Complications: A Surgeon's Notes on an Imperfect Science

2.5 stars

"We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line. There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing. The gap between what we know and what we aim for persists. And this gap complicates everything we do."

Atul Gawande's Complications (2002) strongly resonates with me in at least two ways. My favorite field of mathematics is probability, and one of the topics that excite me the most is how bad most people (including myself) are in dealing with uncertainty, i.e., with practical consequences of randomness. Dr. Gawande dedicates quite some space to this issue in the book, as promised in the snippet from the Introduction, quoted in the epigraph above. Furthermore, when I teach software engineering, I emphasize the topics related to quality assurance. Dr. Gawande's book makes it absolutely clear that the best way to improve medicine is to put a stronger focus on quality assurance in the medical process.

The book contains many fascinating stories of medical cases, often from the author's own practice as a surgery resident. We read about the physiology and psychology of blushing, gastric-bypass surgeries, persistent nausea, evolution of theories of pain, cases of "flesh-eating bacteria" infection, sudden infant death syndrome, and several others. As captivating as these cases are, being in the math and computer science fields, I am more interested in issues of uncertainty in medicine, medical errors, and the potential method of reducing the uncertainty and the number of errors.

The existence of medical error is normal, and I am using the word in two different meanings: normal as 'expected,' 'regular,' 'frequent,' but also normal as in the mathematical term of "normal distribution" that can be illustrated by a bell-shaped curve. Very informally, the so-called Central Limit Theorem, one of the magnificent achievements in the mathematical theory of probability, states that when the outcome of an experiment or event is affected by many, many independent random factors, then the value of the outcome follows the bell-shaped curve: most outcomes are in the fat middle of the graph (these are the average, expected outcomes), and very few in its tails (these are the unexpectedly bad or unexpectedly super successful outcomes).

Consider the author's example of a fairly routine operation of laparoscopic cholecystectomy ("lap chole"). The extreme complexity of human physiology, the complexity of activities in the operating room, the complexity of psychology of the doctors and nurses on the team, etc. result in thousands, probably millions of independent random factors that influence the outcome of the operation. So the outcome must be normal (as in bell-shaped). There will always be the tails of the distribution, and one of these tails may mean the patient's death from a routine surgery. The author writes:

"[...]studies show that even highly experienced surgeons inflict this terrible injury [cutting the main bile duct] about once in every two hundred lap choles. [...] a statistician would say that, no matter how hard I tried, I was almost certain to make this error at least once in the course of my career."

One of the most fascinating fragments of the book deals with the human inability to choose the right decision when randomness and catastrophic results need to be considered. Suppose (this is my example) a patient has a condition that severely imperils the quality of life. Suppose there exists an operation, with a recorded success rate of 99%. But in the remaining 1% of cases the patient will die during the operation. We do know the probabilities but how can we estimate the numerical value of the patient's life relative to the value of their life with the debilitating condition and relative to the value of the healthy life? If we could, the mathematical problem would be simple but, of course, we can't! The additional complication is the natural human inability to understand the difference between probabilities of, say, 0.001 and 0.00001 of something very bad happening. Both events are unlikely to happen, but don't forget that both will eventually happen. To someone, maybe even us.

Dr. Gawande quotes a lot of statistic in Complications. Here's probably the most scary of them:

"How often do autopsies turn up a major misdiagnosis in the cause of death? I would have guessed this happens rarely, in 1 or 2 percent of cases at most. According to three studies done in 1998 and 1999, however, the figure is about 40%."

So is medicine doomed to fail in a high percentage of cases? Or is there a chance for the medical success statistic to improve? The author's answer is positive and he repeatedly offers his suggestion of the best medication for the ailing medicine. In the last chapter he writes:

"[...] to shrink the amount of uncertainty in medicine -- with research, not on new drugs or operations (which already attracts massive amounts of funding) but on the small but critical everyday decisions that patients and doctors (which get shockingly little funding)."

Reduction of uncertainty is the crucial step. It could be achieved by following the quality assurance guidelines from other fields of science and technology. Dr. Gawande mentions various methods and processes that are used to improve aviation safety as recommendations that could easily be adapted for the medical field; I would add the engineering disciplines in general, including software engineering and systems engineering. Standardization, uniformization, "routinization" of medicine are strongly recommended.

A highly worthwhile book! I am sure that also the readers, who are not particularly interested in the issues of uncertainty and error in medicine, will find the medical case stories captivating and valuable reads. Well-written book, accessible, and convincing!

Four-and-a-half stars.

This is a fascinating book by a physician and a great writer. Using real life cases as the focus of the book, he uses the examples and outcomes to discuss many complications in medicine. Not necessarily medical or surgical complications, but philosophical complications. He asks many thought-provoking questions emerging from his experiences. Who should make decisions regarding treatment, for example. Should the knowledgeable party-the doctor-make decisions alone? This is considered paternalistic and often problematic. Should the patient decide? After all, it's his/her body.
The best decision making should involve both. However, in real life this is not always possible, as he shows in several vignettes. Is the patient mentally competent to make decisions? They should be informed of their options in clear language. They should work with the physician to decide on treatment. But the patient may have undisclosed issues, the information provided may be biased or incomplete. There may be emergency situations in which the doctor must make the decision. And with all of this, both patient and physician are humans and are fallible. Mistakes are made. There are cost-benefit issues, family members at odds with the patients wishes.

Throughout the book, the record of his experiences, he is honest and human. Always aware of the enormous responsibility of his role, aware of errors of judgment, he remains a compassionate voice.

Some subjects included are the complexity of pain and how it can vary from patient to patient and be present when there is no physiological reason for it. He discusses the connection between pain and the brain. There is an interesting section on hyperemesis of pregnancy, unrelenting blushing, morbid obesity and other pertinent topics.

This is a highly recommended book for anyone who is ill, for physicians and humans in general!

Complications is a book O rate as 4 stars. It really delved into the world of surgery, yet I was still able to understand a majority of the topics he elaborated on. It is divided into three sections Fallibility, Mystery and Uncertainty. The first section, Fallibility, I would rate as four stars. It is personal, honest and very scary look at Gawande’s life and observations as a surgical resident. He talks about how despite a surgeon’s public face of knowing exactly what they are doing they are often basically practicing on their patients. Even experienced surgeons are constantly faced with new technologies and procedures that they are given limited training for until they have to give it a try on their own on a living, breathing person. The second section, Mystery, I would give three stars to. In this section Gawande discusses several medical cases that are interesting and obviously interest him but which he had either no or only peripheral personal experience with. He does do excellent research on these cases and he conducted in-depth interviews with the doctors and patients for each case but they still lack the personal feel of the other two sections. The last section, Uncertainty, I would rate at almost four stars. In this section Gawande once again goes back to his own experiences while talking about autopsies and how doctors make diagnoses and how they get them wrong.

Complications make you want to take great care of yourself so you'll never have to get surgery again. It's incredible how surgeons and patients are so complicated, how residents are just basically training "on you," and how much goes wrong and right. I'll never be as naive about healthcare again.

i am now horrified of medical errors, but this was a great read

I like this author. I like his candid approach to healthcare and to surgery. This book starts out with a picture of physicians learning procedures by practicing on willing patients. I live in an area where we have teaching hospitals and that it so common. But when you are the one haveing to make the decision to be practiced upon, it is so easy to tell them to move along.

Some of the stories made me a little squeamish. TMI I thought. But overall, an interesting listen this evening. So 4 stars.

I found this book on a coffee shop shelf and couldn't put it down. It is a fascinating journey into the mind of an incredibly reflective surgeon who explains complex medical operations in every day language. Atul Gawande executes the kind of self-evaluation each of us should be inspired to engage in throughout our careers. The way we interact with people matters, the way we lean on our intuition matters, and the way we wrestle through uncertainty in complicated situations matters. I would recommend this book to anyone. Thank you Dr. Gawande for an incredible read.