Atul Gawande's Complications: A Surgeon’s Notes on an Imperfect Science

Prof. David Sowden's winter book review - Atul Gawande's Complications: A Surgeon's Notes on an Imperfect Science

Born in Brooklyn, New York to first generation immigrant Indian doctors Atul Gawande was brought up in Athens, Ohio and began his university education at Stanford. He was awarded a Rhodes scholarship and read PPE at Oxford and then read medicine followed by a Masters in Public Health. He has been an advisor to several Presidents/administrations and has been appointed to advise on the prevention of surgical errors by the WHO. He became a staff writer for The New Yorker magazine in 1998 and his article contrasting high cost, low quality care and lower cost, high quality care in a couple of Texas towns strongly influenced the debate on health inequalities in the US and Obama’s plans for wider government funded healthcare. He was BBC Reith lecturer in 2014 – lectures that are still accessible via the BBC website. He claims that being the son of 2 doctors gave him an early insight into the work and lives of medical professionals. That may be the case but it is really Atul’s intellect and perspicacious insights that shed light on certain aspects of the professional experience and he demonstrates this throughout this book. Complications (his first book) was a finalist in the US National Book Awards and has been published in over 100 countries. Complications is written in 3 sections: the first examines fallibility, the second at mysteries and unknowns and the last at uncertainty itself, how to grapple with ignorance more wisely. From my personal perspective the first and third sections are of greatest interest, and I think that will be the case for most medical readers. The second section deals with patients with symptoms or afflictions (such as pain syndromes and unremitting nausea) for which there is little in the way of reliable, current medical interventions. Whilst he deals with these well, I think their main interest will be to the general reader, as much of what he writes will be at least somewhat familiar to colleague professionals. This, perhaps, highlights an overarching weakness in the book (not a fatal one though) – it is clearly written for a general readership and thus there are times when you just want him to get on with the deeper analysis that the issues he raises warrants. Nonetheless, there is much here that will interest healthcare professionals and most importantly he writes engagingly so even when the pace slows his prose pulls you along. I think the following quote summarises what Gawande is attempting to achieve in this book..

as pervasive as medicine has become in modern life, it remains mostly hidden and often misunderstood. We have taken it to be more perfect……. and less extraordinary”

..than it, in fact, is. Resonates rather well with the author in my first review, I think. One might be tempted to accuse Gawande of simply trying to make doctors appear to be human, with all the usual human frailties and fallibilities, rather than heroes, and thus fall into an ever growing trap of populist writing that addresses such issues by simply taking an unhelpful, 'penny dreadful' potshot at professionals; cutting them down to size, some might say. But this book is much more than this. Why, you might legitimately ask? Firstly, Gawande is considered in what he writes and he takes great care to highlight the uncertainties and problems about oversimplifying the issues he is focusing on. Secondly, he doesn’t draw trite and convenient conclusions; he acknowledges and embraces complexity. Finally, and most importantly he makes the reader do some work and I would be surprised if any reader didn’t pause at times and put the book down to consider their thoughts on the issues raised; I certainly did. Two issues raised in the book highlight this feature. The first of these is about training doctors and the need for them to practice on patients to acquire experience and ultimately competence and in due course, expertise. I read this book just as the court case about Jack Adcock’s death in Leicester in 2011 reached its conclusion with Dr Hadiza Gawa-Garba (a paediatric specialty registrar) being found guilty of manslaughter by gross negligence. Put the particular case together with the general issue and it really does highlight Gawande’s statement that..

the moral burden of practicing on people is always with us, but for the most part [is] unspoken”.

He highlights the attempts..

to mitigate potential harm through supervision and graduated responsibility”

..but emphasises that these can’t ever eradicate the risk of harm or harm itself. He also introduces an uncomfortable American flavour by referring to..

residents practicing on the poor, the uninsured, the drunk and the demented”.

Mind you it probably wouldn’t make for more comfortable reading to hear that in the UK that practice is, democratically, on just about everyone. He emphasises that effectively patients and their relatives, the population at large indeed, want perfection and medical progress without practice but that is clearly impossible. He reasons that some people might intellectually be able to “take on chances for societal benefit” but that when push comes to shove in the reality of an illness in a child or partner this moral stand point quickly dissipates. So does he say anything that might help? – yes, at least to some extent. He feels there is a need for a more open discussion with patients and the wider population; though he doesn’t expand on how. Additionally, he highlights research on the acquisition of new surgical techniques that shows that learner established surgeons with a collaborative approach, undertaking multiple cases in quick succession with pre-operative planning and post-operative wash up meetings showed the best surgical outcomes and the quickest learning. The second issue relates to consent. He highlights the drive toward genuinely informed consent and freedom of choice in treatment and management options, and the view of ethicists that, effectively, patients should be made to make their own mind up about all medical care. Refreshingly, he then highlights the weaknesses of this approach in the reality of reaching decisions in the face of health crises and acute illness; initially by referring to his own personal experiences with one of his children. As Patricia Glyn wrote recently about a similar situation..

I felt blind, deaf and intuitively disabled”.

He then adds in the growing impossibility of providing patients with sufficient information and understanding to make reasoned decisions; medicine is just getting too complicated, at times at least, for many to genuinely understand the pros and cons of any course of action. That isn’t to say that he hankers after the previous benevolent, or not so benevolent, medical paternalism but rather acknowledges that it is part of the human condition to need help and assistance in moments of genuine crisis when the individual’s capacity to make reasoned judgments is reduced or even absent. In such circumstances, Gawande argues for patients making a legitimate choice to ask the professional to propose the most sensible way forward – after all isn’t that what expert professionals should be doing? He emphasises the great responsibility that brings and earlier in the book had highlighted the problems of “good doctors gone bad” (also worth a careful read) but I still believe his open discussion of this issue warrants wider debate and soon. Conclusion As an introduction to Gawande’s writing this is a good place to start. If you don’t have much time, miss out the second section but the other 2 sections warrant closer scrutiny and offer an opportunity to pause and think. Certainly this is one of the few books that I have found myself recalling and thinking about several weeks after my initial read. You might argue that that is an inevitable consequence of reviewing a book, but I am not so sure. Complications: A Surgeon's Notes on an Imperfect Science. Atul Gawande Profile Books eISBN 978-1-84765-124-2 First published 2002. You Tube LINK The Difference between Coaching and Teaching - by Atul Gawande

Prof. David Sowden

MBChB, FRCGP, FRCOG, FFSEM, FAoME, DCH. Now retired. Formerly : Dean of Post-Graduate Medical Education East Midlands (2000 – 2012) Director of Medical Education England (2008/09 and 2012)