have a positive attitude. But really, this is an imperfect science. And we never really know anything for sure. Is it really fair to treat doctors like superhumans? They go home tired at the end of the day, too. Just like the rest of us. (Unless they are on call or working the graveyard shift at the ER!)
Gawande is pointing out flaws on both sides of the table in the "perfect doctor" myth that we cling to. He is criticizing doctors for (a) believing in their own omnipotence, and (b) leading patients to believe that medicine is 100% certain. And he is chiding patients for thinking that their doctors are gods. Neither attitude is especially constructive, when you think about it.
I think we can make an analogy to the parent-child relationship. When you are small, your parents are gods who can solve every problem. But at some point, you start to see the flaws-- the humanness of your parents. Only at that point can you have a mature relationship with them, rather than a paternalistic one. We should learn to be more mature about medicine too. Doctors should allow themselves to appear uncertain (ie, human), and patients should not make perfection the criterion for their trust.
It is worth noting that Gawande got some flak from his colleagues for "exposing" the mistakes of medicine. He used his own real-life mistakes in the book (a poorly performed emergency tracheotomy, for example). He also revealed the case of a doctor who "went bad"-- became sloppy, hurt a lot of people, and eventually had his license revoked. The protest about telling these stories shows that doctors are not quite ready to be seen as human.
But the doctor-patient relationship is in desperate need of an overhaul. I have to agree with Gawande that we are all better off when we allow ourselves to see the blemishes along with the heroism. This message has more clout when stated by a doctor, one of the insiders, a member of the priesthood. I am very glad he stepped forth to do so.
I speak from experience, by the way. I have an unusual condition that manifested in an unusual way (not that there really is a typical way, actually). It was missed completely or misdiagnosed by a whole series of doctors. There are lifelong consequences for me, who used to be an athlete but will never run or exercise hard again. There was probably little the doctors could have done, except save me a lot of pain (both physical and emotional). "Complications" gave me fresh material to roll around my mind as I work through the feelings associated with the whole ordeal.
It gets a "strong +." Anyone who has a body ought to read it.
Copyright © Kim Allen 2003
