Complications: a surgeon's notes on an imperfect science Atul Gawande New York: Metropolitan Books; 2002 269 pp $34.95 (cloth) ISBN 0-8050-6319-6
Surgeons can be a brash lot, and it should come as a surprise to no one that they occasionally put their opinions in print. That some of them (I'm thinking of Sherwin Nuland and Richard Selzer, to name only two) tend rather toward both professional and personal self-aggrandizement does not make them any less readable. But it does, to my mind at any rate, render them just a little less credible. It was thus with a mixture of excitement and skepticism that I approached Complications: a Surgeon's Notes on an Imperfect Science, a new book by Atul Gawande, a resident surgeon in Boston and frequent commentator in The New Yorker. Here was another book of surgical reflections, if I may make a bad pun, but the title, or more specifically the sub- title, was intriguing. As it turned out, Complications was both challenging and accessible: an easy weekend's reading that is also thought-provoking and re-readable.
In medicine, Gawande reminds us, the “stakes are high, and the liberties taken tremendous.” But where others have focused on the first half of this statement in glamorous accounts of daring exploits, Gawande speaks to the second component of this phrase. The first section of the book, “Fallibility,” addresses the huge contribution made by patients — often to their immediate discomfort and sometimes to their long-term detriment — to the education and training of physicians. As Gawande sees it, the allure of the sophisticated university hospital with its promise of cutting-edge care blinds patients to the fact that they are, in many ways, teaching tools. Thus, while a resident may tell a patient that he needs a central line, she virtually never reports that the reason she will be doing it rather than her senior is that she needs the practice. In a nice turning of a phrase, Gawande suggests that “the physician's dodge is inevitable. Learning must be stolen.”
In a similar vein, Gawande describes a hospital administrator who “didn't even allow residents in the room” for the delivery of his child, and tellingly relates how he and his wife declined a cardiology Fellow's offer of care for their sick child, choosing rather to seek the help of a well-established and published expert in the area of their son's particular illness. Who among us wouldn't make a similar choice? Complicated issues these, and Gawande certainly doesn't make any attempt to resolve them in this short work. What he does offer is a “stark confirmation that you can't train novices without compromising patient care.”
On the timely issue of medical mistakes, Gawande notes in simple and concise prose that the “important question isn't how to keep bad physicians from harming patients; it's how to keep good physicians from harming patients.” Admittedly, this is not new. Nor is the idea that “when things go wrong it is usually because a series of failures conspires to produce disaster,” and in this respect medicine might have a great deal to learn from the aviation industry. What is new and important is the astute criticism Gawande levels at morbidity and mortality rounds, the “cultural ritual[s] that inculcate in [physicians] a ‘correct’ view of mistakes.” Gawande is leery of the “fierce ethic of personal responsibility for errors” that he sees underlying the M & M. Complications suggests that by having gallant “attendings” occasionally fall on their swords in these proceedings, hospitals, and medicine in general, sidestep broader issues, problems that inhere in the very structure within which the M & M operates. For it is not the one doctor — or the one nurse or the one pilot — who alone causes or can prevent most mistakes. Rather, “disasters do not simply occur; they evolve.” They do so one small mistake at a time, one person's lack of sleep compounding another's lack of training and another's bitterness at his or her working conditions.
Although these sections alone are worth the price of the book, the criticisms and observations of the second half of the book are slightly less insightful. The reader is treated to a familiar series of interesting patients and curious cases, and to the author's mostly successful attempts to extract meaning from the mundane. This in itself is not a huge criticism, and the book reads well. Gawande provides an annotated bibliography, suggesting that he expects to be read by a curious and interested audience and demonstrating respect for his readers. Add to this a number of clear articulations of some of modern medicine's most pressing problems — or complications — and Gawande's book easily repays the reader's investment.
It should be noted that it cannot be a small challenge to write a book while practising to be a doctor. The fact that Gawande has managed to do so suggests he has priorities that may at once make him a commendable physician and set him at odds with his profession.
Ted St. Godard Third-year medical student University of Manitoba Winnipeg, Man.