Complications: A Surgeon’s Noteson an Imperfect Science
by Atul Gawande
Metropolitan Books, 269 pp., $24.00
Among the huge number of men and women practicing medicine during the past century, only a few have been able to write well about their profession for the general reader. Of the most accomplished among them, it can be said that their words are a natural extension of their healing. Any physician becoming familiar with the stories and essays—and the poems too—of such doctors soon recognizes the depth of their concern for those who come to them for help and their understanding of the difficulties and satisfactions of caring for the sick.
The best example of such dedicated physician-writers is William Carlos Williams, who was for seventeen years co-director of pediatrics at the Passaic General Hospital and physician to tens of thousands of adults and children, some three thousand of whom he delivered. In the poems and stories of Dr. Williams can be sensed what it means to be in a state of clinical watchfulness, and it serves him well. Like Dr. Williams, the best medical writers have let the story come forward unhampered, though they themselves are not only in it but of it as well. Being good clinicians, they have not hesitated to immerse themselves in another’s life or another’s narrative, but they do not take it over. The contemporary writer who best exemplifies these qualities is surely Oliver Sacks, whose immense learning is so unobtrusively woven into his accounts of nervous disorders and evocations of his own personal experiences and those of his patients.
Now we have Dr. Atul Gawande with a new and different voice, bringing to modern high-tech medicine the same clinical watchfulness that writers such as Williams and Sacks have brought to bear on the lives and emotions of often fragile patients. The reader feels that he is accompanying Dr. Gawande at the bedside or operating table and senses that the events are being described and confronted as they should be if we are to get an honest sense of the complexities of twenty-first-century healing. If there is a genre to which the chapters of his collection of essays belong, it is not that of any known form of literature, but is instead an experience familiar primarily to surgeons—the Mortality and Morbidity Conference, in which doctors meet to discuss what went wrong in particular cases or how a better outcome might have been achieved. The purpose of the conference is to reveal and examine human error, specifically the errors of members of specific surgical teams. Acknowledging fallibility is the key to improvement.
But at such conferences, that acknowledgment of fallibility is made only to other physicians. Laws in most states protect the conference discussions from public scrutiny; otherwise few if any participants would be as forthcoming about their errors as they must be if the meetings are to be useful. If the participants cannot be absolutely frank, the aims of the conference are frustrated. Nothing is learned and nothing changes.
Gawande contends that the learning and changing should not be restricted to doctors. The more knowledge that the public and individual patients can acquire about the realities of modern medical practice, the better may be the choices that any of us makes about our own care. The old patterns of a paternalistic form of medicine nowadays are rapidly giving way to what bioethicists call autonomy—the principle that the patients should make their own informed decisions about treatment. One result is an increasing demand for the information they need, whether general knowledge about the ways in which disease affects the body, or specific information about the variety of treatments available. But, with the exception of a few loudly reported cases of malfeasance, very little has been written about the ways in which doctors actually do their work, and most specifically the sources of error inherent in diagnosis, in treatment, and in the training of young physicians.
In this book and in his articles in The New Yorker, where much of its contents first appeared, Gawande has written about the art of healing as it takes place day to day in America’s leading academic medical centers. As though to make clear from the outset that he is dealing with revelations about the unsure ground on which so much of medicine stands, and has always stood, he has chosen to divide his short book into three parts, called “Fallibility,” “Mystery,” and “Uncertainty.” A glance at those headings in the Table of Contents should be enough to concentrate a reader’s mind—if the book’s title has not already done so.
Gawande begins with his own beginning, a fumbling start to his surgical training that will, I am sure, bring back disquieting memories to many doctors who read his book:
This will be good, I tried to tell myself: my first real procedure. My patient—fiftyish, stout, taciturn—was recovering from abdominal surgery he’d had about a week before. His bowel function hadn’t yet returned, leaving him unable to eat. I explained to him that he needed intravenous nutrition and that this required a “special line” that would go into his chest. I said that I would put that line in him while he was in his bed, and that it would involve my laying him out flat, numbing up a spot on his chest with local anesthetic, and then threading the line in. I did not say that the line was eight inches long and would go into his vena cava, the main blood vessel to his heart. Nor did I say how tricky the procedure would be.
During his attempts to insert a plastic catheter into a large vein located just beneath the clavicle, or collar bone, Gawande seems to do everything wrong before finally managing to thread the device into its proper place. The patient, unaware that he is in the hands of a beginner, is subjected to delay and discomfort in the name of medical education. A more experienced resident is standing nearby and could easily have spared him the anguish; but she is there to teach and Gawande is there to learn, and so the patient, who is there to be treated, becomes an object for instruction. The two doctors acknowledge that in helping this man they have also used him:
Outside the room, S. said that I could be less tentative the next time, but that I shouldn’t worry too much about how things had gone. “You’ll get it,” she said. “It just takes practice.” I wasn’t so sure. The procedure remained wholly mysterious to me. And I could not get over the idea of jabbing a needle so deeply and blindly into someone’s chest.
In these ways, the term “medical practice” takes on a little-acknowledged meaning that badly needs to be understood if the process of learning, as Gawande puts it, is not to be “hidden behind drapes and anesthesia and the elisions of language.” Without such practice there would soon be no highly trained physicians to care for the sick. Mishaps will occur that might not have taken place were only the most senior doctor doing every procedure. These are painful truths, but the days of concealing them will be numbered if Gawande has his way. But “everyone is harmed,” Gawande writes, “if no one is trained for the future.”
Mishaps have their usefulness, and this is what the Mortality and Morbidity Conference is all about. Gawande describes one in which the doctors discuss his failure to insert a breathing tube in a surgical opening cut into a rapidly failing woman’s windpipe, a procedure called tracheotomy. At literally the last moment, patient and resident were saved by the arrival of attending physicians who skillfully took over. When the near-tragedy was reviewed at the following week’s conference, every one of the errors leading up to it was described and discussed in an atmosphere where responsibility and correction, not blame, were the themes. As in virtually every such situation, what was clear is that supervision of young doctors by seniors is the key to avoiding the errors that trainees may make.
That medical errors occur and that physicians are culpable in both committing and reporting them is hardly news to the general public. But what is relatively new is the candor with which the profession has begun to deal with it. In one of his many useful references to recent studies, Gawande writes of two much-quoted articles published in the New England Journal of Medicine in 1991, which reported that 4 percent of hospital patients had “complications” resulting from their hospital care, of which two thirds were due to errors in care, and that 44,000 patients died in a year at least partly as a result of that care.
Soon after, the Institute of Medicine of the National Academy of Sciences undertook its own exhaustive study of the problem. When the institute’s conclusions were published in November 1999, the monograph’s title acknowledged the role of human error: To Err Is Human: Building a Safer Health System. Instead of being hidden, the results were made public. To the amazement of many physicians, the report’s frankness has relieved them of some of the burden of personal error. Patients and families have begun to understand the weaknesses built into the systems by which the sick are cared for. And they have also begun to understand the uncertainties of medicine itself, even when it is in the most capable hands. If there is a single characteristic of medicine that every layperson should be aware of when accepting or rejecting an offered medical procedure, it must certainly be its inherent uncertainty.
A hundred years ago, the reigning medical authority of the time, Sir William Osler of Johns Hopkins, in musing on the state of affairs that he called “the uncertainties of medicine,” spoke of “this everlasting perhaps with which we have to preface so much connected with the practice of our art.” Surely, many would say, things are different in the current era of molecular biology. Paradoxically, the opposite is true. The remarkable advances of ultramodern biotechnology have brought with them complexities of such magnitude that medicine sometimes seems in danger of being overwhelmed by forces of increasing intricacy and incomprehension. In certain situations, only the small number of superspecialists who deal in a particular aspect of diagnosis or therapy are equipped to interpret a finding or observation. What conclusions are to be drawn from a hard-to-interpret test of liver function? In what situation is it better to recommend angioplasty rather than coronary bypass? Which of three possible antibiotics is best for a particular resistant bacterium?
The opinions of the highly specialized consultants called to address such problems sometimes conflict. The responsible attending physician who must actually make the major decisions may not fully comprehend every assumption and each piece of medical evidence that should enter into them. And once having chosen a course of action, he must then trust to an unknown number of others that it will be properly carried out. These range from the surgeon doing an operation to the maintenance man servicing a piece of equipment or the orderly cleaning it. We are caught in a spiral of uncertainty that is only magnified by the increasing range of our capacities.