In this unique book, the author Dr. Atul Gawande has done an excellent job of dissecting the existing medical system, especially the surgery process in major hospitals. Contrary to what most people feel, Gawande stresses that medical science is imperfect and that many doctors and surgeons also operate on a hunch many times. The charm of the field lies in the fact that there is a persistent gap between what’s known and what’s unknown. The author believes that the uncertainties arise when the simplicities of science mix with the complexities of individual lives. Throughout the book, Dr Gawande espouses the value of practice and more practice. Although he concedes that a few surgeons are more skillful than others, he firmly believes the difference in ability is almost always due to more practice and not natural talent. A recurrent theme through the book points to the ‘human’ element in doctors and how challenging decision making under uncertainty can be.
Dr Gawande discusses the fallibility of surgeons by citing examples from his own experience as a surgical resident. He believes that a resident’s perspective is fairly unique because of the learning process involved. The author himself struggled through many basic surgical procedures when he started out as a resident and slowly got the hang of things as time progressed. It is this part of the book that is extremely honest and revealing. Gawande recalls how he stared in awe at the precision and composure of senior surgeons. He cites an oft-repeated maxim ‘Sometimes wrong, never in doubt’ to illustrate how confident surgeons are when they begin their surgeries. Given the inadequate information, the ambiguous science and the imperfect knowledge, surgeons cannot take anything for granted. Their only hope of improving is through constant practice. The author’s idea resonates with the one in Mathew Syed’s ‘Bounce’. In the latter book too, Syed claims that natural talent is more of a myth and attributes much of an elite athlete’s success to hours of practice. Gawande too believes that while there are a few naturals, learning through mistakes and experience is what sets the field apart.
Interestingly, Gawande also indicates that top medical schools focus on this very trait when they have to decide on admissions. Conscientious, industrious students are preferred to the more ‘gifted’, lackadaisical ones. Gawande recounts how he fumbled through elementary surgical procedures when he was starting out as a resident. The episodes are funny, yet very genuine. After his initial woes, he recalls how he suddenly got ‘better’ one day and completed the procedure with consummate ease. I particularly enjoyed this section of the book because I was able to draw parallels with other fields too where the learning curve can be steep if not as challenging as the one for surgeons. Gawande also confesses that almost all published success rates for surgeries are those of the most experienced surgeons and not those of all the novices and beginners.
The man versus machine debate has been the focus of many books. Thankfully the topic has been accorded only as much importance as it deserves and not treated in too much detail. Just as Deep Blue trumped Kasparov in the chess contest, the machine triumphs Dr Ohlin, one of the finest cardiologists when it comes to analyzing electro cardiograms. Gawande also discusses the example of Shouldice hospital as a case of an institution that has excelled by mechanizing the surgical process. He uses the term ‘focused factory’ to describe Shouldice. Gawande, in this section of the book, does an excellent job of balancing his support for technology and his love for the human touch in medicine. While he concedes that bias and fatigue will almost always drive humans towards error, he firmly believes that the human touch and experience is vital for healing. When asked if the predictability in the nature of surgeries might make the experience boring, a surgeon at Shouldice remarks that ‘perfection is the excitement’. Gawande however believes that idiosyncrasies of patients have to be taken into consideration.
Gawande’s tone throughout the book is very candid. He uses beautiful examples from real life experiences in the surgical theater to illustrate the challenges faced by surgeons. He celebrates the learning process and supports the rather controversial procedure of getting inexperienced surgeons to practice (and learn) during complicated surgeries. The stories are crafted intricately and filled with a dash of humor. The reader at times might be stunned by the confessions and honesty but is likely to enjoy and appreciate the author’s ability to combine his professional expertise with a brilliant writing style.
Gawande also indicates that surgeons know and feel fear too. They are concerned about how they perform and are consistently worrying about their progress. He stresses however, that surgeons have to be able to hide the fear and nerves lest the patients spot the same. There have been many accomplished surgeons who have lost their way in their careers after a couple of failures. Often, Gawande feels, the surgeons who fail end up blaming everyone around but themselves. The author clearly values the contribution of technology in the field of medicine and believes that statistical analyses and simulation systems can be used to complement and aid surgeons.
Perhaps almost as recognition of human fallibility, most top hospitals have an M&M (morbidity and mortality) conference regularly to discuss their failures and improve on their performance. However, the author does suggest that very few hospitals manage to understand why these errors might be cropping up. Quite often, people expect surgeons to be perfect although they are fully aware of the complications involved in the surgical process and how these complications can affect performance. Also, some of the finest doctors, whose performance has fallen away, have been diagnosed with mental illnesses and erratic behavior. Gawande feels that the key to understanding surgeons and their performances lies in accepting the fact that they are humans too and that they can be overworked, stressed and unstable at times.
Gawande also goes on to discuss the increasing autonomy that patients have in modern day surgical process decision making. Not only do they have more choices – i.e. surgeries for obesity, surgeries to eliminate blushing, curing motion sickness etc but they also have the choice of opting for surgery or not even if it is a more critical one. The author talks about how stigmas attached to appearance and behavior have contributed to certain changes in how patients have started acting and what they have started demanding of doctors. How much of a say should doctors have and how much leeway should they give their patients when it comes to decision making?
The book makes for fascinating reading for anyone who is remotely interested in medicine and the advancements in the field. It is at once shocking to see the uncertainty prevalent in the profession and yet heartening to read a top-class surgeon admitting the flaws. Dr Gawande argues that the biggest challenge for doctors lies in trying to be rational in the face of uncertainty and pressure. He even cites an example from his own experience when he had to let another doctor take over the treatment of his child. Despite being a highly successful doctor himself, Gawande had the awareness and humility to realize that a specialist was needed and that it was not the time to bring up emotional attachments. He believes that the medical profession as a whole is guided by the need to know more and needs to focus on asking the right questions to obtain the best answers. Intuition is dangerous many times, yet could be a life saver too, Gawande reiterates. With an outstanding example of how he instinctively felt that the cause for foot redness might be the life threatening ‘flesh eating’ bacteria and not just any normal infection, Gawande illustrates the value of intuition in the medical context.
Blending compassion with knowledge, experience with wit and simplicity with a free-flowing writing style, Gawande makes a difficult, complicated topic seem extremely readable and enjoyable. There are few weaknesses in this excellent book. Maybe Gawande could have actually suggested a few changes and ideas to deal with certain medical situations instead of merely citing more and more examples. Most medical books are filled with incomprehensible jargon. Gawande refuses to take that path and has instead churned out an engaging read for any type of audience. ‘Complications’ is a highly recommended book for any individual who is inquisitive about the happenings in a mysterious yet simple science.
