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'Complications: A Surgeon's Notes on an Imperfect Science' - 2002-10-27


Medicine is not only a highly prestigious occupation in the United States, but one surrounded by high expectations. Patients don't like to think their doctors can make mistakes, or be stumped by a difficult diagnosis. But in fact, medicine is filled with errors and uncertainties, says American doctor Atul Gawande. He's the author of "Complications: A Surgeon's Notes on an Imperfect Science." The book was recently named a non-fiction finalist for this year's National Book Award.

Atul Gawande finished "Complications" while doing his surgical residency, the final stage in his medical training. He says he wrote the book to explore questions about the challenges and limitations of modern medicine questions his textbooks didn't seem to answer. He believes the same kinds of questions are being asked by patients in the United States, as they take growing responsibility for their own medical care. And as a surgeon, he has a special perspective on the answers.

Gawande: "Surgeons every day deal with uncertainty, information that's inadequate, a science that doesn't always have the answers. The best surgeons I've known are people who seem to be capable of understanding that their abilities aren't perfect, and yet believe they can forge ahead, that the risks of opening somebody up with their own hands are outweighed by the benefits, even if sometimes terrible complications can happen."
Beardsley: "One of the first dilemmas you write about in your book about is that a surgeon becomes a good surgeon not because of talent or good hands. The most important thing is practice, but you have to practice on someone."
Gawande: "You have to practice on people. And what surprised me was to find that the learning curve really never ends in surgery. My father is himself a surgeon, and he told me that 75 percent of what he does today he never learned to do in his training. There's so much new technology, so many new things that come along today. The dilemma is that we want perfection, and we want progress, but we'd like it to happen without practice. And that isn't really possible. We in medicine can even be hypocritical about this. My son had to have cardiac surgery as a very young boy, and thank God, he made it through it, and the resident came to me and gave me a card and said come to an appointment with me in two weeks. But I knew I wanted to see the associate chief of cardiology who had all the experience in this area, and I said no. Thinking back on it, I felt that this was my child, I wanted the best for him. And yet people if asked will always say don't practice upon my child, or upon themselves, but the practice needs to go on."
Beardsley:"Were there some disasters, or near disasters for you when you were just beginning your residency?"
Gawande: "There always are. You sometimes do have to make mistakes to learn. And when you think about the fact that the problem of error is one of how to keep good doctors from making mistakes, that's when you realize how difficult the problem is. One example: I'll write a thousand prescriptions and I know for sure sometimes I'm going to put the decimal in the wrong place and the wrong dosage will be given, or a pharmacist will misread my handwriting. Well, we've had for over a decade, a solution that would eliminate more than eighty percent of these errors, which is writing these prescriptions on a computer. And yet because we're so used to thinking of error as a scandal, rather than as a matter of process, we've missed this solution which would solve one of the most important errors that occurs."
Beardsley: "You also have a section on medical mysteries, pain or illness that doesn't seem to have an obvious cause. And you write not so much about obscure diseases as about commonplace afflictions like nausea or back pain. Are those often the hardest problems to treat?"
Gawande: "You know, our expectation as patients is that at this point medicine has solved most problems. But in fact, there's a great deal we that don't really understand. The common cold still perplexes us. We don't even have a great explanation of how it's passed from one person to another. Back painwe know what happens. Everybody gets X-rays, and if you see something wrong with the spine, we'll even operate on it. And yet the evidence is that people with chronic back pain frequently don't really have anything wrong with their back and as long as the spine isn't actually injured, it's not clear at all that operating on their back is that much better than less invasive interventions. Pain comes from the brain. It's a program in the brain, and that program can sometimes go haywire and fire off almost by itself, and understanding why and how to control these haywire programs is still something we're still trying to do."
Beardsley: "With all the new technology that's available to us and all the new findings, you end the book talking about intuition. What role can that still play in treating patients?"
Gawande: "When we've gotten rid of as many mistakes as we can get rid of, and we've done all the research we can to answer as many questions as we could, there is a moment with every patient when you have to rely on intuition and a hunch. The example I talk about is a woman who came in with a red leg, and it looked to the emergency room physician like a simple skin infection that an antibiotic pill would take care of. He asked for a second opinion and I took a look, and my stomach dropped when I looked at that patient. I thought it was flesh eating bacteria, this rare disease which can kill you within hours. It can start as a tiny infection, just a spot somewhere, and spread through your whole body. And the only way to diagnose it is to open up the leg and look. And I knew that the reason I was thinking about it was the one case I'd ever seen had happened a few weeks before, and yet I had this hunch. In the end we took the patient to surgery, and my hunch was right. She had the flesh-eating bacteria climbing up her leg almost as we watched. We were able to save the leg, but the lesson for me was that medicine is less perfect, less technological, more human than we really expect it to be. But once you realize that, you also realize that it is much more remarkable than we ever knew."

Atul Gawande is the author of "Complications: A Surgeon's Notes on an Imperfect Science." The book is a non-fiction finalist for this year's National Book Award in the United States.

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