Complications: A Surgeon's Notes on an Imperfect Science

Rating:
Summary: Praise from Health Affairs & New England Journal of Medicine
Review: Below are excerpts from two esteemed healthcare journals reviews of this book.

Health Affairs:

"Gawande exposes the fallibility, uncertainty, and mystery of medicine in true stories about real people. In a world where overly cautious attorneys protect physicians and hospitals from overly zealous trial lawyers by urging clients to cloak and hide errors, Complications is testimony that at least one doctor in one system was permitted to speak openly about medicine's failures. He does so to make an important point: Where errors are hidden, learning is squelched, and so, like Sisyphus, workers in these systems are compelled to err and err again.

"What you find when you get in close, however,...is how messy, uncertain, and also surprising medicine turns out to be." Gawande gets us up close. We experience the havoc as the inexperienced and exhausted resident misapplies a central line (a catheter inserted into a major vessel, terminating at or near the heart). We understand how a doc "who's gone bad" continues to harm his patients because those who witness his crimes are silenced by a cult of secrecy. We see how information failures at the point of care, when decisions must be made instantly under great pressure, prevent the application of best practices. In each anecdote, lives are on the line, and medicine, an "imperfect science, an enterprise of constantly changing knowledge, uncertain information and fallible individuals often fails to do the right thing."

This isn't just a sensational collection of tales of medical fiascoes. These stories are accompanied by a very clear prescription for healing. In the chapter titled "When Doctors Make Mistakes," the author applies a surgeon's precision to dissecting the reasons behind the mess and uncertainty of medical care as well as the interventions that will provide relief. This chapter should be assigned reading for all health professionals and students. Gawande believes that we can narrow the limitations of science and of human fallibility. While never exonerating the individual from a responsibility to shoot for perfection when human lives and suffering are at stake, he does not regard avoiding error as merely a matter of will. All humans will err occasionally, but they tend to err in predictable ways. Systems that do not adjust for these realities can end up exacerbating rather than eliminating error.

Gawande calls for a closer examination of the process, and less of the individuals within it. He advocates for removing the system failures that result from a lack of standardized protocols, a culture of secrecy, poorly designed technology, inadequate training, thin staffing, and poor teamwork. He calls for rigorous statistical reporting and sharing of information."

NEJM states:
"Gawande writes about the whole enterprise of learning surgery - and by extension, of learning any kind of medicine - by practicing, in both senses, on human beings. And so the discussion extends from his own experience in learning how to put in a central line to the question of why and how repetition - practice and more practice - brings expertise and smoothness, and then beyond to the moral dilemma of teaching medicine to new learners: "This is the uncomfortable truth about teaching. By traditional ethics and public insistence (not to mention court rulings), a patient's right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden, behind drapes and anesthesia and the elisions of language."

"After th[e] introductory section about his own initiation into surgical technique, Gawande brings home the idea that everyone in medicine always needs to face questions of judgment, competence, and decision making."

"In his discussion of mysterious syndromes, of severe blushing, chronic pain, obesity, and nausea, Gawande confronts issues both at the limits of medical understanding and also, not coincidentally, at the intersection of mind and body. The sufferers he describes - a woman who wants to be a TV anchorwoman but endures debilitating blushes, an architect with years of chronic back pain, a construction contractor who weighs 194 kg (428 lb) - speak vividly through his clear and sympathetic writing, showing and telling how their lives have been damaged and circumscribed and even defined by these medical conditions."

"A beautifully written essay on autopsies includes an unforgettable image of a surgeon watching the much less gentle and elegant cutting done on the body after death"

"In the closing essay, Gawande confronts intuition - what it is, how it works, and how it plays out in medical practice - by taking us through the remarkable story of his "great improbable save," a 23-year-old woman who came in with what looked like a cellulitis of her leg and who turned out to have necrotizing fasciitis - a diagnosis Gawande raised early in the course of her illness partly because he happened to have seen another case of it recently. When you are through with your initiation, when the systems work to support your practice, how do you finally make your decisions? When does inconsistency in how patients with the same problem are treated reflect problems in the system or bad doctoring, and when does it reflect tiny but real differences in human presentation or in instinct and choice on the part of well-trained experts and a willingness to live with the necessary degrees of fallibility, mystery, and uncertainty? Given the nature of the questions, of course, and the nature of the problems, there can be no resolution and no answers, but this book is a wonderful tribute to the complexity itself and to the intellectual, personal, and professional consequences of taking it on"

Rating:
Summary: Cutting edge writing
Review: Even in a wonderfully literate magazine such as The New Yorker, Dr. Atul Gawande's articles have always stood out. Dr. Gawande is a staff writer for the magazine and he writes about issues he can deeply relate to-the science and complexities of medicine. Complications: A Surgeon's Notes On An Imperfect Science is a compilation of many of Gawande's essays, a few of which have appeared before in the New Yorker. Many of the essays, however, are new.

It is immediately apparent upon reading the book what an extremely humble person Dr. Gawande is. Even as a resident surgeon in a prestigious hospital in Boston, he retains a special capacity to see the human side of the person laid out on the operating table. Dr. Gawande is able to distance himself from his profession and analyze its faults and shortcomings (including his own).

Complications, nominated for the National Book Award this year, is divided into three categories. In the first, Dr. Gawande focuses on the fallibility of surgeons. In one of the most honest statements in the book (and there are many!) he says, "Medicine is, I have found, a strange and in many ways disturbing business. The stakes are high, the liberties taken tremendous. We drug people, put needles and tubes into them, manipulate their chemistry, biology, and physics, lay them unconscious and open their bodies up to the world. We do so out of an abiding confidence in our know-how as a profession. What you find when you get in close, however-close enough to see the furrowed brows, the doubts and missteps, the failures as well as the successes-is how messy, uncertain, and also how surprising medicine turns out to be." Surgeons, it turns out, are only human, and they do make mistakes on the job. All have to learn on the operating floor. It is a fine line between learning and the betterment of all patients with no harm caused.

The second part of Complications deals with the mysteries surrounding some of the most common of physical ailments-pain, blushing, obesity, morning sickness to name a few. It is in these pages that I was struck by how keen Dr. Gawande is to keep track of his patients. He continues to be in their lives long after the surgery has been done.

Dr. Gawande addresses the uncertainties that plague medical decisions in the last part of his book. How much rights do patients have when the doctor knows "what is good for them". The book features a brilliant discussion of patient autonomy. "The new orthodoxy about patient autonomy has a hard time acknowledging an awkward truth: patients frequently don't want the freedom that we've given them. That is, they're glad to have their autonomy respected, but the exercise of that autonomy means being able to relinquish it." In one of many personal examples in the book, the author himself admits to letting his doctors decide how to care for his premature baby when she was gasping for breath. Sometimes laying the entire decision burden of patient care on the patient can be too emotionally exhausting.

Apart from Dr. Gawande's precise writing (the book reads like a thriller!), I was struck by his strong feelings for the socio-economic underprivileged. He does not neglect to make the case that in a medical setting where learning needs to be done it is often at the expense of the underprivileged or the uninformed. The doctor's child gets special treatment, but the truck driver's child doesn't.

Complications is the kind of wonderful book that makes me feel better prepared the next time I or one of my own is lined up on the operating table. I have been given a view into how the system works. I know I can keep myself informed and hope for the best. If I am lucky, my surgeon will be like Dr. Atul Gawande, capable, sincere, and a person who knows how to "preserve kindness."

Rating:
Summary: Great Pre-med reading!
Review: Definately an excellent book. Being a Pre-medical student, I found the book quite enlightening. Dr. Gawande paints a vivid picture of what life is like as a general surgeon during the residency training. I'd recommend this book to any pre-medical student with interest in the surgical field, or to anyone that's interested in the trials and tribulations a surgical resident must endure.

Rating:
Summary: If you like Oliver Sacks - you'll love this.
Review: I love books that you can lose yourself in. This is so well written - so involving. Dr. Gawande sets up each essay as a little documentary - part mystery, part science, part human interest, but completely fascinating. Anyone who likes books on forensic science or medical mysteries, or anyone who likes just plain good writing will enjoy this.

Rating:
Summary: Amazingly Good
Review: I read quite a few books ranging from pretty bad to extremely good; I do not often post a review or comment. This book is the exception. The writing is incredibly good, very tight and suspenseful and it deals with a subject matter that touches ALL of us as human beings: our health and how we care for it. I would feel the same way even if I did not work at an academic teaching hospital. I hope Dr. Gawande will write more. He writes intelligently, thoughtfully and with a flair for the dramatic. Sometimes I disagreed with his analysis, but it was ALWAYS thought-provoking, which is what we all need in this subject area.

Rating:
Summary: WELCOME - New "Deepak Chopra" Of the Operating Theatre
Review: An amazing thriller...

Dr.Atul's superb portrayal of finest qualities of a doctor, yet the limitations of an individual, their weekness,strengths, system flaws etc with vivid examples of real life cases makes "Complications" the best medical book I'v ever read..

Certainly the pinnacles of the book is the story of Joseph Lazaroff, Atul's Anguish depicting the finest of human character and also the professionalism of a doctor, also his questions behind the ethics of "absolute insane rights of patient's expression". I felt a pain in the heart for that "unknown soul" ( a gist of that chapter is below)

It's not the content of the book alone that deserves appreciation, it's also the flow of words that blend with the topic. I could extract couple of sentences from few chapters to make the point explicit ( excuse me if my editing and the lack of context might not bring the impact the author drives in the book)

Chapter : Whose body is it Anyway :

...I turned the ventilator off, and the suddenly the room was quiet .His breathing slowed ...Joseph Lazaroff had died.But Knowing how much Lazaroff had dreaded dying the way he died....

Chapter : Education of a Knife:

I said to the patient that there were "slight risks" involved....And the disasters weighed on my mind: the woman who had died from massive bleeding, the man who had to have a chest opened, the man who had a cardiac arrests....I said nothing of such things when I asked my patient's permission to do this
Chapter : When Doctors Make Mistakes:

At 2 A.M on a crisp friday in winter a few years agao, I was in sterile gown , pulling a teenage knifing victim's abdomen open, when my pager sounded "code trauma, three minutes"

Chapter : When Good doctor's Go bad:

Before the license of Dr.Goodman was taken away, he was a highly respected and sought after surgeon...he could do some of the best, most brilliant work around....In one case , he put the wrong-size screw into a patient's ankle,another case when he refused to do hip replacement. For the last several years, he was the defendent of a stream of malpractice suits.

Chapter : The Man Who Cannot stop Eating :

...He had to let his legs apart to let his abdomen sag between them. He cannot lie down and breath properly because of excess fat in the tongue and upper airway. He had to sleep in the recliner and every thirty minutes or so , he would wake up asphyxating, He could no longer stand up to urinate, he had to shower after moving his bowels to get clean

Chapter : Final Cut :

The patient is dead; the family is gathered. How would you ask for an autopsy?

A Must Read book...Afterall, someday you might be an example in a chapter of Dr.Atul's books ( Do Not Worry, He disguises your name and personal details)

Atul Gonwande's "Complications", Dinesh's "What's so great about America" and GurcharanDas's "India Unbound" - Each by an Indian - Each a masterpiece in their particular Field

Chandra Sekhar, The reviewer is the author of the book "Internet Marketing And Search Engine Positioning - A "Do It Yourself" Guide

Rating:
Summary: A well written, fascinating book.
Review: Each chapter deals with a different issue or topic, such as medical error, surgical treatment of eating disorder, even the decline in the number of autopsies. The author draws on his personal experiences as a surgical resident, as well as research, both textual and journalistic. The chapters are always fascinating. Gawande understands systems analysis and the scientific method, and is apparently a very warm, caring personality, with a strong commitment to the best possible medical practice. My only reservation is that in the chapters most removed from surgical practice, Gawande reaches conclusions that may overstate the case, for example in identifying the role of obesity in causing snoring, or the role of the unconscious in causing chronic back pain (I don't snore; I have mild chronic back pain). In general, however, he is very sensitive to the complexities of issues, while not shying away from strong conclusions. One chapter is on the training of surgeons, and the consequent need to subject patients to procedures performed by inexperienced hands: I came away wondering why there is not more training on animals, and how much economics or animal rights inhibits use of such training (yes, I do believe in animal intelligence and even consciousness).

Rating:
Summary: A view behind the curtain!
Review: A gem-like collection of essays on medicine by eighth-year surgical resident, Harvard Med graduate, Rhodes scholar, and New Yorker staff writer Gawande, himself the son of physicians. Part I contains chilling stories of medical errors, some the near-inevitable results of young docs learning their craft by practicing on live patients, some due to the burnout or depression of seasoned specialists. (To his credit, Gawande includes a tale of his own poor judgment in a medical emergency that fortunately ended happily.) Practice does make perfect, the author demonstrates; hospitals specializing in hernia repair, for example, maximize their efficiency for the greater benefit of patients. With profound empathy, Part II chronicles medical mysteries. Readers will feel for the pregnant woman whose nausea and vomiting could not be stopped no matter what antiemetic drug she was given-until her twins were born and that same night she was able to eat a hamburger with blue cheese and fries. Sadly, these anecdotes often serve as reminders that what doctors can't pin down they often dismiss, as when a man with incapacitating back pain was advised by specialists to see a shrink. In Part III, Gawande addresses the issue of uncertainty, an ever-daunting challenge in a profession where information is always imperfect. Autopsies, which would help clarify many cases, are performed with appalling infrequency, perhaps because they reveal a depressing rate of misdiagnosis. The new, more democratic relationship between physicians and patients may also have a downside when patients make the wrong decision. The final chapter reports on a case of heart-stopping suspense, lacking clear indications and plagued by great uncertainty, in which the doctors' intuition was critical. If Gawande's hands in the operating room are as sure as his handling of words, his success in his chosen career is all but guaranteed.

Rating:
Summary: A masterpiece, insightful and gripping!
Review: As someone who has a vague understanding of the human anatomy (the pancreas is somewhere north of the thigh and south of the throat), I found "Complications" to be a truly wonderful book. I devoured the book voraciously over a lazy weekend and found myself going through an emotional roller coaster - and after I finished reading the book I almost felt a pang of regret because the ride was over.

As a surgeon, Atul's ability to narrate the incidences is remarkable - he wields the pen with equal dexterity as he probably is with his scalpel. What is even more interesting is that he smoothly weaves research findings from boring medical journals, his experiences and thoughts in between real life narratives - like a camera which pans into the head to reveal thoughts and then throws you back to the reality. I almost felt Amy Fitzpatrick's pain when she went through several months of no solid food, nausea and vomiting bouts, and smiled in celebration when she eats a burger, fries and cheese. Like wise, when another of Atul's patient Lazaroff dies, you wonder what could have been different. Or when you read about Caselli's inability to stop eating and then his triumph over his own self, you realize that the human body functions in a truly mysterious way.

In a world where the doctor barely remembers a patient's name, Atul has done an amazingly good job of keeping in touch with his patients over prolonged period of time, sometimes years. Also, his humility is a touching reminder that the best in class can also be down to earth.

At the end of the book, there was no moment of epiphany but a very sobering empathy for the life, work and world of surgeons. The surgeon's skills, work atmosphere, decision making and empathy required are unique - in the acknowledgements, Atul writes that by writing this book and shattering the ivory tower, he could have raised flak (from the medical community). On the contrary, the reaction of an average reader is that of a better understanding, appreciation and respect of the surgeon's profession.

I developed an overwhelming distaste about the entire concept of "medical malpractice" - guess that's a byproduct of reading such a wonderful masterpiece of insights into the surgeon's mind.

Rating:
Summary: Very Intriguing
Review: This book was an interesting look into the secret lives of surgeons. In the age of the lawsuit, this author should be commended for writing so candidly ahout the mistakes he and other surgeons have made. Readers will be both surprised and grateful.

Even though he went to Harvard Medical School, he is not a snob and does not think he is a god. Instead, he is a down-to-earth, straightforward writer who is happy to pull aside the curtain and let us all take a fascinating glimpse.

My only problems with the book were a few chapters that seemed to bog down with meaningles detail, and a syrupy, pointless chapter about an upper-middle-class woman's fight against severe morning sickness.

Other than that, this book is a keeper. Enjoy!