Complications: A Surgeon’s Notes on an Imperfect Science

In surgery, as in anything else, skill and confidence are learned through experience—haltingly and humiliatingly. Like the tennis player and the oboist and the guy who fixes hard drives, we need practice to get good at what we do. There is one difference in medicine, though: it is people we practice upon.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 18). Kindle Edition.

Surgeons, as a group, adhere to a curious egalitarianism. They believe in practice, not talent. People often assume that you have to have great hands to become a surgeon, but it’s not true. When I interviewed to get into surgery programs, no one made me sew or take a dexterity test or checked if my hands were steady. You do not even need all ten fingers to be accepted.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 19). Kindle Edition.

As one professor of surgery put it to me, given a choice between a Ph.D. who had painstakingly cloned a gene and a talented sculptor, he’d pick the Ph.D. every time. Sure, he said, he’d bet on the sculptor being more physically talented; but he’d bet on the Ph.D. being less “flaky.” And in the end that matters more. Skill, surgeons believe, can be taught; tenacity cannot.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (pp. 19–20). Kindle Edition.

Indeed, the most important talent may be the talent for practice itself.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 20). Kindle Edition.

I still have no idea what I did differently that day. But from then on, my lines went in. 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.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 21). Kindle Edition.

In medicine, we have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm through supervision and graduated responsibility. And there is reason to think patients actually benefit from teaching. Studies generally find teaching hospitals have better outcomes than non‑teaching hospitals.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 24). Kindle Edition.

This is the uncomfortable truth about teaching. By traditional ethics and public insistence (not to mention court rulings), a patient’s right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden, behind drapes and anesthesia and the elisions of language. Nor does the dilemma apply just to residents, physicians in training.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 24). Kindle Edition.

As patients, we want both expertise and progress. What nobody wants to face is that these are contradictory desires. In the words of one British public report, “There should be no learning curve as far as patient safety is concerned.” But that is entirely wishful thinking.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 28). Kindle Edition.

“Three‑quarters of what I do today I never learned in residency,”

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 25). Kindle Edition.

Sometimes we do feel obliged to admit when we’re doing something for the first time, but even then we tend to quote the published success rates—which are virtually always from experienced surgeons. Do we ever tell patients that because we are still new at something, their risks will inevitably be higher, and that they’d likely do better with others who are more experienced? Do we ever say that we need them to agree to it anyway? I’ve never seen it. Given the stakes, who in their right mind would agree to be practiced upon?

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 30). Kindle Edition.

In a sense, then, the physician’s dodge is inevitable. Learning must be stolen, taken as a kind of bodily eminent domain. And it was, during Walker’s stay—on many occasions, now that I think back on it. A resident intubated him. A surgical trainee scrubbed in for his operation. The cardiology fellow put in one of his central lines. None of them asked me if they could. If offered the option to have someone more experienced, I certainly would have taken it. But that was simply how the system worked—no such choices were offered—and so I went along. What else could I do? The advantage of this coldhearted machinery is not merely that it gets the learning done. If learning is necessary but causes harm, then above all it ought to apply to everyone alike. Given a choice, people wriggle out, and those choices are not offered equally. They belong to the connected and the knowledgeable, to insiders over outsiders, to the doctor’s child but not the truck driver’s. If choice cannot go to everyone, maybe it is better when it is not allowed at all.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (pp. 32–33). Kindle Edition.

In psychology, there’s something called the broken‑leg problem. A statistical formula may be highly successful in predicting whether or not a person will go to a movie in the next week. But someone who knows that this person is laid up with a broken leg will beat the formula. No formula can take into account the infinite range of such exceptional events. That’s why doctors are convinced that they’d better stick with their well‑honed instincts when they’re making a diagnosis.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (pp. 42). Kindle Edition.

It is one thing to be aware of one’s limitations. It is another to be plagued by self‑doubt. 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. “It was a clean kill,” he said. Afterward, he could barely bring himself to operate. When he did operate, he became tentative and indecisive. The case affected his performance for months. Even worse than losing self‑confidence, though, is reacting defensively. There are surgeons who will see faults everywhere except in themselves. They have no questions and no fears about their abilities. As a result, they learn nothing from their mistakes and know nothing of their limitations. As one surgeon told me, it is a rare but alarming thing to meet a surgeon without fear. “If you’re not a little afraid when you operate,” he said, “you’re bound to do a patient a grave disservice.”

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 61). (Function). Kindle Edition.

The buzzword at General Electric these days is “Six Sigma,” meaning that its goal is to make product defects so rare that in statistical terms they are more than six standard deviations away from being a matter of chance—almost a one‑in‑a-million occurrence.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 62). (Function). Kindle Edition.

James Reason makes another important observation: disasters do not simply occur; they evolve. In complex systems, a single failure rarely leads to harm. Human beings are impressively good at adjusting when an error becomes apparent, and systems often have built‑in defenses. For example, pharmacists and nurses routinely check and countercheck physicians’ orders. But errors do not always become apparent, and backup systems themselves often fail as a result of latent errors. A pharmacist forgets to check one of a thousand prescriptions. A machine’s alarm bell malfunctions. The one attending trauma surgeon available gets stuck in the operating room. When things go wrong, it is usually because a series of failures conspires to produce disaster. The M & M takes none of this into account. For that reason, many experts see it as a rather shabby approach to analyzing error and improving performance in medicine. It isn’t enough to ask what a clinician could or should have done differently so that he and others may learn for next time. The doctor is often only the final actor in a chain of events that set him or her up to fail. Error experts, therefore, believe that it’s the process, not the individuals in it, that requires closer examination and correction. In a sense, they want to industrialize medicine. And they can already claim successes: the Shouldice Hospital’s “focused factory” for hernia operations, for one—and far more broadly, the entire specialty of anesthesiology, which has adopted their precepts and seen extraordinary results.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (pp. 63–64). (Function). Kindle Edition.

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.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 74). (Function). Kindle Edition.

The truth is that doctors like me are grateful to the pain specialists, too. Though we want to be neutral in our feelings toward patients, we’ll admit among ourselves that chronic‑pain patients are a source of frustration and annoyance: presenting a malady we can neither explain nor alleviate, they shake our claims to competence and authority.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 118). (Function). Kindle Edition.

If an overactive neuronal system is the problem, then what one needs is a drug that will damp it down. That’s why, in what a decade ago might have seemed a strange development, pain specialists increasingly prescribe anti‑epileptic drugs, like carbamazepine and gabapentin, for their most difficult‑to‑treat patients. After all, that’s what these drugs do: they tune brain cells to modulate their excitability.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 126). (Function). Kindle Edition.

In a famous 1992 paper, however, the evolutionary biologist Margie Profet made a compelling case that pregnancy sickness is actually protective. She pointed out that natural foods that are safe for adults commonly turn out to be unsafe for embryos. All plants produce toxins, and in order to be able to eat them we have evolved elaborate detoxification systems. But these systems don’t eliminate harmful chemicals completely, and embryos can be sensitive to even tiny amounts. (For example, toxins in potatoes have been found to cause neural malformations in animal fetuses, even at levels that are nontoxic to their mothers; indeed, Ireland’s heavy potato consumption may account for its having the world’s highest rate of neural defects, such as spina bifida.) Pregnancy sickness, Profet suggested, may have evolved to reduce an embryo’s exposure to natural toxins. She pointed out that women with pregnancy sickness strongly prefer bland foods that do not spoil easily (like breads and cereals) and are particularly averse to foods associated with high levels of natural toxins, such as bitter or pungent foods and animal products that are not extremely fresh. The theory also explains why sickness occurs mainly during the first trimester. That is when the embryo develops organs and is most sensitive to toxins; at the same time, it is small and its calorie needs are easily supplied by the mother’s fat stores. Overall, women with moderate to severe morning sickness have a lower rate of miscarriages than women with mild nausea or none at all.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (pp. 134–135). (Function). Kindle Edition.

We want progress in medicine to be clear and unequivocal, but of course it rarely is. Every new treatment has gaping unknowns—for both patients and society—and it can be hard to decide what to do about them. Perhaps a simpler, less radical operation will prove effective for obesity. Perhaps the long‑sought satiety pill will be found. Nevertheless, the gastric bypass is the one thing we have now that works. Not all the questions have been answered, but there are more than a decade of studies behind it. And so we forge ahead.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 184). (Function). Kindle Edition.

Your patient is dead; the family is gathered. And there is one last thing that you have to ask about: the autopsy. How should you go about it? You could do it offhandedly, as if it were the most ordinary thing in the world: “Shall we do an autopsy, then?” Or you could be firm, use your Sergeant Joe Friday voice: “Unless you have strong objections, we will need to do an autopsy, ma’am.” Or you could take yourself out of it: “I am sorry, but they require me to ask, Do you want an autopsy done?”

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 187). (Function). Kindle Edition.

How often do autopsies turn up a major misdiagnosis in the cause of death? I would have guessed this happened 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 percent. A large review of autopsy studies concluded that in about a third of the misdiagnoses the patients would have been expected to live if proper treatment had been administered. George Lundberg, a pathologist and former editor of the Journal of the American Medical Association, has done more than anyone to call attention to these figures. He points out the most surprising fact of all: the rates at which misdiagnosis is detected in autopsy studies have not improved since at least 1938.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 197). (Function). Kindle Edition.

Still, these calcifications are not equivocal findings. They commonly do indicate cancer—even if they don’t always—and typically at an early and treatable stage. Now, if having control over one’s life is to mean anything, people have to be permitted to make their own mistakes. But when the stakes are this high, and a bad choice may be irreversible, doctors are reluctant to sit back. This is when they tend to push. So push. Your patient is getting ready to walk out the door. You could stop her in her tracks and tell her she’s making a big mistake. Give her a heavy speech about cancer. Point out the fallacy in supposing that three negative biopsies proves that the fourth one will be negative as well. And in all likelihood you’ll lose her. The aim isn’t to show her how wrong she is. The aim is to give her the chance to change her own mind. Here’s what I’ve seen good doctors do. They don’t jump right in. They step out for a minute and give the woman time to get dressed. They take her down to the office to sit and talk, where it’s more congenial and less antiseptic—with comfortable chairs instead of a hard table, a throw rug instead of linoleum. And, often, they don’t stand or assume the throne behind the big oak desk but pull up a chair and sit with her. As one surgical professor told me, when you sit close by, on the same level as your patients, you’re no longer the rushed, bossy doctor with no time to talk; patients feel less imposed upon and more inclined to consider that you may both be on the same side of the issue at hand.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (pp. 218–219). (Function). Kindle Edition.

But the conundrum remains: if both doctors and patients are fallible, who should decide? We want a rule. And so we’ve decided that patients should be the ultimate arbiter. But such a hard‑and‑fast rule seems ill‑suited both to a caring relationship between doctor and patient and to the reality of medical care, where a hundred decisions have to be made quickly. A mother is in labor: should the doctor give hormones to stimulate stronger contractions? Should he or she break the bag of water? Should an epidural anesthetic be given? If so, at what point in labor? Are antibiotics needed? How often should the mother’s blood pressure be checked? Should the doctor use forceps? Should the doctor perform an episiotomy? If things don’t progress quickly, should the doctor perform a cesarean section? The doctor should not make all these decisions, and neither should the patient. Something must be worked out between them, one on one—a personal modus operandi. Where many ethicists go wrong is in promoting patient autonomy as a kind of ultimate value in medicine rather than recognizing it as one value among others.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (pp. 223–224). (Function). Kindle Edition.

But, as the field grows ever more complex and technological, the real task isn’t to banish paternalism; the real task is to preserve kindness.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 224). (Function). Kindle Edition.

One, for example, from the Medical College of Virginia, found that doctors ordering blood cultures for patients with fever overestimated the probability of infection by four- to tenfold. Moreover, the highest overestimates came from the doctors who had recently seen other patients with a blood infection.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 238). (Function). Kindle Edition.

Judgment, Klein points out, is rarely a calculated weighing of all options, which we are not good at anyway, but instead an unconscious form of pattern recognition.

Gawande, Atul. Complications: A Surgeon’s Notes on an Imperfect Science (p. 248). (Function). Kindle Edition.