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Complications: A Surgeon's Notes on an Imperfect Science
This is a stunningly well-written account of the life of a what it is like to cut into people's bodies and the terrifying - literally life and death - decisions that have to be made. There are accounts of operations that go wrong; of doctors who go to the bad; why autopsies are necessary; what it feels like to insert your knife into someone.
270 pages, Paperback
First published May 16, 2013
About the author
Atul Gawande
28 books5,685 followersAtul Gawande is author of three bestselling books: Complications, a finalist for the National Book Award; Better, selected by Amazon.com as one of the ten best books of 2007; and The Checklist Manifesto. His latest book is Being Mortal: Medicine and What Matters in the End.
He is also a surgeon at Brigham and Women’s Hospital in Boston, a staff writer for The New Yorker, and a professor at Harvard Medical School and the Harvard School of Public Health. He has won the Lewis Thomas Prize for Writing about Science, a MacArthur Fellowship, and two National Magazine Awards. In his work in public health, he is Executive Director of Ariadne Labs, a joint center for health systems innovation, and chairman of Lifebox, a nonprofit organization making surgery safer globally. He and his wife have three children and live in Newton, Massachusetts.
He is also a surgeon at Brigham and Women’s Hospital in Boston, a staff writer for The New Yorker, and a professor at Harvard Medical School and the Harvard School of Public Health. He has won the Lewis Thomas Prize for Writing about Science, a MacArthur Fellowship, and two National Magazine Awards. In his work in public health, he is Executive Director of Ariadne Labs, a joint center for health systems innovation, and chairman of Lifebox, a nonprofit organization making surgery safer globally. He and his wife have three children and live in Newton, Massachusetts.
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Displaying 1 - 30 of 3,150 reviews
March 12, 2012
A year or more ago, I mistakenly placed a review for Gawande's book Better under this title. I have fixed the mix up, and I have now read Complications.
Gawande is pure pleasure to read. His writing is fluid and full of germane examples as he addresses big issues like error and incompetence as well as topics that seem less significant but which he makes worthy of consideration such as blushing and nausea. The headings for each section of the book--Fallibility, Mystery, and Uncertainty--are thematic in the text. As one reviewer wrote, "Thank heaven someone wrote this book." Gawande is unapologetic and totally direct in his appraisal of medicine. What I really appreciate is that in Better, which he wrote after Complications, he gives equal time to discussing ways in which medicine can improve.
I'm a fan. A good writer and a good doc. What more could I ask for?
Gawande is pure pleasure to read. His writing is fluid and full of germane examples as he addresses big issues like error and incompetence as well as topics that seem less significant but which he makes worthy of consideration such as blushing and nausea. The headings for each section of the book--Fallibility, Mystery, and Uncertainty--are thematic in the text. As one reviewer wrote, "Thank heaven someone wrote this book." Gawande is unapologetic and totally direct in his appraisal of medicine. What I really appreciate is that in Better, which he wrote after Complications, he gives equal time to discussing ways in which medicine can improve.
I'm a fan. A good writer and a good doc. What more could I ask for?
February 4, 2008
This book wss filled with about 25 anecdotes flimsily tied together by Gawande's less than inspiring reflections. I have the book in front of me at the moment and I am paging through rereading sections that I noted along the way:
"I had come into residency to learn how to be a surgeon. I had thought that meant simply learning the repertoire of move and techniques involved in doing an operation or making a diagnosis. In fact, there was also the new and delicate matter of talking patients through their decisions - something that sometimes entailed its own repertoire of moves and techniques." pg 217
Next to this paragraph I had written "NO SHIT!"
The book is full of these minor, pseudo-epiphianic moments that come off as weak aphorisms. However, given the audience of this book (everyone) he does well to treat people about how uncertain medicine really is and how it really comes down to the tricky nature of making decisions and how they should be made in the medical setting:
"But the conundrum remains: if both doctors and patients are fallible, who should decide? We want a rule. And so we've decided that the patients should be the ultimate arbiter. But such hard and fast rule seems ill-suited both to a caring relationships between docotr and patient and to the reality of medical care, where a hunderred decisions have to be made quickly... The doctor should not make all of these decisions, and neither should the patient. Something must be worked out between then, one on one - a personal modus operandi. Where many ethicits go wrong is in promoting patient autonomy as a kind of ultimate value in medicine rather than recognizing it as one value among others...(A)s the field grows ever more complex and technological, the real task isn't to banish paternalism; the real task is to preserve kindness." pg 223-4
This simply makes sense, nothing new here.
The best part of the book is the last two paragraphs (and is all you really need to read have said that you have read the book, in my opinion.):
"The possibilities and probabilities are all we have to work on within medicine...What we are drawn to in this imperfect science, what we in fact covet in our way, is the alterable moment- the fragile but crystalline opportunity for one's know-how, ability, or just gut instinct to change the course of another's life for the better. In the actual situations that present themselves, however, [...] we can never be sure whether we have such a moment or not. Even less clear is whether the actions we choose will prove either wise or helpful. That our efforts succeed at all is still sometimes a chock to me. But they do. Not always, but often enough." pg 251-2
In a way, the whole thesis of this book (which I think is summed up in the sentence in bold above) is pretty remarkable. There is so much talk about the fallibility and humanity in medicine right now... fallibility is so hot right now. However, as is apparent in this book, the medical community is only at the stage of recognizing this fallibility. Gawande doesn't do what I thought he would: suggest what we should do given the increase visibility of the fallibility of the practice of medicine. He really doesn't have any good ideas. In all his articles, he seems to be advocating a technocratic answer (using checklists etc.). The biggest problem I have with the book is the way Gawande seems to view the profession medical community of independently-acting people, who, in the aggregate, are not too of an impressive lot. In this, Gawande is entirely old-school. He fails to recognize the possibility of alternative ways to approach patient care. In a way, I think that he is dangerously anecdotal. Maybe it is just me being tired of reading anecdotal medical non-fiction, but it just seems like a lame format (don't hold these words against me because I really don't know what I am looking for, or what type of book I would write). He treats them like data points. I believe that the book could be reduced by about 80% for someone like you or I who are as far in the medical field as we are.
However, I believe there to be value within this book. I am really really happy that millions of people (future patients) are reading books like this and Groopman's "How doctor's think" as it really does educate them to get real about what medical care is all about. It will serve to empower people and get them involved in their care and think about how they want it to go down. But, to me, I really did expect a lot more from this guy. The reviews that it got are ridiculous, they are way over the top! It is pretty incredible- it goes to show how easy it is to be heard once you have written for the New Yorker and got a MD from Havard. I will keep reading his books, though, for no other reason than that he is so hot right now, millions are reading him. I at least have to know other people are thinking about.
"I had come into residency to learn how to be a surgeon. I had thought that meant simply learning the repertoire of move and techniques involved in doing an operation or making a diagnosis. In fact, there was also the new and delicate matter of talking patients through their decisions - something that sometimes entailed its own repertoire of moves and techniques." pg 217
Next to this paragraph I had written "NO SHIT!"
The book is full of these minor, pseudo-epiphianic moments that come off as weak aphorisms. However, given the audience of this book (everyone) he does well to treat people about how uncertain medicine really is and how it really comes down to the tricky nature of making decisions and how they should be made in the medical setting:
"But the conundrum remains: if both doctors and patients are fallible, who should decide? We want a rule. And so we've decided that the patients should be the ultimate arbiter. But such hard and fast rule seems ill-suited both to a caring relationships between docotr and patient and to the reality of medical care, where a hunderred decisions have to be made quickly... The doctor should not make all of these decisions, and neither should the patient. Something must be worked out between then, one on one - a personal modus operandi. Where many ethicits go wrong is in promoting patient autonomy as a kind of ultimate value in medicine rather than recognizing it as one value among others...(A)s the field grows ever more complex and technological, the real task isn't to banish paternalism; the real task is to preserve kindness." pg 223-4
This simply makes sense, nothing new here.
The best part of the book is the last two paragraphs (and is all you really need to read have said that you have read the book, in my opinion.):
"The possibilities and probabilities are all we have to work on within medicine...What we are drawn to in this imperfect science, what we in fact covet in our way, is the alterable moment- the fragile but crystalline opportunity for one's know-how, ability, or just gut instinct to change the course of another's life for the better. In the actual situations that present themselves, however, [...] we can never be sure whether we have such a moment or not. Even less clear is whether the actions we choose will prove either wise or helpful. That our efforts succeed at all is still sometimes a chock to me. But they do. Not always, but often enough." pg 251-2
In a way, the whole thesis of this book (which I think is summed up in the sentence in bold above) is pretty remarkable. There is so much talk about the fallibility and humanity in medicine right now... fallibility is so hot right now. However, as is apparent in this book, the medical community is only at the stage of recognizing this fallibility. Gawande doesn't do what I thought he would: suggest what we should do given the increase visibility of the fallibility of the practice of medicine. He really doesn't have any good ideas. In all his articles, he seems to be advocating a technocratic answer (using checklists etc.). The biggest problem I have with the book is the way Gawande seems to view the profession medical community of independently-acting people, who, in the aggregate, are not too of an impressive lot. In this, Gawande is entirely old-school. He fails to recognize the possibility of alternative ways to approach patient care. In a way, I think that he is dangerously anecdotal. Maybe it is just me being tired of reading anecdotal medical non-fiction, but it just seems like a lame format (don't hold these words against me because I really don't know what I am looking for, or what type of book I would write). He treats them like data points. I believe that the book could be reduced by about 80% for someone like you or I who are as far in the medical field as we are.
However, I believe there to be value within this book. I am really really happy that millions of people (future patients) are reading books like this and Groopman's "How doctor's think" as it really does educate them to get real about what medical care is all about. It will serve to empower people and get them involved in their care and think about how they want it to go down. But, to me, I really did expect a lot more from this guy. The reviews that it got are ridiculous, they are way over the top! It is pretty incredible- it goes to show how easy it is to be heard once you have written for the New Yorker and got a MD from Havard. I will keep reading his books, though, for no other reason than that he is so hot right now, millions are reading him. I at least have to know other people are thinking about.
December 4, 2023
Complications is a really interesting book about exactly what the title says: complications in the surgical field. How necessary practice is for surgeons to get better at their jobs, but how reluctant many are to be practiced upon; whether certain surgeries are ethical to do; the critical, yet ethically tricky role of the doctor's intuition. Gawande, in the humble and thoughtful way he always does, ponders these issues and conundrums while also telling patient stories to illustrate his points.
Is it as life-changing as I found Being Mortal: Medicine and What Matters in the End? No. But it was still very thought-provoking and enjoyable.
Is it as life-changing as I found Being Mortal: Medicine and What Matters in the End? No. But it was still very thought-provoking and enjoyable.
November 6, 2021
This was Gawande's first book (2002), who is most well-known for the excellent Being Mortal. The title may lead one to think this all about medical errors, but the subtitle provides a better insight into the contents. It was a National Book award finalist. Gawande writes with candor, thoughtfulness, and empathy in this highly readable exploration of the "imperfect science" of medicine.
The topics are placed in three different sections: 1) Fallibility: here we get the medical errors or misadventures
2) Mystery: those cases that perplex the profession. Not necessarily rare phenomena or bizarre, but those symptoms such as nausea & vomiting, blushing or pain that seems to resist all typical treatments. This was a fascinating section.
3) Uncertainty: a mismatch of ethics, forensics and gut feelings
A thoroughly enjoyable, and edifying read!!
The topics are placed in three different sections: 1) Fallibility: here we get the medical errors or misadventures
2) Mystery: those cases that perplex the profession. Not necessarily rare phenomena or bizarre, but those symptoms such as nausea & vomiting, blushing or pain that seems to resist all typical treatments. This was a fascinating section.
3) Uncertainty: a mismatch of ethics, forensics and gut feelings
A thoroughly enjoyable, and edifying read!!
October 25, 2007
Complications is a book of anecdotes about a surgical resident’s experiences and impressions of the current health care environment. Gawande divides his stories into three sections: fallibility, mystery, and uncertainty. The fallibility section demonstrates that doctors can make mistakes. Some fallibility arises from there being a learning curve. For example, it is hard to do a central line correctly the first time. But for a doctor to learn how to do a central line, he must have a first patient to try it on. The concern then arises as to which patients receive care from the inexperienced versus the experienced. Yet fallibility occurs in even the most experienced doctors. Gawande reports on one doctor who became so careless that he was no longer allowed to practice. The frightening part of that story is how long his colleagues let him continue when they had concerns. (The Doctor also brings up this issue.) It is understandable that doctors are reluctant to come down too hard on their colleagues. They need each other as a support system and thus need to maintain trusting relationships. Furthermore, medicine is uncertain, and it can take a long time to see a pattern of truly irresponsible behavior as opposed to just having more complicated cases. Gawande makes the point that discipline of doctors works best when it done by a group outside the doctors peer group or employer because it is more objective. Then this outside group can propose a plan of action which the employer can implement. Unfortunately, this model has been too expensive to be much of a viable option.
The mystery section details stories of conditions that cannot be explained by current medical science, like blushing, pain, and nausea. In each of these cases, the doctors could not explain why the patient had the condition. Much of the time, the patient just wanted the doctors to believe them even though there did not seem to be a physiological source of the problem. It is interesting that the patient is more willing to accept that there is no medical explanation than the doctors. Yet the doctors are the ones with the training and have probably seen many more circumstances when they cannot make a diagnosis.
The uncertainty section deals with how to make the right diagnosis or judgment. There are several points in this section that have come up in the other literature reviewed for this independent study. First is the declining use of the autopsy. The autopsy is how doctors can determine what was actually wrong with the patient. It is the final way to get rid of uncertainty. Its purpose is to help the doctors recognize such conditions in the future. Yet autopsies are done less and less. (Although many times the family is opposed to the autopsy and will not allow it.) Another recurring point is the decision-making power of the patient. Patients have become more pro-active in their desire for decision-making ability, but they are much more ambivalent about actually exercising it. Especially in situations where there is uncertainty, patients do not feel comfortable or emotionally able to make the decision. Some do not think they can handle the responsibility if it turns out to be the wrong decision. Gawande notes that doctors also prefer to make the decision. One of the things he had to learn as a resident is how to persuade patients to the decision he thinks is best. As health care becomes more consumer-driven, the debate over the level of physician agency is likely to continue.
The mystery section details stories of conditions that cannot be explained by current medical science, like blushing, pain, and nausea. In each of these cases, the doctors could not explain why the patient had the condition. Much of the time, the patient just wanted the doctors to believe them even though there did not seem to be a physiological source of the problem. It is interesting that the patient is more willing to accept that there is no medical explanation than the doctors. Yet the doctors are the ones with the training and have probably seen many more circumstances when they cannot make a diagnosis.
The uncertainty section deals with how to make the right diagnosis or judgment. There are several points in this section that have come up in the other literature reviewed for this independent study. First is the declining use of the autopsy. The autopsy is how doctors can determine what was actually wrong with the patient. It is the final way to get rid of uncertainty. Its purpose is to help the doctors recognize such conditions in the future. Yet autopsies are done less and less. (Although many times the family is opposed to the autopsy and will not allow it.) Another recurring point is the decision-making power of the patient. Patients have become more pro-active in their desire for decision-making ability, but they are much more ambivalent about actually exercising it. Especially in situations where there is uncertainty, patients do not feel comfortable or emotionally able to make the decision. Some do not think they can handle the responsibility if it turns out to be the wrong decision. Gawande notes that doctors also prefer to make the decision. One of the things he had to learn as a resident is how to persuade patients to the decision he thinks is best. As health care becomes more consumer-driven, the debate over the level of physician agency is likely to continue.
June 16, 2022
I thought I wrote a review -years ago -- read another review of this book by 'Chris' --(thanks Chris)
Fabulous --book!
I never forgot it!
Fabulous --book!
I never forgot it!
March 22, 2023
A look under the hood of the profession of surgeons from a thoughtful practitioner and sympathetic writer. At some point in our lives we intersect with the medical profession and perhaps surgeons. It’s good to have thought of some of the issues he covers, such as how training requires doctors to practice on living humans, how doctors are only flawed humans and not supermen who don’t make mistakes or suffer from conditions such as alcoholism or depression, how tricky decision-making can be, how much to trust intuition or expertise.
Another nice offering from a writer I really like. 3 and 1/2 stars.
Another nice offering from a writer I really like. 3 and 1/2 stars.
July 3, 2019
I finished this book about a week ago and the next day my mom fell and f#*$*%* broke her hip. So, this is NOT the type of book to read or even think about when you have someone in the hospital.
Most doctors, especially surgeons, are viewed as infallible but in reality they are just like us. They have bad days, they make mistakes and some of them should really change careers.
The author writes eloquently, with compassion and a clear love for surgery, which made this a fascinating book to delve into. Most of the stories felt anecdotal rather than a deep dive into the details which for a layman like me was perfect.
The author also poses a lot of ethical questions about the profession and how much patient autonomy should be allowed when making health decisions.
If you have any interest in medical memoirs you should try this author at least once.
Most doctors, especially surgeons, are viewed as infallible but in reality they are just like us. They have bad days, they make mistakes and some of them should really change careers.
The author writes eloquently, with compassion and a clear love for surgery, which made this a fascinating book to delve into. Most of the stories felt anecdotal rather than a deep dive into the details which for a layman like me was perfect.
The author also poses a lot of ethical questions about the profession and how much patient autonomy should be allowed when making health decisions.
If you have any interest in medical memoirs you should try this author at least once.
April 18, 2009
Although I am interested in the medical profession, motivation to learn more about it often elludes me. Gawande was able to keep my attention and present points that I could understand in spite of my limited medical knowledge.
Admittedly, some of his information scared me. After reading some points about surgery, I wondered how I ever allowed anyone to cut into me and place a plate and seven screws in my leg. Also, some of his writing made me squeemish. I had to pause or skip places that became too graphic for my weak stomach. Some of his writing discouraged me. Why am I trying to lose weight if no one is able to succesfully lose weight and keep it off unless they are dangerous and intensive surgery? I also felt discouraged over the problems he presented that really have no attainable answers.
In spite of my difficulty with his unanswerable questions, I appreciated Gawande's straightforward honesty about the medical profession and its weakness. Ironically, his admission of the fallibility of doctors and medicine, makes me more willing to approach a doctor. It makes it easier for me to ask questions if I don't expect the doctor to have all the right answers (especially if that doctor is willing to admit such a possibility).
Admittedly, some of his information scared me. After reading some points about surgery, I wondered how I ever allowed anyone to cut into me and place a plate and seven screws in my leg. Also, some of his writing made me squeemish. I had to pause or skip places that became too graphic for my weak stomach. Some of his writing discouraged me. Why am I trying to lose weight if no one is able to succesfully lose weight and keep it off unless they are dangerous and intensive surgery? I also felt discouraged over the problems he presented that really have no attainable answers.
In spite of my difficulty with his unanswerable questions, I appreciated Gawande's straightforward honesty about the medical profession and its weakness. Ironically, his admission of the fallibility of doctors and medicine, makes me more willing to approach a doctor. It makes it easier for me to ask questions if I don't expect the doctor to have all the right answers (especially if that doctor is willing to admit such a possibility).
November 24, 2014
Read these sentences and tell me that this writer isn't an unbearable idiot:
"If choice [of one's surgeon] cannot go to everyone, maybe it is better when it is not allowed at all."
"Taking time to bond with patients is fine, but every X ray must be tracked down and every drug dose must be exactly right."
"Hospital lawyers warn doctors that, although they must, of course, tell patients about injuries that occur, they are never to intimate that they were at fault, lest the 'confession' wind up in court as damning evidence in a black-and-white morality tale."
"This was not guilt: guilt is what you feel when you have done something wrong. What I felt was shame: I was what was wrong. And yet I also knew that a surgeon can take such feelings too far [...] One surgeon with a national reputation told me about an abdominal operation in which he had lost control of bleeding while he was removing what turned out to be a benign tumor and the patient had died. [...] The case affected his performance for months."
"In its way, the M&M is an impressively sophisticated and human institution. Unlike the courts or the media, it recognizes that human error is generally not something that can be deterred by punishment."
So sophisticated that it doesn't include compensation for negligently injured patients! Or consequences for negligent doctors besides ~*shame*~ in the conference room!
"There are all sorts of reasons that it would be wrong to take my license away or to take me to court. Those reasons do not absolve me. Whatever the limits of the M&M, its fierce ethic of personal responsibility for errors is a formidable virtue."
Personal responsibility so long as it's a fifteen minute shaming directed at your mentor. And note that he doesn't discuss why it would be wrong to take his license away - wow, what a great look at the complexities of the situation! rme
"But the problem of bad doctors isn't the problem of [frightening aberrations like James Burt, a notorious Ohio gynecologist who subjected hundreds of women, often they had been anesthetized for other procedures, to a bizarre, disfiguring operation involving clitoral circumcision and vaginal 'reshaping' which he called the Surgery of Love]. It is the problem of what you might call everyday bad doctors [...] the illustrious cardiologist who has slowly gone senile and won't retire [...]"
Ahahaha, trying to treat James Burt as an isolated freak when other doctors knew what he was doing, said nothing and later refused to testify against him. Years wherein they said and did nothing about this man who was not licensed as a surgeon and was bragging about mutilating women while they were unconscious. James Burt is an illustration of the extent to which the medical community are willing to look the other way. If doctors will ignore the James Burts of the world, then how can we expect them to turn in the hypothetical illustrious but senile cardiologist? It is the same problem. Nice try though, Gawande.
"Was money part of the problem?"
Gawande tries to portray a surgeon who admits to booking far more patients than he could handle and rushing through their care in order to make more and more money (despite making 400k) as a poor little rich boy. Sorry, no. The question is, was greed part of the problem and the answer is yes.
"There are both honorable and dishonorable reasons for [doctors finding themselves unable to do anything decisive about bad doctors] [...] The honorable reason, and probably the main reason, is that no one really has the heart for it. When a skilled, decent, ordinarily conscientious colleague, whom you've known and worked with for years, starts popping Percodans, or becomes preoccupied with personal problems, and neglects the proper care of patients, you want to help, not destroy the doctor's career."
I love that his first concern isn't the patients or even the doctor, but the doctor's career. I also love that the example bad doctor he discusses didn't end up getting the sack for ruining a 28 year old woman's life but because he didn't go to M&M conferences. Injure all the patients you like, but don't you dare thumb your nose at our rituals wherein we discuss these injuries!! And then he cries about how this poor disgraced doctor only succeeded in getting malpractice insurance after a year. Oh gosh, a whole year? How terrible for him.
"People actually prefer the world of don't ask, don't tell. Just ask yourself, could you abide by a system that rehabilitated drug-addicted anesthesiologists, cardiac surgeons with manic psychosis, or a pediatrician with a thing for little girls if it meant catching more of them?"
...one of these things is not like the others... and that isn't your only option. and rn, there are plenty of doctors who have been disciplined for egregiously terrible stuff and should never be allowed to practice again and yet somehow, are so what would be the difference.
"Could it have been a mistaken, then, even to have told him about the surgical option? [...] People are rightly suspicious of those claiming to know better than they do what's best for them. But a good physician cannot simply stand aside when patients make bad or self-defeating decisions - decisions that go against their deepest goals. [goes into an anecdote about how a doctor convinced a woman to start her physical therapy and it was all for the best]"
Yeah, because not giving a patient the full range of their surgical options is the same as encouraging a patient to do rehabilitative therapy! Definitely! Has this man done zero law in the zillion years it must have taken him to get a MPH and become a surgeon?
Ok, I've parsed enough. I will say that his musings on patient autonomy are truly disgusting though (he thinks we should replace the autonomy principle with a concept of 'kindness' because paternalism is not the enemy, what the everlasting fuck) and show that he doesn't understand the concept of patient autonomy or the emergency exception doctrine (I only know about it through canadian law but I'm sure Americans must have the same thing).
This was probably the most hateful thing I've read in years. Wow.
"If choice [of one's surgeon] cannot go to everyone, maybe it is better when it is not allowed at all."
"Taking time to bond with patients is fine, but every X ray must be tracked down and every drug dose must be exactly right."
"Hospital lawyers warn doctors that, although they must, of course, tell patients about injuries that occur, they are never to intimate that they were at fault, lest the 'confession' wind up in court as damning evidence in a black-and-white morality tale."
"This was not guilt: guilt is what you feel when you have done something wrong. What I felt was shame: I was what was wrong. And yet I also knew that a surgeon can take such feelings too far [...] One surgeon with a national reputation told me about an abdominal operation in which he had lost control of bleeding while he was removing what turned out to be a benign tumor and the patient had died. [...] The case affected his performance for months."
"In its way, the M&M is an impressively sophisticated and human institution. Unlike the courts or the media, it recognizes that human error is generally not something that can be deterred by punishment."
So sophisticated that it doesn't include compensation for negligently injured patients! Or consequences for negligent doctors besides ~*shame*~ in the conference room!
"There are all sorts of reasons that it would be wrong to take my license away or to take me to court. Those reasons do not absolve me. Whatever the limits of the M&M, its fierce ethic of personal responsibility for errors is a formidable virtue."
Personal responsibility so long as it's a fifteen minute shaming directed at your mentor. And note that he doesn't discuss why it would be wrong to take his license away - wow, what a great look at the complexities of the situation! rme
"But the problem of bad doctors isn't the problem of [frightening aberrations like James Burt, a notorious Ohio gynecologist who subjected hundreds of women, often they had been anesthetized for other procedures, to a bizarre, disfiguring operation involving clitoral circumcision and vaginal 'reshaping' which he called the Surgery of Love]. It is the problem of what you might call everyday bad doctors [...] the illustrious cardiologist who has slowly gone senile and won't retire [...]"
Ahahaha, trying to treat James Burt as an isolated freak when other doctors knew what he was doing, said nothing and later refused to testify against him. Years wherein they said and did nothing about this man who was not licensed as a surgeon and was bragging about mutilating women while they were unconscious. James Burt is an illustration of the extent to which the medical community are willing to look the other way. If doctors will ignore the James Burts of the world, then how can we expect them to turn in the hypothetical illustrious but senile cardiologist? It is the same problem. Nice try though, Gawande.
"Was money part of the problem?"
Gawande tries to portray a surgeon who admits to booking far more patients than he could handle and rushing through their care in order to make more and more money (despite making 400k) as a poor little rich boy. Sorry, no. The question is, was greed part of the problem and the answer is yes.
"There are both honorable and dishonorable reasons for [doctors finding themselves unable to do anything decisive about bad doctors] [...] The honorable reason, and probably the main reason, is that no one really has the heart for it. When a skilled, decent, ordinarily conscientious colleague, whom you've known and worked with for years, starts popping Percodans, or becomes preoccupied with personal problems, and neglects the proper care of patients, you want to help, not destroy the doctor's career."
I love that his first concern isn't the patients or even the doctor, but the doctor's career. I also love that the example bad doctor he discusses didn't end up getting the sack for ruining a 28 year old woman's life but because he didn't go to M&M conferences. Injure all the patients you like, but don't you dare thumb your nose at our rituals wherein we discuss these injuries!! And then he cries about how this poor disgraced doctor only succeeded in getting malpractice insurance after a year. Oh gosh, a whole year? How terrible for him.
"People actually prefer the world of don't ask, don't tell. Just ask yourself, could you abide by a system that rehabilitated drug-addicted anesthesiologists, cardiac surgeons with manic psychosis, or a pediatrician with a thing for little girls if it meant catching more of them?"
...one of these things is not like the others... and that isn't your only option. and rn, there are plenty of doctors who have been disciplined for egregiously terrible stuff and should never be allowed to practice again and yet somehow, are so what would be the difference.
"Could it have been a mistaken, then, even to have told him about the surgical option? [...] People are rightly suspicious of those claiming to know better than they do what's best for them. But a good physician cannot simply stand aside when patients make bad or self-defeating decisions - decisions that go against their deepest goals. [goes into an anecdote about how a doctor convinced a woman to start her physical therapy and it was all for the best]"
Yeah, because not giving a patient the full range of their surgical options is the same as encouraging a patient to do rehabilitative therapy! Definitely! Has this man done zero law in the zillion years it must have taken him to get a MPH and become a surgeon?
Ok, I've parsed enough. I will say that his musings on patient autonomy are truly disgusting though (he thinks we should replace the autonomy principle with a concept of 'kindness' because paternalism is not the enemy, what the everlasting fuck) and show that he doesn't understand the concept of patient autonomy or the emergency exception doctrine (I only know about it through canadian law but I'm sure Americans must have the same thing).
This was probably the most hateful thing I've read in years. Wow.
June 24, 2019
4.5 stars
I had a great time reading this with Heidi from My Reading Life. The book is broken up into three sections named for ideas that vex doctors - Fallibility, Mystery, and Uncertainty. He looks at the way surgeons are educated, advancements in medicine, hard to pin down diagnoses, and more with a liberal sprinkling of fascinating cases.
The pacing is perfect, there are edge of your seat moments to see if a patient makes it, and he brings up ethical issues that appear in his later books, such as medical error and treatment decisions at the end of life. Those in the know will recognize that medicine has changed over the years since publication, but even so it holds up incredibly well.
I kinda wish I had more to say but it's one of those books that's so good you don't need to say all that much in the first place. If you have any little interest in medical nonfiction you'll want to pick up Complications, as well as Gawande's other books, post haste.
I had a great time reading this with Heidi from My Reading Life. The book is broken up into three sections named for ideas that vex doctors - Fallibility, Mystery, and Uncertainty. He looks at the way surgeons are educated, advancements in medicine, hard to pin down diagnoses, and more with a liberal sprinkling of fascinating cases.
The pacing is perfect, there are edge of your seat moments to see if a patient makes it, and he brings up ethical issues that appear in his later books, such as medical error and treatment decisions at the end of life. Those in the know will recognize that medicine has changed over the years since publication, but even so it holds up incredibly well.
I kinda wish I had more to say but it's one of those books that's so good you don't need to say all that much in the first place. If you have any little interest in medical nonfiction you'll want to pick up Complications, as well as Gawande's other books, post haste.
September 22, 2018
“Practice is funny that way. For days and days, you make out only the fragments of what to do. And then one day you've got the thing whole. Conscious learning becomes unconscious knowledge, and you cannot say precisely how.”
I have always been intrigued by medicine. I know it’s a scary thought, but inevitably, illness will impact each of us in one way or another. Either we will get sick or somebody we love will get sick. Which is why learning about medicine and healthcare is so important. However, a lot of books about medicine and healthcare can be pretty dry, which is where Dr. Gawande comes to the rescue. His clear prose makes even the most difficult medical concepts easy to understand.
In this book, Gawande is just starting out his medical career. Like most new graduates, Gawande is excited yet nervous about the new challenges that await him in the workplace. But he soon realizes that medical school only teaches you a tiny smudge of what being a doctor is actually about. Medicine is so much more than just a science - it is a messy and imperfect art. A lot of what doctors do is intuitive; they piece together symptoms to formulate a treatment plan. However, uncertainty feels grander in medicine because human lives are at risk. And as a doctor, you not only need book smarts, but the ability to navigate unforeseen challenges with integrity and fortitude.
A lot of this book comprises of fascinating case studies: a victim who was shot in the buttock leaves the hospital virtually unharmed, a pregnant woman with nausea so debilitating that she has to leave work, a neurosurgeon who copes with severe blushing, and a young woman whose inconspicuous leg pain turns out to be a deadly infection. If you like suspense, then this book is for you. The saying “everything can change in an instant” is ever so applicable to medicine.
Although I enjoyed this book, I thought it was a bit dull at times. I think it could have been improved if it contained a tad bit of humor. But overall, I did enjoy it. I would recommend “Complications” to medical professionals or anybody who is interested in learning about the healthcare field.
I have always been intrigued by medicine. I know it’s a scary thought, but inevitably, illness will impact each of us in one way or another. Either we will get sick or somebody we love will get sick. Which is why learning about medicine and healthcare is so important. However, a lot of books about medicine and healthcare can be pretty dry, which is where Dr. Gawande comes to the rescue. His clear prose makes even the most difficult medical concepts easy to understand.
In this book, Gawande is just starting out his medical career. Like most new graduates, Gawande is excited yet nervous about the new challenges that await him in the workplace. But he soon realizes that medical school only teaches you a tiny smudge of what being a doctor is actually about. Medicine is so much more than just a science - it is a messy and imperfect art. A lot of what doctors do is intuitive; they piece together symptoms to formulate a treatment plan. However, uncertainty feels grander in medicine because human lives are at risk. And as a doctor, you not only need book smarts, but the ability to navigate unforeseen challenges with integrity and fortitude.
A lot of this book comprises of fascinating case studies: a victim who was shot in the buttock leaves the hospital virtually unharmed, a pregnant woman with nausea so debilitating that she has to leave work, a neurosurgeon who copes with severe blushing, and a young woman whose inconspicuous leg pain turns out to be a deadly infection. If you like suspense, then this book is for you. The saying “everything can change in an instant” is ever so applicable to medicine.
Although I enjoyed this book, I thought it was a bit dull at times. I think it could have been improved if it contained a tad bit of humor. But overall, I did enjoy it. I would recommend “Complications” to medical professionals or anybody who is interested in learning about the healthcare field.
October 14, 2015
Not quite a 4 star read, but close enough. It's fairly short & does make his major points fairly well. They boil down to medicine isn't perfect.
Doctors are humans, so need to learn & will make mistakes, even with the best intentions. Do I want a doctor to learn on me or mine? Hell no! Gawande admits that he doesn't either & he makes sure they don't, BUT we won't get any new ones if they don't start somewhere. So what's the solution? There isn't a good one. Deal with it.
Patients are humans, so they're complicated. They do things that are bad for them & all demand the highest level of care. Since the mid-80's, they've been getting more say in what their treatment is & often they're not well equipped to do so either due to ignorance or just feeling like crap. Balance between what the doctor recommends & what the patient wants is tough.
Medicine has come a LONG way in a short time, but they still don't know a lot. As it becomes more complicated, it's tougher for doctors to stay on top of even their specialty. Unspoken, but obvious in the subtext, is that it takes more people to do the job & a lot depends on every one & thing's availability & doing their job properly. Facilities are often stretched.
Overall, it was an interesting tour inside the field from a young surgeon's point of view. I think this was his first book & it suffered a bit from that. It's also a bit dated in some respects having been written 15 years ago or so. Still, it's well worth reading.
Doctors are humans, so need to learn & will make mistakes, even with the best intentions. Do I want a doctor to learn on me or mine? Hell no! Gawande admits that he doesn't either & he makes sure they don't, BUT we won't get any new ones if they don't start somewhere. So what's the solution? There isn't a good one. Deal with it.
Patients are humans, so they're complicated. They do things that are bad for them & all demand the highest level of care. Since the mid-80's, they've been getting more say in what their treatment is & often they're not well equipped to do so either due to ignorance or just feeling like crap. Balance between what the doctor recommends & what the patient wants is tough.
Medicine has come a LONG way in a short time, but they still don't know a lot. As it becomes more complicated, it's tougher for doctors to stay on top of even their specialty. Unspoken, but obvious in the subtext, is that it takes more people to do the job & a lot depends on every one & thing's availability & doing their job properly. Facilities are often stretched.
Overall, it was an interesting tour inside the field from a young surgeon's point of view. I think this was his first book & it suffered a bit from that. It's also a bit dated in some respects having been written 15 years ago or so. Still, it's well worth reading.
September 7, 2022
i am now horrified of medical errors, but this was a great read
September 22, 2019
Let’s play the “who wants to be horrified” game. Complications made it hard to sleep. Not because of gore necessarily but because it made clear to me that doctors are just people who were given a scalpel. Yes, they have a ton of education but at some point, they must get experience.
In one section Gawande discusses a procedure in which he must put in a central line which goes into a major vein in your chest which can technically kill you. All he tells the patient is that he must put in a central line, not that it is dangerous or that it is his first time doing this procedure. I completely understand why he didn’t tell the patient, but that doesn’t make it any less terrifying. I have thought about how doctors have to start at some point, but it was never so clear to me that there is a first patient for every procedure for every doctor. For every surgeon, there will be the first surgery. There is a first time for cutting into the flesh of a still-living person.
It was published in 2002 so I’m sure some things have changed, but it’s still current enough about how the training takes place.
It’s an important realization of how much control doctors have over our bodies and how little they have over everything else in the hospital. They don’t get to choose...
For the full review please visit https://www.literarydragonreviews.web...
In one section Gawande discusses a procedure in which he must put in a central line which goes into a major vein in your chest which can technically kill you. All he tells the patient is that he must put in a central line, not that it is dangerous or that it is his first time doing this procedure. I completely understand why he didn’t tell the patient, but that doesn’t make it any less terrifying. I have thought about how doctors have to start at some point, but it was never so clear to me that there is a first patient for every procedure for every doctor. For every surgeon, there will be the first surgery. There is a first time for cutting into the flesh of a still-living person.
It was published in 2002 so I’m sure some things have changed, but it’s still current enough about how the training takes place.
It’s an important realization of how much control doctors have over our bodies and how little they have over everything else in the hospital. They don’t get to choose...
For the full review please visit https://www.literarydragonreviews.web...
April 16, 2009
Atul Gawande writes for The New Yorker, and I always read his articles as soon as I spot the by-line. I read "Better" last year and think it is even, yes, better. But both books have rare qualities. Gawande is a physician who can step back from his ego and write with compassion and insight about the relationship between vulnerable sick people and those whose skill and judgment they are compelled to trust.
July 9, 2020
There was a time in my life when I looked to Reader's Digest as a more credible source of information; I even garnered some sort of feeling of being in the presence of wisdom when the correct stars were in alignment. The time when I felt such is as long ago as is the date of publication of this book, so perhaps, had I read it then, I would have liked it a great deal more. As it stands, I don't read nonfiction for the express purpose of being coddled into a feel-good view of a certain section of the world that views itself as above and beyond the influence of everyone and everything in and around it. If I did, I wouldn't have bothered to single out Gawande as hopefully a source that was somewhat free of the pale, comfortingly eugenicist meanderings that require black patients be wary of white doctors and fat patients be wary of pretty much everyone in the medical field. I didn't expect him to be an expert on the havoc that certain ideologies, probingly detailed in Medical Apartheid and other works, have wreaked and continue to wreak on the concepts of health, medicine, and healing in the United States, but it was rather pathetic to watch him fumble around seemingly mysterious patterns of occurrences that would be rather hard to parse if one didn't ever consider the state of health insurance in this country. In other cases, there was a nod towards systemic, dehumanizing biases that significantly the efforts of any well meaning doctor, but Gawande had already spent so much time normalizing the status quo that the critique seemed little more than the fine print of a drug ad. So, observations of a morally grey environment equipped with a healthy amount of cited literature? Sure. A rendering of the medical field that acknowledged "complications" stemming from far less good-intentioned sources? No, and it was the latter I was looking for.
I got some bits and pieces out of this, which is why this is a two star for the moment. Still, the obscenely high rating for a work that phrases increased rights for disabled people leading to more people being publicly disabled as a bad thing is little more than nonfiction that falls right in line with filth such as 'Me Before You'. It would've been a surprise had I viewed phrases such as "Harvard Medical School" and "The New Yorker" as having any measure of inherent credibility, but I knew plenty of pre-meds back in my BioE days at UCLA, and they were only ever in it for the money. Abusive (male) doctors mutilating, if not outright murdering, tens to hundreds of patients because their staff were too wibbly wobbly/genuinely afraid of retaliation to do anything about it, weight considered purely in terms of what is ingested and nothing else, egotistical rolls of the dice being favored over a scientific approach just so a single fallible individual can feel like a hero every once in a while: give me a break. The medical field truly is a complicated one, but I came to this piece expecting to be able to read up on some sort of MRI procedure (something which is, fun fact, I can't have myself due to my ink), not a fancier rendition of toothbrush and toothpaste. Now, I don't read a lot of this type of nonfiction, so this review may be suffering a tad from overdue-vent-itis. However, it's not like the evidence isn't there, so I'm fine with leaving it like this for now.
The perfect test or scan may have been available, but the physicians never ordered it.As you may be able to tell, I don't have the best relationship with the health industry. I have enough separate things wrong with me to necessitate regular visits to one or more institutions, but ever since a youth filled with borderline Munchausen By Proxy experiences and my undergrad days when my collegial institution would only give me treatment if I agreed to being experimented on by students, I don't do more than is absolutely necessary. Successive years of being in a community with my fellow neuroatypicals has given me plenty of stories of forced institutionalization, fat-shaming, racism, transphobia, and general abuse that was often only marginally lessened by rigorous research on the patient's side. I didn't expect Gawande to be all doom and gloom, but there was a pattern of pointing out fat patients as particularly difficult to operate on that wasn't much alleviated by a later article that all but swore by gastric bypass surgery. I could go into experiments that found rats became drug addicts when not offered enough positive stimulation and generally good environments, the all but 100% monetization of public spheres, the nearly ubiquitous inhumane conditions of workplaces that refuse all semblance of a healthy amount of sitting, standing, and general movement, but I won't. All I'll say is, there are a number of times when my teeth cleaner, aware of my pretty optimal dental status and less than optimal financial means, has offered to let me skip the MD's visit and spend half what I would have otherwise, and I can't think of a time when I refused the offer. So, that perfect scan or test? Doesn't mean jack squat if it's a choice between that and rent.
I got some bits and pieces out of this, which is why this is a two star for the moment. Still, the obscenely high rating for a work that phrases increased rights for disabled people leading to more people being publicly disabled as a bad thing is little more than nonfiction that falls right in line with filth such as 'Me Before You'. It would've been a surprise had I viewed phrases such as "Harvard Medical School" and "The New Yorker" as having any measure of inherent credibility, but I knew plenty of pre-meds back in my BioE days at UCLA, and they were only ever in it for the money. Abusive (male) doctors mutilating, if not outright murdering, tens to hundreds of patients because their staff were too wibbly wobbly/genuinely afraid of retaliation to do anything about it, weight considered purely in terms of what is ingested and nothing else, egotistical rolls of the dice being favored over a scientific approach just so a single fallible individual can feel like a hero every once in a while: give me a break. The medical field truly is a complicated one, but I came to this piece expecting to be able to read up on some sort of MRI procedure (something which is, fun fact, I can't have myself due to my ink), not a fancier rendition of toothbrush and toothpaste. Now, I don't read a lot of this type of nonfiction, so this review may be suffering a tad from overdue-vent-itis. However, it's not like the evidence isn't there, so I'm fine with leaving it like this for now.
September 2, 2020
Brilliant!!! Many of the topics covered were close to my heart. This was the second time I am reading this book after abandoning it once but after the halfway mark found it engrossing especially the pain and nausea parts.
August 10, 2007
An very well written book in which Gawande argues that surgery is an evolving and imperfect art. He begins by describing in compulsively readable detail some occasions during which it has failed its patients. An overarching theme in the book is an idea of what makes a good surgeon; Gawande points out that it's not about innate talent. It's about practice, commitment, a willingless to learn new things, a willingness to teach others, specialization, and perhaps attentiveness to the patient. (I also read Blink, recently, by Malcolm Gladwell, and he points out that the number of medical malpractice lawsuits a doctor will have filed against him or her can be predicted based on the tone of voice they take with patients during their first appointments- it has almost nothing to do with malpractice and everything to do with the way the doctor made the patient feel. Regular people were asked to listen to tape recordings of appointments in which the actual words were blurred somehow and all you heard was tone. They predicted with some phenomenal degree of accuracy who would get sued.). Anyway, Gawande's "good surgeon" reminded me a lot of what it takes to be a good public servant of any kind, and it was a thought-provoking, at times frightening, and inspiring book.
January 8, 2021
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.
Some of the stories made me a little squeamish. TMI I thought. But overall, an interesting listen this evening. So 4 stars.
May 9, 2021
This book made me question expertise, and not just in medicine. He shows that doctor's titles can be stripped away when good doctors become less fastidious about treating their patients with utmost care. They can be overcome with issues that everyday people face—alcoholism, depression. He is candid in his account of how he learned to do a central line, his fumbling, and tentativeness in the beginning. I always love to read about people looking back at their own mistakes in hindsight. Most of all, I enjoyed this book because of his honesty and surrender, when he illustrates the dualities and complexities of being a surgeon who needs to make life or death decisions. Yes, medicine is constantly advancing with the amount of scientific research, but there is always a factor of uncertainty and randomness that cannot be surmounted by hard facts. In making difficult decisions about the outcome of someone’s life, it the job of the surgeon to guide the patient on what is it that they are willing to compromise and not compromise in their life, and then find the best action that corresponds. I think that is prevalent in any field where there is an expert.
June 20, 2021
"No matter what measures are taken, doctors will sometimes falter, and it isn't reasonable to ask that we achieve perfection. What is reasonable is to ask that we neve cease to aim for it"
One of the most profound books I have read on Surgery - which we get to know, not so comfortingly, is an imperfect science. Credit to the author for not making things too technical and covering a wide range of discussion points.
I loved the cases chosen for discussion and even better the musings on the rightness of the discussion. For example the role of M&M meetings or autopsies to keep the doctors on their toes is something which only the people in the field would understand. I could not even remotely imagine a similar role in any other field where every decision is scrutinised and "not-judged".
The more I think about, of all the ways to present a book, the book presented from the standpoint of a someone not brimming with confidence is possibly the most effective. Many of the chapters - you put yourself in the shoes of the doctor and the patient alternatively and you come up with opposing view points.
We all have had experience with medical opinion and treatment options either for us or our relatives. And thanks to series like House and Scrubs - an average individual is more aware of the field/rare cases that he should be. So the writing is even more commendable given it is not a specialised subject matter topic.
It is also interesting to note how many doctors are really good writers. This is one more brilliant book in the long line of books that are increasingly improving our understanding of the life of medical professionals (and about ourselves).
One of the most profound books I have read on Surgery - which we get to know, not so comfortingly, is an imperfect science. Credit to the author for not making things too technical and covering a wide range of discussion points.
I loved the cases chosen for discussion and even better the musings on the rightness of the discussion. For example the role of M&M meetings or autopsies to keep the doctors on their toes is something which only the people in the field would understand. I could not even remotely imagine a similar role in any other field where every decision is scrutinised and "not-judged".
The more I think about, of all the ways to present a book, the book presented from the standpoint of a someone not brimming with confidence is possibly the most effective. Many of the chapters - you put yourself in the shoes of the doctor and the patient alternatively and you come up with opposing view points.
We all have had experience with medical opinion and treatment options either for us or our relatives. And thanks to series like House and Scrubs - an average individual is more aware of the field/rare cases that he should be. So the writing is even more commendable given it is not a specialised subject matter topic.
It is also interesting to note how many doctors are really good writers. This is one more brilliant book in the long line of books that are increasingly improving our understanding of the life of medical professionals (and about ourselves).
June 26, 2021
"Emesis" is a pretty little word, two palindromes side-by-side, but until I read this book I could never quite find the proper words to describe the actual process: "intensely aversive".
Dr. Gawande occupies a rarified Valhalla of people who understand medicine, who understand public policy and who understand how to write. You want facts? Got 'em:
The above citation was edited considerably for length. So why all this recounting of such an "intensively aversive" experience at all? Who wants to think about this stuff? Well, some women have such a problem with morning sickness during pregnancy that it threatens not only the embryo's life but the mothers as well. And part of the job of the doctor is to figure out exactly how to deal with this problem, which can be far from simple. After all, you don't want to poison the embryo with strong, potentially toxic medicines; hypersensitivity to toxins appears to be the root cause of morning sickness in the first place.
I've read a lot of medical memoirs, and encountered surprisingly few accounts of morning sickness. Generally the stories deal with emergency C-Sections, roadside surprises and the like. The fact that the author chooses to dwell at length on what is, for many women, the most awful part of pregnancy testifies that he actually listens to his patients, and takes their fear and suffering seriously.
Regarding public policy, Gawande is a well-known speaker and patient advocate, and writes clearly and well about things we could do to improve patient care (getting bad doctors away from patients, for example) and also about the impossibility of doctors knowing exactly what to do in any given situation. This puts part of the public policy back on the public: We're very complicated creatures, and we need to stop expecting miracles.
Unlike some of his other books (The Checklist Manifesto, for example), this was really a collection of unrelated essays and didn't quite hang together as well. But it was still packed with nice writing, fascinating science and humane stories. Recommended.
Dr. Gawande occupies a rarified Valhalla of people who understand medicine, who understand public policy and who understand how to write. You want facts? Got 'em:
She was in what physicians call the "prodomal phase of emesis." Salivation increases, sometimes torrentially. The pupils dilate. The heart begins to race. The blood vessels in the skin constrict, increasing pallor..
While all this is going on, the stomach develops abnormal electrical activity, which prevents it from emptying and causes it to relax. The esaphagus contracts, pulling the upper portion of the stomach from the abdomen, through the diaphragm, and into the chest...Then, in a single movement, known as the "retrograde giant contraction," the upper small intestine evacuates its contents backward into the stomach in preparation for vomiting...In the expulsive phase, the diaphragm and stomach undergo a massive, prolonged contraction, generating intense pressure in the stomach; when the esophogus relaxes, it's as if someone had taken the plug off a fire hydrant.
The above citation was edited considerably for length. So why all this recounting of such an "intensively aversive" experience at all? Who wants to think about this stuff? Well, some women have such a problem with morning sickness during pregnancy that it threatens not only the embryo's life but the mothers as well. And part of the job of the doctor is to figure out exactly how to deal with this problem, which can be far from simple. After all, you don't want to poison the embryo with strong, potentially toxic medicines; hypersensitivity to toxins appears to be the root cause of morning sickness in the first place.
I've read a lot of medical memoirs, and encountered surprisingly few accounts of morning sickness. Generally the stories deal with emergency C-Sections, roadside surprises and the like. The fact that the author chooses to dwell at length on what is, for many women, the most awful part of pregnancy testifies that he actually listens to his patients, and takes their fear and suffering seriously.
Regarding public policy, Gawande is a well-known speaker and patient advocate, and writes clearly and well about things we could do to improve patient care (getting bad doctors away from patients, for example) and also about the impossibility of doctors knowing exactly what to do in any given situation. This puts part of the public policy back on the public: We're very complicated creatures, and we need to stop expecting miracles.
Unlike some of his other books (The Checklist Manifesto, for example), this was really a collection of unrelated essays and didn't quite hang together as well. But it was still packed with nice writing, fascinating science and humane stories. Recommended.
March 4, 2012
Wow! I loved this and I love Dr. Gawande.
The first section is about how it is necessary for medical residents to learn how to do procedures on people, but how it's just as necessary to sort of glide over that fact with patients. This was the most exciting part of the book because he went over his own early surgeries and the complications that arose.
The rest of the book is about how, even though medicine is a 'scientific' field, it's ultimately human and fallible. My anxiety was high during most of this, because being a doctor is so high pressure! It was a rollercoaster ride because I kept changing my mind. For a while, I'd think, "Oh, I guess you should never have surgery unless it's absolutely necessary," but then a while later, I'd think, "Oh shit! Just have the biopsy! Don't be ridiculous!!!!" I loved this. I can't wait to read "Better."
Sarah Montambo Powell
The first section is about how it is necessary for medical residents to learn how to do procedures on people, but how it's just as necessary to sort of glide over that fact with patients. This was the most exciting part of the book because he went over his own early surgeries and the complications that arose.
The rest of the book is about how, even though medicine is a 'scientific' field, it's ultimately human and fallible. My anxiety was high during most of this, because being a doctor is so high pressure! It was a rollercoaster ride because I kept changing my mind. For a while, I'd think, "Oh, I guess you should never have surgery unless it's absolutely necessary," but then a while later, I'd think, "Oh shit! Just have the biopsy! Don't be ridiculous!!!!" I loved this. I can't wait to read "Better."
Sarah Montambo Powell
January 12, 2018
Fascinating. I only wish Gawande brought a biblical worldview into the topic. It was the missing dimension in many stories—What role does human depravity play here? How could prayer make a difference there? What if we applied basic principles of wisdom in this case? What if the gospel were presented in that one? Man is so complex—body, mind, and spirit so inextricably intertwined—that we're never going to understand the complexities of any one of them without bringing our knowledge of the others to bear. Someday we'll get there.
July 29, 2011
Great. Reminds me of why I wanted to do medicine.
November 2, 2017
Disturbing. Fascinating. Illuminating.
March 29, 2008
Hmmm... I love surgery, it means.. when a handy book of more-humanity-and-less-cut of surgery was published.. how can i resist?
Well.. for being honest, it makes me feel bored when i've red the middle-part. it turns 'in' again in a few last chapter. I agree to middle-rating, (in Indonesia means, lumayanlah.. bukan buku sampah) of this book. but i truly disagree when sumone gave only one star rating to this stuff. (Cari deh di tinjauan lain. Huh. You make me angry dude.. pelit amat sih. Gue nggak tahu ada penulis laen yang pernah, bisa, dan berhasil bikin tulisan tema ini) Nevertheless, Atul gawande deserve for sum appreciation, and He already had..
the Most interesting part from me.. is a chapter when Atul writes about "the curve of learning". He statistically showed about transision safety rate of "great artery transposition" surgery, between the convensional and the latest method. Now, Using the latest method, a child who has born with "great artery transposition" can reach the age of 40. But, when its was first introduced, the safety rate was really low. (i forget about its number.. hmm 8 survivals against 100 operations? sorry, i forget the number)
Then, surgeons keep practicing, keep using the latest method, do a preparation surgery, training the nurse, using a team who spesialized on its procedure, maintain the team.. then.. the safety rate increase. Like i said before, these days, a child with "great transposition artery" can celebrate his or her 40's birthday..
It means, we can never resist a failure. A medical student can never resist a failure..
Too bad, people dont care about it. A simple or even hard failure of a medical student (physicians is a life-long medical students, right?), is a condition that makes them an expert someday. But, people dont care.. they never care
Haah.. tiba2 gue kepikiran soal pendidikan di kampus gue..
= |
Oya, buku ini salah satu favorit gue (biarpun cuma 3-bintang) karena punya "kenangan" tersendiri. ^_^ huehehe...
Well.. for being honest, it makes me feel bored when i've red the middle-part. it turns 'in' again in a few last chapter. I agree to middle-rating, (in Indonesia means, lumayanlah.. bukan buku sampah) of this book. but i truly disagree when sumone gave only one star rating to this stuff. (Cari deh di tinjauan lain. Huh. You make me angry dude.. pelit amat sih. Gue nggak tahu ada penulis laen yang pernah, bisa, dan berhasil bikin tulisan tema ini) Nevertheless, Atul gawande deserve for sum appreciation, and He already had..
the Most interesting part from me.. is a chapter when Atul writes about "the curve of learning". He statistically showed about transision safety rate of "great artery transposition" surgery, between the convensional and the latest method. Now, Using the latest method, a child who has born with "great artery transposition" can reach the age of 40. But, when its was first introduced, the safety rate was really low. (i forget about its number.. hmm 8 survivals against 100 operations? sorry, i forget the number)
Then, surgeons keep practicing, keep using the latest method, do a preparation surgery, training the nurse, using a team who spesialized on its procedure, maintain the team.. then.. the safety rate increase. Like i said before, these days, a child with "great transposition artery" can celebrate his or her 40's birthday..
It means, we can never resist a failure. A medical student can never resist a failure..
Too bad, people dont care about it. A simple or even hard failure of a medical student (physicians is a life-long medical students, right?), is a condition that makes them an expert someday. But, people dont care.. they never care
Haah.. tiba2 gue kepikiran soal pendidikan di kampus gue..
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Oya, buku ini salah satu favorit gue (biarpun cuma 3-bintang) karena punya "kenangan" tersendiri. ^_^ huehehe...
July 16, 2021
"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:
Dr. Gawande quotes a lot of statistic in Complications. Here's probably the most scary of them:
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.
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.
August 6, 2015
This is an absolutely fascinating book from a US surgeon in Boston (his parents originally from India, Atul was brought up in Athens, Ohio). It's the old cliché of not being able to put it down (how work gets in the way of reading). I found that I kept reading out parts to my partner and work colleagues (do you know that most surgeons in the US will be sued at least once in their career, do you know that a lady from the US went to Sweden to have an operation to stop her blushing, do you know...). Some of these chapters have come from articles he had written for the The New Yorker magazine.
He goes over some of the cases when he was a newly trained surgeon plus looks at things like nausea, vomiting, blushing, motion sickness, pain without any physical issues, good doctors gone bad, making decisions and getting a diagnosis correct. I have bought his new book 'Being Mortal' which I am very much looking forward to reading.
He goes over some of the cases when he was a newly trained surgeon plus looks at things like nausea, vomiting, blushing, motion sickness, pain without any physical issues, good doctors gone bad, making decisions and getting a diagnosis correct. I have bought his new book 'Being Mortal' which I am very much looking forward to reading.
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