Fallibility, mystery, uncertainty

The DO Book Club, May 2021: Complications: A Surgeon’s Notes on an Imperfect Science

Atul Gawande, MD, MPH, shares insights on residency training, difficult treatment decisions and medical errors.

Editor’s note: The views expressed in this article are the author’s own and do not necessarily represent the views of The DO or the AOA.

Welcome back to The DO Book Club!

For May, Joan Naidorf, DO, read Complications: A Surgeon’s Notes on an Imperfect Science by Atul Gawande, MD, MPH.

If you’ve read this one, please share your thoughts in the comments below. And if you’d like to write a book review for a future month, please email Rose Raymond at rraymond@osteopathic.org.

Plot summary

During medical school and residency, when the rest of us were struggling to show up with clean clothes and combed hair, Atul Gawande, MD, MPH, was keeping a journal and crafting the tales of his experiences and special interests. The essays he wrote were published in The New Yorker and later, in 2002, compiled into the book Complications: A Surgeon’s Notes on an Imperfect Science, the first of Dr. Gawande’s many books.

Dr. Gawande divides the book into three sections that correspond with the general topics of his essays and anecdotes. The first section, Fallibility, includes several personal experiences and insights from the early days of his residency. Fallibility, the tendency to make a mistake or to be wrong, exists everywhere, including in medicine. Some fallibility arises from there being a learning curve for every skill, particularly those learned in surgery.

Dr. Gawande’s own experience of central line insertion is highlighted in an early chapter. Subclavian central line insertion is difficult to do correctly the first time (particularly before the advent of bedside ultrasound). For a physician to learn how to do a central line, he or she must have a first patient to try it on. Dr. Gawande missed his first three times and worked himself into quite a funk before a supportive senior resident talked him through a successful attempt.

Fallibility occurs in even the most experienced doctors, and Dr. Gawande reports in the chapter “When Good Doctors go Bad” on one orthopedic surgeon who became so careless that he was no longer allowed to practice. Unfortunately, his colleagues let him continue for quite a while, even when they had concerns about multiple complications.

He explains that it can take a long time to see a pattern of truly irresponsible behavior as opposed to just having more complicated cases. Dr. Gawande notes that discipline of physicians works best when it is done by a group outside of one’s peer circle or employer because it is more objective.

Dr. Gawande candidly shares a painful personal experience with a difficult patient airway and the delay he caused while performing an emergency tracheostomy. The patient died. Dr. Gawande was consumed by guilt and shame as he sat through a discussion of the case in a weekly Morbidity and Mortality (M & M) conference at his hospital.

He observed, “In fact, the M & M’s ethos can seem paradoxical. On the one hand, it reinforces the very American idea that error is intolerable. On the other hand, the very existence of the M & M, its place on the weekly schedule, amounts to an acknowledgement that mistakes are an inevitable part of medicine.” (page 62)

The second section of the book, Mystery, concerns several stories of unusual signs and symptoms that are not easily explained or treated. Dr. Gawande includes events such as blushing, nausea, and pain. 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 and take their problem seriously. The patients were more willing than the doctors to accept that there was no conclusive medical explanation for their ailment.

The final section, Uncertainty, addresses the problem doctors have when it comes to important decisions like making certain diagnoses or treatment recommendations. He discusses the declining use of the autopsy. The autopsy is one way for physicians to determine what was actually wrong with the patient. It is the final way to get rid of uncertainty and to educate doctors on recognizing such conditions in the future.

He laments that autopsies are done less and less for various reasons: either physicians no longer request them, they are costly or the deceased’s family is opposed to the procedure.

The decision-making power of the patient is a recurring topic in this section. Dr. Gawande notes that patients have become more proactive in their desire for decision-making ability, but they are much more ambivalent about actually exercising it. In situations of great uncertainty, many patients do not feel comfortable making tough decisions. Some do not think they can handle the responsibility if it turns out to be the wrong decision.

Dr. Gawande notes that doctors prefer to make tough decisions. One of the skills the author had to learn as a resident was how to persuade patients to make the decision that he thinks is best. Nearly 20 years later, as our patients go online to read reams of medical information and misinformation, the ongoing challenge for physicians is to determine what the patient wants and to collaborate on a treatment plan.

Notable quote

In the book, Dr. Gawande discusses the concerns that arise over which patients receive care from inexperienced versus experienced practitioners. Regarding the training of physicians, he writes, “We want perfection without practice. Yet everyone is harmed if no one is trained for the future.” ( p. 24)

Takeaways

Osteopathic physicians will enjoy reading Complications and will likely nod in agreement with many of Dr. Gawande’s observations. At the time of publication in 2002, the essays may have felt to the lay public to be shockingly honest and insightful accounts of what actually was happening in the American medical system.

Like me, many DOs who read this book may reflect on the mistakes we have made in our own journey of practicing medicine. The perfectionist tendencies we curate so skillfully will often leave us feeling inadequate and unworthy. However, as human physicians, we are going to make mistakes and face uncertainty at times.

He writes, “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 never cease to aim for it.” ( p.73)

As an emergency physician faced with high-impact decisions and tons of uncertainty, I identified strongly with Dr. Gawande’s feelings of guilt and remorse over the mistakes that he made. The spotlight he has shone on medical errors through his many essays and books has surely opened up the discussion of mistakes in medicine.

June’s book

For June, The DO Book Club will be reading How Not to Die: Discover the Foods Scientifically Proven to Prevent and Reverse Disease by Michael Greger, MD, and Gene Stone. We encourage all who are interested to read along (this book club can be followed at any pace)! If you are unable to get out to a local library or bookstore due to COVID-19, we recommend checking out eBook options.

As a reminder, if you read Complications or any previous Book Club selection and want your reflections to be shared in future posts, or want to write your own book review for a future month, please leave a comment below or email rraymond@osteopathic.org.

Happy reading!

Related reading:

The DO Book Club, April 2021: When Breath Becomes Air

The DO Book Club, March 2021: The Pull of the Stars

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