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.
Originally discussed at the Las Vegas Meharry Medical College Alumni Fall chapter meeting on 10/10/2015
Luther Adair, II, MD, ‘06
- The struggle to produce doctors of color remains
- Preservation of a legacy of leadership in service to underserved communities
- There are more choices than ever now
- Opportunity to reach within our pool of resources
Number 1. The struggle to produce more doctors of color remains at many crossroads: teaching institutions such as Meharry Medical College, Morehouse School of Medicine, and Howard University College of Medicine are in prime positions to nurture community-based partnerships in order to address the shortage of underrepresented minorities in the health professions. According to the Bayer corporation in 2010, the top three reasons for minority underrepresentation in the sciences are lack of quality science and math programs in poor school districts, persistent stereotypes that minority students can’t cut it, and financial issues related to the cost of education. Furthermore, as of 2006 when I graduated from medical school, underrepresented minorities made up just 6% of all physicians and 5% of dentists.
Number 2. The second reason centers around the preservation of a legacy of leadership in service to underserved communities. The legacy of African American leaders and principles continues to be questioned or marginalized. These things are especially hurtful to the future generations who will grow up without role models that resemble them. The problems faced by underserved populations remain constant while the definition of what constitutes a minority becomes nebulous. In every city that my wife and I have lived, this population is clear. And while it doesn’t always look the same or even speak the same language, the challenge is binding.
Whether it’s “Aloha!” on the West side of Honolulu, “Hola!” in East Las Vegas, or “What’s up!” in North Las Vegas, our connection with someone in these communities or communities with similar patterns is almost certain. To know that the color of one’s skin predisposes them to certain disease processes and healthcare risks is both a threat to good science and to the United States as a world leader.
Number 3. There are more choices than ever as the world is flat. Demographics are changing in cities quicker than ever, which also provides unique opportunities for some of our students. While the world remains flat, it is not time to dilute our product but to invigorate it with more cultured and achieved participants. Meharry Medical College committed to this very principle by placing Dr. James Hildreth at the helm as president of the College this past spring. Hildreth, who is attributed with groundbreaking research in HIV prevention, is not enough. We need 130 more James Hildreth’s each year between the graduating classes of dental and medical schools.
Number 4 . Reaching within our pool of resources becomes an opportunity for us to restore faith in ourselves. The funny thing is that with the three reasons I just mentioned, minority communities, particularly the African American community, aren’t always in agreement about the strength of its resources. However, having a consolidated group of resources that you can count on is a huge help in the real world. This is the talented tenth restoring faith in itself.
Now is not the time to become inert, as if you are not in the game, you or someone you love will become a casualty of it. Let’s support our beloved alma mater as institutional level commitments are needed in this fight and this is where it all starts.
U.S. Women and Minority Scientists Discouraged from Pursuing STEM Careers, National Survey Shows, Bayer Corporation Press Release, March 24, 2010, CSR Wire, http://www.csrwire.com .
Zayas, LE & McGuigan, D (2006) Experiences promoting healthcare career interest among highschool students from underserved communities. Journal of the National Medical Association; 98:15231531. Organized Noise: Partnering with the Community to Address the Shortage of
Underrepresented Minorities in the Health Professions, Issue Brief July 2011, Kweli R. Henry. Brooklyn Health Disparities Center, http://www.downstate.edu/healthdisparities .
A Report of the Sullivan Commission on Diversity in the Healthcare Workforce, Missing Persons: Minorities in the Health Professions (2004), www.sullivancommission.org.
If you don’t know what happened in Pakistan recently, here’s some background reading:
We are two voices.
Two entities in one.
Me and you – a hybrid
Of downs and lows,
Of ups that never got too high,
Of cognitive and emotional.
And we only speak the words of silence
Because we are the dream of reality.
We are the silent scream
Everyone hears, but never truly heard.
My sister’s predisposition
I was made for you,
But I’m what’s wrong with you.
We are two in one – a hybrid
“Schizophrenia and Bipolar”
They like to call it
But – I mean, let’s be honest here.
Mental disorders don’t really exist.
Only White people pop pills because they are having a bad day.
Let’s admit it, being Black every day is a struggle.
So move on, suck it up.
Depression, Schizophrenia, Anxiety –
Are you serious?
No need to visit a doctor or therapist,
It’s called life, Sweety, get over it.
Or so they say,
But that belief has never gotten me far.
Years after my talks with God,
Denial can only last so long.
Because she still speaks a distant language
I can no longer comprehend.
The voices are putting a curse on her,
Reading her mind and now everyone knows her thoughts –
Especially the Hispanics.
The Spanish neighbors saw the photos taken by the construction workers
Never leave the window open
They can see you.
Leviticus Ch. 24 v 16 says,
“And he that blasphemeth the name of the Lord, shall surely be put to death,
All the congregation shall certainly stone him”
She is a heathen now,
Cursing God in her mind
So she will starve herself for 40 days and 40 nights.
So go ahead…
Give her another diagnosis.
But I want you to know
She is my prescription.
And you’ve never seen psychotic
Until you’ve seen me
Listen to another white man in another white coat
Identify her based on the silence of her tears.
His books, His doctorate, His degree
Screams louder than the voice
That always dreamt to sing
Just like Alicia Keys.
His words muffle your dreams
Choke you with medication –
Crippled by a label from a stranger,
Who thinks he knows everything.
You don’t know the entities that exist together.
Because together divided,
I lost and found.
I found what I lost,
Although not exactly what I was looking for.
So yes, there is a heavy heart that weighs down my mind.
But I will still be by its side, helping to carry it.
So the next time you say she is different.
When you deem her an outcast
And look strange upon her
And she doesn’t understand the noises.
I beg of you to stop talking long enough to listen.
You see after talking all of these years
All of these days, hours, minutes and seconds to you.
I took one second out to listen to the voices.
It cried for silence
Do you hear it?
It’s a song so foreign to your ears.
I’m talking at its pace,
Dancing to its beat.
It’s a language even God can speak.
And only the open-mind can hear.
The problem with health care in the United States is not that it is inadequate. This is the furthest thing from the truth. Though there are constant mentions of unsavory health outcomes, namely infant mortality and its link to the unserved, the United States health care system has been at the forefront of medicine and innovation many times. In some ways, the extensive bureaucracy and heavy regulations that are instituted are present as a way to protect citizens from being victim to products and services that are cost consuming and inadequate. The real issue with US health care is how it is paid for and who gets covered.
With that said, it is also obvious that our current health care system leaves quite a bit to be desired. Even with the passage of the Affordable Care Act, there will still be a substantial amount of Americans who are not covered and many more that remain underinsured. Approximately 7.1 million individuals signed up for health care through the Affordable Care Act. However, in a recent survey by The Henry J. Kaiser Family Foundation, 36% of Americans between the ages of 18-64 who remain uninsured stated that they opted out of buying insurance because the plans available were too expensive.
So, what can be done to improve the American health care system and keep costs low if the Affordable Care Act is not the final answer?
Many physicians believe that the answer lies in the adoption of a single payer system. Such a system has already proven to be successful in Great Britain and Canada. Citizens of these nations enjoy quality healthcare that is government funded. Such a system is successful for a variety of reasons. By establishing a payment system in which citizens pay taxes that are then designated toward health care, there is an implied idea of transparency in health care spending and financing at the federal level. Citizens will have the ability to see where their money is being spent. Also, such a system would take the power away from insurance companies. Consumers will no longer have to look to insurance agents for decisions on health matters.
Another important idea is the fact that there will be a substantial decrease in health care costs in the United States. The US health care system is one of the most expensive. In 2010, The United States spent roughly 2.6 trillion dollars on health care. Greater than $8,000 per person. There is obviously a huge discrepancy between yearly health care costs and health care outcomes. By adopting a single payer system, costs will be reduced on many fronts, but mainly through greater promotion of preventative medicine strategies. If more patients are able to establish primary care and receive preventive screening and intervention, Emergency room visits, which are amongst some of the costliest care, will be reduced. Also, there will be a natural decrease in disease treatment because illnesses will be treated at an earlier stage, thus requiring less intervention in the form of costly surgeries and diagnostic and therapeutic technology.
There is also the huge implication that such a system would have on physicians. Not only would physicians be able to be paid for providing healthcare, but also they would be rewarded for implementing preventive medicine techniques. If physicians are better compensated, at the primary care level, this would allow for a greater incentive for medical students to pursue primary care fields as opposed to higher paid specialties.
The most important reason why single payer or “Medicare for all” is such a novel and legitimate idea is that coverage would be expanded to most, if not all, citizens. This idea does what Obamacare could not by allowing all people to have adequate access to health care, something that is truly their right. Also, there is the idea of expanded autonomy, in which citizens are more in charge of their own health. By implementing a system where medical services are paid for from a central source, health care would be re-routed toward its original goal, which is giving people optimum care and an improved quality of life.
Morolake Amole, MS IV
Support your fellow Meharrians on the Timmy Global Health Challenge by clicking VOTE NOW for team North of Charlotte!
You can vote multiple times. Let’s help the mission of Meharry reach global levels!
GIVE (Guyana International Volunteer Experience)!
According to the World Health Organization, the adult mortality rate in Guyana is 379 per 1000 for males and 258 per 1000 for females. In addition the prevalence of HIV is 814 per 100,000 and the incidence of malaria is 6049 per 100,000. These statistics are far above the global averages for these ailments. In collaboration with the Davis Memorial Hospital of Georgetown, Guyana it is our goal to raise funds to bring medical, dental, and graduate students for an opportunity to serve from June 21 – June 28. Our group has aptly been named GIVE (Guyana International Volunteer Experience). It is our plan to bring needed health supplies for the medical and dental clinics as well as provide assistance to the health providers of Davis Memorial Hospital in working with the physicians, dentists, and hospital administrators in addressing the health needs of the locale. We hope to establish a long lasting relationship with Davis Memorial Hospital and the country of Guyana as we give our students practical experiences in our service to mankind.
Last year, with your support, we were able to organize a successful medical mission trip to Haiti. We were able to bring much needed supplies to one of the largest Tuberculosis Clinics in the country. Our actvities can be seen in the video that is on this page. With your assistance we would like to have similar success in meeting our goals for this trip. We humbly ask for your monetary support and thank you in advance for your generosity. Upon our return, pictures, videos, and documentation will be provided so that you can see where your support went.
Rechelle Jackson, D2
Last semester, The PULSE, formally introduced the college’s 12th president, Dr. James E.K Hildreth in our fall edition. Dr. Hildreth was named president in July 2015 and since then has been working tirelessly to make his presence known and goals realized.
However, as the old adage states, behind every great man is a great woman and Mrs. Phyllis Hildreth is no exception. The PULSE was able to have a few moments with the new first lady of the institution and learn more about her past, present and future.
Mrs. Hildreth was born in Berkley, California to an Oklahoma father and Missouri mother. During the interview, she frequently spoke of her love of history and how she felt everything happened for a reason and during a certain time. “I believe that our individual stories and community stories are so heavily marked by larger national and historical stories that seem not to be related, but when we pull back and pay attention we see why something happened,” she recollected.
During the Civil Rights movement, her father graduated from Lincoln University, an HBCU in Jefferson City, Missouri. Concurrently, the Korean War was taking place and opportunities for blacks were very limited. Therefore, young black scientists and doctors ended up on the West Coast where they could thrive.
“I was trained in California schools during a time when Sputnik happened and the Russians got to space first, so everyone felt the need to train more scientists,” she said. She also stated that she was brought up during a time where there were linear roles and individuals had to identify as one particular job. “There wasn’t any deciding my career path, it was fairly organic, the question wasn’t was I going to be a scientist, but more so what kind.”
Although Mrs. Hildreth did major in biology in undergrad and soar through ecology and learning about the macro systems, a part of her did not feel complete because of the lack of interaction with people. “There was no social component, so it did not interest me,” she said. She admitted to enjoying the bonding and identifying with others during her self-proclaimed “15 minute” stint as a pre-med student.
After graduation, working as a laboratory technician for five years did not stop Mrs. Hildreth from her true passion. She instinctively felt the need to help the family and believed that healthy families were the core of healthy communities. “I loved the centrality of maternal child health,” she said. “Maternal and child health systems are the heart of my universe.”
She recalls her last job being at Johns Hopkins University in the pharmacology department. She remembers one of her husband’s mentors pulling her to the side and asking what it was she truly wanted to do because she could not continue to hide in the lab.
“He did me a great service. I would have signed up for a career that did not have much black life or culture,” she said.
With the hopes of pursuing a degree at the School of Hygiene and Public Health at Johns Hopkins and the ultimate goal of studying maternal and child health, Mrs. Hildreth applied to the University of Maryland’s law school. In 1984, she became part of the first law school class at the university to matriculate a large number of African-American students. Incorporating her love of history she said, “With Brown vs. Board of Education they continued to segregate high school and higher education, so this class was a part of completing the desegregation process.”
In the course of her first year of law school, Mrs. Hildreth discovered that she actually liked it. Upon searching for a job during school she was forced to carry around her one-page resume stating that she had majored in biology, worked in a lab for five years and now wanted to be a lawyer. “The only person who said ‘yes’ was the public defender of Baltimore city,” she said. “They put me over the CINA (Child In Need of Assistance) division and I clerked there for the remainder of law school.”
Mrs. Hildreth went on to graduate in 1988—and because of her great work ethic and willingness to work in a narrow, but nevertheless, important area of law, she was offered a position at the public defender’s office. Immediately after swearing in, she had piles of cases waiting for her. “We must focus on that which we have passion and do it with exhausting excellence,” she advised when reminiscing.
Our first lady is currently a professor at Lipscomb University teaching conflict management where she was previously a student in the same program. When asked how she felt about having to move back to Nashville after her husband accepted the president’s position, she said that she had never left after he departed Meharry for California. “We were forced to have a long distance marriage for four years,” she stated. “But during that time I was able to empathize with mothers in a way that I had not previously. I was able to see what it was like for other families to have to do this and make it work,” she continued.
When asked how she deals with the pressure of being a professor, first lady and public figure, she said that she may work long and non-traditional hours, but the minute she gets home she has released everything and work is not the focus. Her hobby, knitting, is also a stress reliever that helps to ease the day’s worries.
In addition to assisting in fulfilling her husband’s goals for Meharry, she also hopes that, by her presence and practice, women of her generation begin to institutionalize a way to be easily accessible. “I want to figure out a way to have couch hours and it will be known that at a certain time on a certain day I will be findable,” she said.
Lastly, Mrs. Hildreth wants all Meharry students, whom she affectionately calls her babies, to know and understand that we are not just training to become doctors, dentists and researchers. We must realize that our purpose is bigger than ourselves, she said, and in some cases the things we want to do may not have been invented yet.
“If your goal is a value, then you have great freedom and flexibility to adapt to the different ways in which that value is manifested and addressed,” she continued. “However, if your goal is to a particular process, when that process is no longer needed, neither are you.”