It’s Complicated…
Lennoxville Library
Complications: A Surgeon’s Notes on an Imperfect Science was a 2002 National Book Award finalist for non-fiction.
In a rare moment of inexplicable perversity I chose to read and review this book, despite the fact that, due to an inefficient aortic valve, I am currently approaching the up-close-and-personal experience of heart surgery myself. What was I thinking? Honestly, I don’t know, but I had read Atul Gawande’s more recent book, Being Mortal (2014), shortly after it was published and loved it. With this meditation on “how people can better live with age-related frailty, serious illness, and approaching death”, Gawande proved that he is not only an excellent surgeon, but a pretty darned good writer as well. There are very few medical writers out there who have Gawande’s knack for rendering the complicated simple enough for any lay person to read, understand and enjoy.
Gawande wrote Complications in his last year of an eight-year surgical residency program, and he wisely divided his book into three sections: Fallibility, Mystery, and Uncertainty. Each section tackles a variety of medical, usually surgical, issues that he has encountered, drawing on his personal experience as well as research. In one chapter in the first section, Fallibility, he deals with the universal problem of surgical error. It turns out that it is not only “bad” surgeons who make mistakes, but in fact ALL surgeons. “Mistakes do happen. We tend to think of them as aberrant. They are, however, anything but.” Using himself as one example, Gawande recounts his experience of very nearly killing a patient, and the resultant Morbidity and Mortality conference (the M&M) which dissected why and how the error occurred, and what was learned from his experience. Many studies have been done on why errors occur, and how to prevent them. “Medical malpractice suits are a remarkably ineffective remedy…. Research has consistently failed to find evidence that litigation reduces medical error rates.” So what does help? Practice, for a start, and judicious use of computer technology. Learning to do something perfectly through repetition is delineated in the chapter entitled The Computer and the Hernia Factory. At a medical centre outside Toronto, hernia operations take from thirty to forty-five minutes, with a recurrence rate of only 1%, and at a cost of about half of the regular rate. Why? Because each surgeon on staff does hernia operations, and nothing else, repairing between 600800 hernias a year. Gawande notes that a “defining trait of experts is that they move more and more problem solving into an automatic mode.” When asked if he ever got bored, one of the surgeons replied, in a very logical manner, “No. Perfection is the excitement.”
In the chapter entitled 9000 Surgeons, Gawande describes his first experience at a week-long surgical convention, where he was one of 9312 surgeons on site, perusing a 380-page schedule of programs. When considering whether this is a worthwhile way to spend precious time away from their practice, he notes that “We may have each had good practical reasons for coming here: the new ideas, stuff to learn. We are, for a few days, with all the pluses and minuses it implies, our own nation of doctors.”
The second section, Mystery, is also broken up into chapters, starting with the role of superstition in medical decisions. Based on his own research, Gawande concluded that there was no connection between Full Moon Friday the 13th (the chapter title) and bad luck, but was unable to convince his colleagues that this was the case. The Pain Perplex takes a detailed but intriguing look at the immensely puzzling condition of chronic pain, in particular back pain. “Scores of studies have looked for physical factors that can predict which acute back injuries will evolve into chronic back pain, but they haven’t found any.” The rest of the chapters in this section look at the horror of nausea that lasts for months (A Queasy Feeling); pathological blushing (The Crimson Tide); and finally, insatiable appetite leading to lifethreatening weight gain, and the various measures available to curb those cravings and rid the body of excess weight ( The Man Who Couldn’t Stop Eating).
The final section, Uncertainty, looks at, fittingly, autopsies (The Final Cut), and how they can help pin down cause of death, even when the cause seems to be self-evident; the devastating loss of a baby’s life known as crib death, aka SIDS ( The Dead Baby Mystery); the consequences, both positive and negative, of leaving life and death decisions essentially up to the patient (Whose Body is It, Anyway?); and finally, The Case of the Red Leg, which concerns itself with the fate of a young patient who may or may not have necrotizing fasciitis, the infamous flesh-eating disease.
Gawande, 54, is an American surgeon, writer, and public health researcher. He currently practices general and endocrine surgery at Brigham and Women’s Hospital in Boston, Massachusetts, and in his spare time, is a staff writer for The New Yorker magazine. His writing is both engaging and compelling, and he is an accomplished wordsmith. Even more importantly, I learned something new in virtually every chapter, one of my criteria for a worthwhile read. For all these reasons and more, I recommend this book very, very highly. Complications is a slim, 252 page volume, with an additional 12 pages of source notes for those who want to delve more deeply into Gawande’s subject matter. Fortunately, both this book and Being Mortal are available at the Bibliothèque Lennoxville Library.
Postscript: Needless to say, recently Dr. Gawande has had a few well-chosen words in print and on social media about the U.S. government’s reaction to the COVID-19 pandemic. He is obviously not in favour of the anti-scientific, individualrights hysteria that has inflamed our neighbours to the south, and has written and spoken about the balanced, organized and highly effective reaction to a COVID-19 outbreak that took place at his Boston hospital, Brigham and Women’s.
Post-postscript: Wish me luck!