A review of Atul Gawande’s Complications: A Surgeon’s Notes on an Imperfect Science
Peter Oluwaṣeyitan Bamikole, MSI
“Read Gawande.” That was the brief answer a doctor gave me when I asked him what medicine is like. So I started with this book, and thoroughly enjoyed it. To better commend it to you, I will briefly review it here. Dr. Atul Gawande, an American surgeon, opens Complications with two central assertions: “[Medicine is not] an orderly field of knowledge and procedure,” but instead “it is an imperfect science, an enterprise of constantly changing knowledge…” (Kindle p. 7). To support these claims, he compiles 14 essays loosely federated under three headings: Fallibility, Mystery and Uncertainty.
Acquiring a new skill demands a learning curve. “As patients, we want both expertise and progress. What no one wants to face is the contradiction” (p. 27). Novices improve best with experience, under expert supervision. But the skills practiced in medicine involve real-life human beings, and this makes all the difference. What ailing person wants to be practiced on? When Dr. Gawande had a sick child, he himself—at the time a resident—refused to let a resident treat his daughter. He demanded an attending. This understandable fear means that doctors must be discreet about the training process, and trained physicians are necessary handmaidens to their trainees’ mistakes.
This bothers us so much because contemporary medicine prioritizes machine-like perfection in delivering care. Dr. Gawande visited Ontario to find his illustrative example. North York’s Shouldice Hospital is a ‘hernia factory’: they exclusively perform hernia repairs, cheaper and faster than anywhere else, yet with better outcomes. From the staff to the building’s very design, Shouldice “deliver[s] hernia repairs the way Intel makes chips” (p. 40). But could this “factory model” work on a grander scale? According to Gawande, the medical establishment is wary of this sort of automation especially as it pertains to the “art” of diagnosis.
Yet, regardless of their operative model, doctors must be healers. After all, “nothing splits a patient and doctor like a mistake” (p. 45). An instance of medical error is usually seen as a case of bad doctoring. It is often not so. Medical mistakes happen. He offers this advice to physicians: be diligent, expect perfection and own your errors.
Our view of pain is historically Cartesian (“pain is like pulling on a rope to ring a bell in the brain”), but was replaced by Gate-Control theory (the spinal cord modulates pain percepts before they reach the brain, so the “bell itself modulates the rope”). Now we think pain is “all in the head.” Under this dispensation, pain and other sensations are “neuromodules” in the brain, like computer programs. But these neuromodules are entire networks (mood, emotion, memory, anticipation etc.) that together decide the threshold at which they play. Pain, therefore, “is a symphony” (p. 124). This means that a mere toe stub is more complex than we thought, and it also explains why limbless people feel limb pain. Despite its physical basis, in the brain all pain is the same. Gawande weaved the story of a patient through this essay to strengthen his conclusion: the social coordinates of chronic pain merit our attention. By paying attention to the non-physical factors that may cause pain, this new model has, surprisingly, made pain political. What unites the essays in this section is the observation that mystery comes with the territory of doctoring. So make your peace with it, early and often.
In the opening essay, Gawande cites a 1971 paper about the nature of fallibility in science. Its authors argued that in applied sciences like medicine, perfect knowledge of a particular case is impossible. For example, who knows precisely where a hurricane makes landfall? They called this “necessary fallibility.” Yet some things (like ice cubes in a fire) are firmly predictable. Ignorance and ineptitude are surmountable sources of error, but necessary fallibility cannot be helped. So in medicine, “are people more like ice cubes or like hurricanes?” (p. 198).
Autopsies are on the decline, perhaps because of “medicine’s 21st century tall-in-the-saddle confidence” (p. 193). Folk wisdom states that autopsies rarely implicate misdiagnoses in the cause of death. But the four studies Gawande provides suggest that 33 to 40 percent of autopsies revealed misdiagnoses that would have saved lives had they been caught. And these rates haven’t improved since at least 1938. For his part, Gawande reckons that humans are equidistant between hurricanes and ice cubes: “permanently mysterious” in some sense, yet—given enough systematic investigation—“entirely scrutable” (p. 199). Gawande’s final essay recounts the case of a young girl with necrotizing fasciitis, and the book ends with the unsettled nature of his treatment decision. It helps the reader see what medical uncertainty looks and, perhaps, feels like.
These 14 essays are a humanizing account of medicine for doctor and patient alike. From Gawande’s description of cutting live skin for the first time (“thick and springy”) to his reflectiveness as an author, his writing gives one a sense of what it is like to newly enter this guild. Altogether, the essays are fertile ground for thinking about what it means to practice compassionate health care amid the necessary competencies of 21st century medicine. If systems simplify modern medicine, then remember older dimensions of care like talking to patients. To reduce medical errors, go after processes, not people. Don’t be so certain about the relationship of appetite and willpower in obese people. There are many more insights to glean, and some of the essays even function as a kind of cultural anthropology. Apparently, doctors—like all humans—are a superstitious lot. Also, who knew surgeons got lonely? And prior to a medical tragedy, does anyone care? Most of these essays are open-ended and consequently great for reflection. For us who strive to worship God by serving mankind, books like this are grist for the mill.