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Complications: A Surgeon's Notes on an Imperfect Science by Atul Gawande (2003-04-05) Audio CD – January 1, 1801
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FALLIBILITY (I.e., doctors make mistakes) ----
EDUCATION OF A KNIFE: New surgeons learning their craft by operating on real patients.
COMPUTER & THE HERNIA FACTORY: Using computers and ultra-specialization to reduce medical errors.
WHEN DOCTORS MAKE MISTAKES: Most doctors make mistakes. How can they be reduced?
NINE THOUSAND SURGEONS: What it’s like at going to a surgeon’s convention.
WHEN GOOD DOCTORS GO BAD: When an experienced doctor’s performance markedly declines.
MYSTERY (I.e., not everything about medicine is known) ----
FULL MOON FRIDAY THE 13th: Does the emergency room really get unusually busy on these superstitious evenings?
THE PAIN PERPLEX: What causes pain? What drives the intensity of pain?
A QUEASY FEELING: Nausea. Like pain, sometimes hard to determine its cause or alleviate its discomfort.
CRIMSON TIDE: Nope, it’s not about periods – it’s about blushing.
THE MAN WHO COULDN’T STOP EATING: Hunger and the gastric-bypass operation.
UNCERTAINTY (I.e., what’s really the right thing for the doctor to do?) ----
FINAL CUT: Autopsy
THE DEAD BABY MYSTERY: SIDS (Sudden Infant Death Syndrome)
WHOSE BODY IS IT, ANYWAY?: Letting patient’s make their own informed decisions about their medical care.
THE CASE OF THE RED LEG: Diagnostic uncertainty, doctor’s gut instinct and flesh-eating bacteria.
The theme of this book is reflected in its three parts: Fallibility, Mystery and Uncertainty. Each part talks about a particular aspect of Gawande’s career as a surgeon that deals with the less-certain side of being a doctor. Each concept is accompanied by one or more anecdotal references to his own real-life cases that illustrate his point brilliantly.
And that point is that doctors know a lot - but they don’t know everything. Their education and practical experience can help prepare them with knowledge, but skill comes from years of learned real-world practice. I could really sympathize with him and the stressors he has to deal with. I’ve been guilty as well of feeling my doctor must and should know everything that is right for me to do. The truth is a lot more complicated than that.
This book doesn’t even take into consideration the patient frustrations with healthcare - cost, attention, etc. It really does focus on pulling the screen back and giving you a glimpse into the vast uncertainty that accompanies this sometimes wondrous profession.
This is NOT a book that says, “I’m a surgeon. Here’s all the supercool things I’ve done and this is why I’m awesome and don’t you wish you could get me as your doctor?” This book shows the doctor, warts and all, and makes them much more human.
***What of this book?
1. It is written in three sections.
a. Fallibility (The shortcomings of physicians)
b. Mystery (Mystery Illnesses)
c. Uncertainty (Gray areas and diagnostic uncertainty)
2. I get the distinct impression that the author wrote a series of essays and then chose the best of them as could be fit into this book. It's like he didn't write only as many "songs" as he needed for this "album." He had a whole bunch of them in a vault somewhere and then just pulled some number of them together and then made the concept of the "album" after the fact.
***What can we learn from this book? Much, as it happens. I can give some of the things that popped out at me the most
1. Medicine is an empirical science. A lot of things are learned/ decided on the fly and with more information they might have been decided differently. There are no algorithms or simple answers.
2. There are questions about ways that surgeries can be set up. Do you train one surgeon to do many things, or do you train many surgeons (teams?) to do one thing only. The discussion of the hernia repair team and the way that they improved their efficiency by doing the same thing OVER AND OVER again (p. 35) is food for thought.
3. The training of physicians has to happen on *someone*. And the training for procedures to be done on humans can only be done on humans. And yes, people who are poor and unable to purchase their own insurance are more likely to be guinea pigs. And that's just the reality of things.
4. There are no clear mechanisms to sanction physicians when they are past their prime and start killing patients. This book is about 15 years old, but then (as now), government accountants and colleagues will catch the physician before any ethics/ disciplinary board.
Verdict: Recommended. The fact that this book is still high priced in spite of being 15 years old is its strongest recommendation. The present reviewer is offering one more.
Top international reviews
A perfect example of this, although extreme, is the final case he discusses of an otherwise healthy young woman who presents with an inflamed red leg. Is this a severe case of cellulitis (probability approaching 100%) or is the leg infected with the bacteria necrotizing fasciitis (probability vanishingly small, but with potentially devastating consequences)? The author honestly admits that hunches, gut feelings and other unscientific considerations inevitably play a role in decisions about what actions to take, however much he wishes that they didn't. He is just as frank about other aspects of medical practice, such as the need for surgeons to hone their technique on real patients, with the inevitable consequences that the less advantaged in society become the `guinea pigs' and some operations will not be done well. But when his own child becomes dangerously ill he honestly confesses that he does not want an operation to be done by an inexperienced junior surgeon, as would any parent wanting the best for their child. How do we resolve this dilemma?
There are many other dilemmas of medical practice discussed in the book, such as: how should poorly performing surgeons be disciplined in a way that does not make the profession in general too conservative and hence hinder surgical progress; to what extent is a surgeon entitled to `steer' a patient into a course of action that they, the doctor, thinks is the right choice, even though the risks may be high; and should a doctor attempt to prolong life, even when the treatment will not prevent the inevitable outcome and may even produce more suffering?
This well-written book brings home to the reader not just the technical difficulties of being a surgeon, but also the ethical responsibilities it entails and the stark problems that surgeons have to face daily. It can usefully be read by both medical students and professionals, as well as by anyone who is liable to be a patient at some time, and that means all of us.
I think the one thing which comes over to me from all the medical books I read is that however much medical science advances there is just so much about the human body which remains undiscovered. Doctors are never going to get it right all the time however well trained they are and however much experience they have. I was interested to see how much of an inexact science diagnosis is and the autopsy figures quoted by the author show that the cause of death may turn out to be incorrect as many as a third of cases. The figures haven't changed in the US since the 1930s in spite of the huge increase in modern technology and ways of seeing inside the human body.
It is all too easy to assume that modern medicine has all the answers and this book will swiftly disabuse the reader of this idea. I found the chapter about patients being given all the risks and options fascinating. Do we want doctors to make decisions for us or do we want to be given enough information to make our own decisions? What should a doctor do if he/she believes a patient is making the wrong decision? This author's books are a must read for anyone who has had any dealing with modern medicine if only because it helps to remind us all that doctors are people too
Thought provoking and highly recommended.
At times I found the narrative too detailed when providing an argument to his point. I would not fuss about it though.
Reading it made me realise that a practicing clinician needs both medical knowledge and loads of common sense. This book tries to help us improve on the second aspect.
Very interesting all the same.
Very well written.