Author: Atul Gawande

Publisher: Metropolitan Books, Henry Holt Company LLC, New York, 2002

Book Reviewed By: Shakesha Coleman

Atul Gawande wants to know if we can all just get along. On a superficial level, Gawande's Complications: A Surgeon's Notes On An Imperfect Science is advice to patients, physicians, and the medical industry, about how to weaken the smoke screen that exists between science (physicians) and observers (patients). A deeper reading however, reveals that Complications is about the dishonesty that hinders the growth of every industry, and the solutions that will come about when people dare to be honest. Further, one is reminded through this text that science, like life, is complicated by a reluctance to be honest about the unknown.

Gawande proposes that the relationship between physicians and patients is blurred by "fallibility," "mystery," and "uncertainty"-the respective titles of parts one through three of his book. Each part of the book is divided into about five chapters that contain examples of medicine as an "imperfect science" that mystifies even some practitioners. Gawande's encounters as a surgical apprentice are spoken of vividly, and read like a novel. The text is well organized, and despite the medical jargon-which Gawande does a superb job of explaining-Complications is a very user-friendly read. The reader leaves the text enlightened about many subjects, including ethics, politics and policy.

Gawande disguises his wisdom about the pretensions that complicate all professions through the advice he gives to patients, physicians, and the medical industry in general.

In "Fallibility," Gawande advises patients that physicians, regardless of expertise, are not perfect. This imperfection we are told, stems in part from the fact that new technologies are constantly being created. The constant implementation of new technology often leaves even the most experienced physicians on the same academic footing as interns. Gawande tells: "For the established surgeon, inevitably, the opportunities for learning are far less structured than for a resident." This means, as Gawande points out, that many patients are treated on the basis of trial and error. This is a necessary imperfection, as Gawande goes on to state that: "You can't train novices without compromising patient care."

This understanding is particularly important given Gawande's assertion that patients and doctors are made adversaries by the media. On the one hand, there are medical dramas that portray surgeons as complacent experts that discuss yuppie-life while performing delicate operations. On the other hand, there are reports about malpractice lawsuits. In "Fallibility," Gawande urges readers to consider the anxiety that even expert surgeons experience when preparing to operate. The refusal of people to understand this angst perpetuates a cycle of doom in the practice of medicine-one is which doctors are forced to view themselves as infallible machines-the anxiety created by this view, which some practitioners adopt, leads to mistakes that physicians do not want to admit to, for a fear of being discovered. An example of this cycle is given in the section entitled "When Good Doctors Go Bad."

Gawande mentions a mistake he makes when he gives a trauma patient with an improperly sized tracheostomy tube. Interestingly, Gawande mentions the patient's blood alcohol level, seemingly, in an attempt to remove accountability from himself. One might suggest that the author himself is a victim of the cycle he describes.

Further, Gawande proposes that patients ought to find another method of dealing with the mistakes of physicians, other than the malpractice suits encouraged through television, as they are, in Gawande's words, a "remarkably ineffective remedy." He goes on to state:

"The deeper problem with medical malpractice suits is that by demonizing errors they prevent doctors from acknowledging and discussing them publicly. The tort system makes adversaries of patient and physician, and pushes each to offer a heavily slanted version of events. When things go wrong, it's almost impossible for a physician to talk honestly about mistakes. Hospital lawyers warn doctors that, although they must, of course, tell patients about injuries that will occur, they are never to intimate that they were at fault, lest the "confession" wind up in court as damming evidence in a black-and-white mortality tale. At most, a doctor might say , "I'm sorry things didn't go as well as we'd hoped."

This is why even at the weekly Mortality and Morbidity Conferences, called "M&Ms", that take place "at nearly every academic hospital in the country," physicians speak in a passive voice: "A [insert procedure here] was attempted without success."

The desired outcome is that patients will remove doctors from the pedestal on which society now has them. The realization that physicians are fallible, will give them the freedom to make and correct mistakes-a process that will result in the production of better physicians, and a more honest relationship between practitioner (physician) and observer (patient). In this sense, "Complications" is about the mistakes that occur in every industry, and the solutions that never come about because of people's desire to live up to expectations. Gawande proposes that this was part of the reason that Dr. Goodman eventually lost his job.

Dr. Goodman was what Gawande calls an "everyday bad doctor." These are physicians who become senile and refuse to retire, surgeons who "lose their touch," and complacent physicians that make cavalier decisions. Dr. Goodman may have been one of these physicians.

Being available at inconvenient hours and attracting new patients, Dr. Goodman began to call himself, "only half in jest, 'The Producer'." Goodman took on too many patients, and rushed through, and botched, medical procedures. Gawande coins University of Michigan sociologist Marilyn Rosenthal's term "Terribly Quiet Chat," in speaking of the measures that were taken by Goodman's colleagues to help him correct his behavior. The more courageous colleagues chastised Goodman privately, but most, as people in any profession, were too afraid to speak up about his abuses-opting instead to steer patients away from the once very respected Dr. Goodman. In what appears to be a wall of silence, much like that which exists in police departments, Gawande proposes that Goodman was "burned out." Others might conclude that he was simply motivated by cash.

Gawande advises physicians to steer clear of the pressures of expectations, by asking questions and seeking the advice of supervisors. Gawande tells of an experience in which he mistakenly prescribed a dosage of Vitamin K to a patient because he did not consult a senior staff member.

Gawande also advises that perfection comes through repetition. He urges those in training to constantly practice those procedures that still seem daunting, and to continue doing so until one can perform them as accurately as surgeons at Shouldice Hospital perform hernias. Shouldice is a center in Toronto, Canada known for their expertise and efficiency treating hernias and related illness. In fact, this hospital is referred to as a "hernia factory." The repetition that occurs here is the reason for their success, notes Gawande. In fact, Gawande's advice to the medical industry is to promote greater practice and specialization. Gawande believes that a greater service will be provided when physicians get more practice. Extended practice will lesson the "complications."

In the section entitled "Mystery," Gawande tells of the human tendency some physicians have towards the supernatural, such as belief in superstitions, and the tendency that physicians have-like all people-to be confused about the origin of some problems. Gawande gives examples of patients experiencing pain and illnesses that are unique, and that to this day, remain unexplained. The man experiencing excruciating back pain and the pregnant woman experiencing extraordinary amounts of nausea, are just two examples of science's "imperfection." Gawande offers an interesting discussion about the origins of pain in this section, as the reader is left with the notion that doctors often have to take guesses about subject matter just as anyone else would.

In the section entitled "Uncertainty," Gawande reminds us of the Marie Noe case, in which Noe's ten babies mysteriously died in her home. The cause of these mysterious deaths was named Sudden Infant Death Syndrome, commonly called SIDS. The circumstances surrounding the death of these children were a medical and social mystery. Ultimately however, Noe pleads guilty to eight counts of murder. In this section, Gawande also advises patients that doctors, even with all of their vast knowledge, rely on the information that patients give. In this regard, sometimes patients are misdiagnosed when physicians receive the wrong information. This is best summed up where Gawande states: "In the end, it is sometimes not science but what people tell us that is the most convincing proof we have." Such was the case with Marie Noe.

Doctors are people too. Like most people, many have unresolved issues from childhood, substance abuse problems, and pedophilic tendencies-there is a mention in Gawande's book about a doctor who on several occasions invited young male patients on excursions with him.

One solution to the God-complex may be programs like Dr. Kent Neff's in Minneapolis, where judges, doctors, lawyers, company executives, and other such kindred go to be evaluated and treated. As Dr. Neff states, his program is "hard on [the] behavior [and] soft on the person."

Students of any discipline can enjoy Complications, but students of public health policy, general policy, political science, and philosophy may be especially interested in its content. Complications is a memoir about the fallacies that occur in society on an everyday basis-in law, medicine, and any other industry-and about how everyone's façade overlaps. Further, through this text, one realizes that the degree of separation between medicine and other disciplines is often slight.

Complications is a good read for anyone who deals with expectations on a daily basis-which is everyone. Science, like life, is complicated by a reluctance to be honest about the unknown, and one's imperfections.

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Shakesha Coleman is a graduate student at the State University of NY at Albany's Rockefeller College of Public Affairs.

04/12/2002