Complications: A Surgeon's Notes on an Imperfect Science
by Atul Gawande
288 pages, $24.00
Early on in his new book, Complications, Atul Gawande describes the tasks of the men and women of the medical trade in a way that many may find unsettling: "We drug people, put needles and tubes into them, manipulate their chemistry, biology, and physics, lay them unconscious and open their bodies up to the world." This sentence has none of the antiseptic, doctor-as-deity gloss with which medicine is often painted; a slow cultural shift over the past twenty years, led by television (from St. Elsewhere to E.R), has been humanizing our view of the practice of medicine, and Gawande's book is perhaps the biggest and most convincing step in that direction so far. What makes Complications such a breath (or perhaps a gasp) of fresh air is not only the authority with which it's written—Gawande is a surgical resident in his last year of training—but also its willingness to take on subjects from which others have shied away. Tellingly, the book is divided into sections titled "Fallibility," "Mystery," and "Uncertainty." The topics Gawande takes on include the practical necessity of having surgical students train on live patients, the confusing psychology of bodily illness, the question of why doctors make mistakes, the repercussions when they descend into periods of incompetence (they often keep practicing), and the peculiarities of relying on intuition in situations of life and death.
Complications is also marked by a straight-talking descriptiveness. Gawande takes his readers deep into the hospital, even leading them into the operating room and pulling back the drapes, where he shows them the knife sliding into flesh, as in this passage: "I cut down the middle of our patient's belly, through skin and then dense inches of glistening yellow fat.... We put metal retractors in place to hold the wound open and keep the liver and the slithering loops of bowel out of the way." Gross. But that is Gawande's point. He has imbued his prose with physicality because medicine is predicated on exactly that: physical action. And physical action means risk, confusion, complexity, and sometimes mistakes. Gawande believes that we as patients have been sheltered from the reality of medicine for too long, and as the title of his book suggests, he wants us to start confronting the full truth. That means opening our eyes and taking a long look at the highest-stakes profession that exists in society—a profession that is still, for all its technological and scientific advancement, "a fundamentally human ... endeavor." No matter how much we yearn for medicine to be neat, Gawande argues, it's not. So we might as well be well-informed. Atul Gawande works at a hospital in Boston that he'd rather not name, having been flooded with phone calls after doing so in the past. He received his M.D. from Harvard Medical School and an M.P.H. from the Harvard School of Public Health. Many of the essays in his book have appeared in The New Yorker, where Gawande is a staff writer. He lives in Newton, Massachusetts, with his wife and three children. I spoke to him by phone on April 10.
I wanted to start by asking about the word "imperfect," which appears in the subtitle of your book. It strikes me as a pretty strong and troubling concept when applied to medicine. It's also clear that a major theme of your book is that, like the rest of us, doctors can get tired and angry and stupid and depressed. Did you see it as your goal to humanize medicine?
Well, I was trying to demystify medicine. I think we're at a difficult juncture. On the one hand, medicine has become extraordinarily aggressive and bewildering and also powerful, in the sense that it is capable of truly extending people's lives, whether they have heart disease or kidney failure or even cancer. On the other hand, patients are being asked to make more choices and take on responsibilities of a greater magnitude than they ever have had to before. And that's because we have finally come to grips with the notion that, okay, doctors are not gods. But what comes after that? No one has really prepared anyone for this, and I think that's because we've never really shown people how medicine works: what decisions really matter, how they're made, how much uncertainty there is, how that uncertainty is dealt with. The thing that most startled me upon entering the medical profession is how human an endeavor it is. We have all the technology and studies and science and know-how and yet, in the end, it's still this tiny pair—the individual doctor and the individual patient—who are left to try to sort through it all. It's the decisions that are really critical. And those decisions are inherently imperfect because both doctor and patient are fallible, because there are still mysteries in medicine—things that we don't understand—and because there is always going to be uncertainty.
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Is a patient better off knowing all that you just said, having it pushed upon them that doctors are fallible? Fallibility isn't something that patients can do very much about, especially if their medical problem is an emergency. Is it possible that the knowledge you're meting out could just produce more anxiety?
I think your question is really fundamental. Let me put it this way: it's the question of whether we need to believe in the myth of the infallible doctor in order to be able to put ourselves in his hands. I think a lot of doctors have certainly thought so for a long time. But we've reached a point where that myth seems to do more harm than good. It means that patients aren't asking questions, aren't getting second opinions, and that doctors are sometimes providing bad care without being questioned about it. So I think fallibility is important to know about for two reasons. Number one, there are sometimes things that patients can do on an individual level. There is an art to being a patient in the same way that there is an art to being a doctor. It's an art because it's very hard to be a patient. You have to know when to question and ask for second opinions and sometimes even anger your own physician, and then you also have to know when to put yourself in someone else's hands and simply trust them and go along. And as you say, an emergency may be the exact time when you simply have to trust that the system works more often than it doesn't, that it's going to be to your benefit.
Part of all this, though it isn't necessarily stated directly in the book, is that by seeing exactly what happens—understanding it, getting the stories, the real cases of people living and dying—you begin to grasp what's really hard about medicine, how doctors really are good today at the same time that they are ordinary and fallible. Out of that comes, yes, some anxieties, but I think it also wipes away a lot of the unnamed dread that people have of medicine and health care. You go into a hospital and it is an incredibly foreboding place. You don't really understand what's going on and people are injected with things, their bodies are opened wide, they're given drugs, and every process in their system is tinkered with. The public has become ironically fearful of medicine at the very time that it's become as capable as it's ever been. Some of that fear is justified but some of it disappears when you begin to see up close how it is that things really happen, even when you see the warts that I'm sometimes willing to show.
So I suppose the hope is that with a demystification will also come a reduction in fear?
I think there's also another layer to demystifying medicine, which is that there are certain things beyond paying attention to the individual patient that the public needs to do and that medicine needs to do. I talk, for example, about the decline in autopsies and the importance of bringing the autopsy back. I talk about ways in which we've failed to do important kinds of research, about how mistakes occur and also about how we often put the blame in the wrong place. I talk about how the media can sometimes be irresponsible in these matters. So there are important things for our society, I think, that come out of being forthright and honest about what's right and what's wrong in medicine.
I'd like to stay with the idea of the patient. Reading your book I found it hard to shake the image of a patient reading certain passages and growing increasingly disconcerted. For example, you write in one section, about putting in an intravenous line, "This is a big goddamn needle, I kept thinking. I couldn't believe I was sticking it into someone's chest." Incredibly honest, and yet I couldn't help picturing myself as the patient who was maybe—
On the other end?
Exactly. On the other end. You've already spoken of the two ends of the spectrum—the paternalism of medicine on one side and patients' knowing the fallibility of their doctors on the other. Is the hope to move as close as possible to the latter or to establish some happy medium?
Well, I also show patients themselves making bad decisions at times. I think part of the purpose is simply illumination—grasping the dilemmas so we don't pursue ideas as individual patients that are going to be harmful to ourselves. Let me try to be more specific. Experience matters. Knowing the experience level of your own physician is important. At the same time, learning is absolutely necessary for the progress of our society. We have to have new doctors for tomorrow. The only way that that can occur is if it occurs as equitably and as safely as possible. But the reality is, learning will still involve mistakes along the way. Trying to understand why things are happening the way they are happening and what parts of it are right and what parts of it are wrong is hard news to absorb but still important.
You said earlier that patients are more knowledgeable now than they used to be. What do you think led to that shift?
I think that's been the direction of all knowledge, thanks to technology, thanks to culture over time. People know more and they have a better understanding of the right questions to ask and what they want. Although it's not always perfect, the Internet is an important source of information for a lot of patients. It's also an important source of a lot of wrong information for people. But, then, it used to be neighbors that people turned to, and neighbors didn't always have great information, either. I think some doctors can be annoyed by how much information patients sometimes come in with, because it's hard to make patients understand that it's not enough to simply have one study in front of you that says X. The trick is understanding what to make of not only the science that you have in front of you but also of the gaps that are not filled in and of all the uncertainties that abound in decision-making. In the book I tell the story of a young woman who had an infection in her toe that crept up her leg over the course of a couple of days. I walked into the emergency room and when I saw her, the first thing that happened was that my stomach dropped out because I thought: this could be flesh-eating bacteria. It was not a rational response on my part. It had everything to do with the fact that a month earlier I'd seen a patient with this incredibly rare and deadly problem. I couldn't get rid of that intuition. So I recommended to her that we take her to the operating room and take a piece of her leg to make sure it wasn't flesh-eating bacteria. And you can bet that her father, who was at her side, insisted on getting a second opinion. How do you go about asking for a second opinion and still keep your doctor on your side and feel like you're making the right decisions and not being too pushy? That's really hard, but he made the right decision. In the end—I don't want to give away the whole story—but when the other doctor was confronted with my intuition, his opinion was that when a doctor is fearful about something like this, there's little choice but to recommend looking at a piece of the tissue from the patient's leg under a microscope.
I'm not going to give away what happened, but I have to tell you that that section scared the hell out of me, more than any other story in the entire book. I've stopped shaving since I read that section. And I promised myself I'd ask: is flesh-eating bacteria still around? Please say no.
Flesh-eating bacteria is absolutely still around. We understand very little about it. It is something that hits about a thousand or two thousand Americans a year. It kills somewhere between 50 to 75 percent of them, and we don't know where it comes from. It can hit the young, it can hit the old, although the old are at higher risk of it.What makes it such a scary disease and what makes it scary for me as a doctor is that it moves so fast. You have to decide to act as if it's there, maybe even amputate someone's arm or leg on a hunch. Well, not on a hunch, but maybe amputate it on the basis of what starts out as just a hunch.
How have your colleagues reacted A) to the theme of medical imperfection and B) to the fact that when working you're often, I imagine, looking for ideas.
These are very sensitive topics that I'm trying to write about and talk about. And I'm doing it because I think there's good reason to talk about them. But it's also understandable that other doctors would be very nervous about whether it's handled in a way that's measured and careful. I've been very fearful in writing this book that the response could be quite negative from colleagues. The surprise to me is that it hasn't been. It's been the opposite. And I think the reason why is that these struggles over the uncertainty of medicine and the ways that mistakes occur and trying to avoid them yourself are the daily struggles of every physician. Thinking about them and writing about them and trying to show everything we know about them is something that's new even for doctors, let alone for patients, and so it's been seen as an opportunity rather than as what some might have feared it would be.
So you haven't found that doctors or colleagues are more careful around you?
Well, I don't really write exposés. When I write about the mistakes that have happened they've been the mistakes that I've made, and I think everybody I work with understands I'm not writing about them as individuals or about things they do wrong. Once in a while they'll joke about needing to have a metal detector at the door to make sure it picks up any pens that I might have on me before I come into the operating room, but in truth among my colleagues no one has ever given me a hard time about the articles. There are definitely people who will argue with the conclusions I reach and so we have some excellent debates, but the support has been more than I really expected.
I'm curious as to whether any patients have recognized your name.
The first chapter of the book, which talks about learning how to put a central intravenous line into somebody's chest, recently came out in The New Yorker, and I had to do that procedure on a patient who happened to have that issue of the magazine at his bedside. I was really gratified to find that the effect was not the one that I feared, which was that he would take one look at me and say, "Oh, no." Instead the patient said he was glad to know how everything worked, and in fact I took a junior resident through the procedure with this patient, and she did a great job, and the patient was great, too. It was surprising, but also I think there's some evidence that having an understanding of how things work in medicine doesn't mean what people in medicine sometimes think it does, which is that suddenly no one is capable of trusting their doctor. I think it turns out that you don't need to believe that your doctor is a god in order to be able to trust him. I think most people feel it's enough that their doctor is someone who has worked as hard as he can to be good at what he does and is going to do his best to make it go right despite all the constraints and all the contradictory directions that he's being pulled in.
I'd like to move on to a different theme in your work: the idea that we need to confront the psychological aspects of physical illness. In a chapter titled "The Pain Perplex" you explain how pain can often have a non-physical cause. I'd like to ask you about the word "non-physical," by which I gather you mean psychological.
I guess the way I was trying to describe it was as a structural cause. I told the story of an architect who had this disabling back pain and yet X-rays and MRIs of his back could find nothing structurally wrong to account for the pain. And yes, as you suggest, it's not really that it had a non-physical cause, because even the psychological can be physical. It's that age-old mind-body divide that we still have a hard time grappling with and knowing what to do about.
Well, that's precisely what I'd like to talk about a little bit more—that mind-body divide in medicine, whether having medicine embrace the understanding of the psychological aspects of symptoms of pain, for example, is simply a matter of working toward medicalizing psychology. In your experience, how much is the brain and psychology taken into account in the medical profession?
I don't think enough. But it may be less that we're medicalizing psychology than that we're psychologizing medicine, and I don't think that's necessarily bad. But patients do fear being told something is in their mind. They feel like you're judging them when you come around to saying that, look, there really is nothing wrong with your spine when you have your back pain. They feel like you're saying that they're not having real pain. The difficult thing for us to wrap our minds around—and this is one of the mysteries that we are still grappling with—is that pain can be exactly the same whether it comes from a hammer to someone's back or a signal that somehow emanates from one's brain. But the treatments are going to be different, even though the pain will feel exactly the same. One case may involve a spinal surgery to correct a patient's back and its alignment, and in the the other you wouldn't want to use surgery at all because that may in fact only be harmful. So what does work? Well, where does this pain come from? We're only beginning to understand that sometimes, for some people, an injury that may start in their back can cause a pain that becomes almost imprinted in the brain and then is stimulated by even ordinary sensations, so that just a touch to the back can be enough to elicit something that is exactly like a nail being driven into their back. It means we have to be more wide-ranging in our understanding of where some things come from. For example, when I talk about people with unusual problems like disabling blushing or nausea that simply can't be explained, it makes you realize that there are sometimes unusual areas in which you have to examine how even society can sometimes instigate disease. One of the examples I gave in that pain piece is how there's an epidemic of back pain among physicians, and that the number of physicians who are applying for disability has skyrocketed. The cause seems to be that increasing dissatisfaction in the practice of medicine is leading more physicians to experience back pain, not that they're faking it. That's the part people don't seem to necessarily grasp. It's that the dissatisfaction itself is an important component in the generation of what can become chronic and genuine pain.
What would be the best step in accepting the reality of physical symptoms that do not have a below-the-neck cause? Is it simply a matter of waiting for brain science to catch up?
I think that's right. There are a couple of things. One is that this new understanding about where problems like chronic pain can come from is leading to the development of new drugs that don't target your back or your shoulder but instead target the cells and the neurons in your brain where the pain signals come from. And those drugs, some of them from the same families as anti-depressants and others from the same families as anti-seizure medications, have had surprising results in being able to reduce people's pain. The second part of it involves researching the ways in which problems like serious, ongoing, and seemingly intractable pain can emanate from the brain itself. We can start to develop new kinds of therapies that try to teach the brain to stop making those signals. Those, I think, are some of the surprising new areas which are still only beginning to be explored.
Is the brain still the bastard child in hospital medicine?
It isn't so much that it's the bastard child, but that it is a source of incredible mystery. I think that in terms of the brain and the immune system, we still are fundamentally in the dark not only about how we might make things better for people who are afflicted by conditions that begin in these places but also how to explain them.
I wanted to ask you a question about medical writing itself. I'm fascinated by the way that medical writers use metaphors. I don't know if you've ever read David Sedaris's essay "Ashes," in which his mother is dying from cancer and she complains—
She asks why doctors always compare tumors to fruit. Someone else has said, I think, that doctors compare tumors to fruit if their patients are women and to sports objects if their patients are men.
At one point in your book you call a tumor "football-sized" and at another point "tennis-ball sized."
I wouldn't do that again.
What would you do? How aware are you in writing of the metaphors of illness?
Our bodies are what people have been writing about for millennia. And so trying to find a new way to write about it is the hardest part of the task. I am very aware of the descriptions I use and of how I'm almost deliberately trying not to write lyrically, as someone might say, or poetically, but very vividly and descriptively. I want people to see the tumor that's in somebody's back, and I want somebody to feel the slide of the needle as it's pushed into someone's chest so you begin to grasp what it is that's being done to people and why and what the stakes are. So to do that, I think, requires moving beyond the clichés of medicine. Medicine is so full of clichés it's hard to avoid them, so you look for metaphors in new places or sometimes just scrap them altogether and just say what you see.
And so you find yourself dissatisfied with the football-sized tumor at this point?
It seems a difficult situation to be in as a writer: How does one describe cancer, something as loaded with meaning as a tumor, without trivializing it?
That is the trick. I think what works best in medicine is just to try to show what happens. What I find myself doing is trying to show what people do rather than who they are or what they're wearing. I do want readers to see them, but I find the easiest way for people to grasp what another person is like is to see how that person does something. Knowing how a doctor holds a knife can tell you a lot about that person. Or how they walk out the door. Medicine, fortunately, is an area in which people are doing things constantly, and so there's a lot to describe, a lot to explain about what's going on. It also has an added advantage for most readers, which is that it hasn't really been explained to them very often. I don't have to be terribly fancy about how I describe things, because the novelty can come from simply seeing things you've never seen before.
Was there any limit to the disclosure of your own mistakes?
I think the main limit is my own stomach.
How do you mean?
Just in the sense that there's no inherent limit on my being able to explain the truth of the mistakes I've made along the way. But there's no question that acknowledging these things made me very uncomfortable and scared about what people would think of me. I'm still a young doctor; I still have a career to make, I go out on the job market a year from now.
How old are you?
I'm thirty-six; I'll be finishing my last year of surgical training next year. I absolutely want to be as responsible as I can be while also being as honest as I can be, so I have to resist the urge to soft-pedal things because I think readers see right through it. When you're vague or indirect, people know you've got something up your sleeve or something's not quite the way things really happen. It only works when you lay it out as honestly as you can. Though I'm sure there are still blinders and limits to what I can put out there.
Does your worst mistake appear in this book?
Oh God, I've made so many terrible mistakes. I have no idea how I'd even begin to rank them. I mean, certainly my most vivid mistakes appear in the book, the ones that I've struggled with the most.
Which is the mistake that's most vivid?
It's in "When Doctors Make Mistakes," the chapter about a woman who was in a car crash and needed an emergency tracheotomy and every other physician who could do it better than I could was stuck in the operating room, so I was left having to proceed on my own. I don't mean to suggest that this book is entirely filled with confessions. I describe lots of successes of my own and of others as well, but this book isn't about explaining the worst mistake I've made or the best save I've ever had. It's more an effort to try to take the ordinary but still kind of astonishing things that happen along the way and put them under the microscope.