Complications: A Surgeon's Notes on an Imperfect Science by Atul Gawande. Metropolitan Books, $24, pp 288. ISBN 080 506 3196. Rating: ★★★
Complications is a collection of essays about doubt and uncertainty in medicine. As well as being a surgeon, Atul Gawande is a staff writer on medicine and science at The New Yorker, and some of the essays in this volume have appeared before. For example, “When Doctors Make Mistakes,” which is a frank account of what often happens “behind the scenes,” was included in a collection of the “best American science and nature writing 2000,” and with good reason. Gawande has a way of writing that demystifies medicine.
In “Education of a Knife,” Gawande touches upon the sensitive issue of training in a way that is rarely discussed outside the medical fraternity. Medicine—especially surgery—is the classic example of learning by trial and error. For obvious reasons, no one wishes to be the patient on whom the learning is done. What this means is that the learning, and the mistakes—sometimes fatal ones—have to be done at the expense of the unconnected and the poor, usually in teaching or university hospitals, while the rich get the choice of being seen by fully qualified senior physicians.
Gawande would, however, be happy to know that at least one study has shown that, contrary to common belief, there is no increase in deaths in early August, when newly qualified doctors become house officers . Practice makes perfect, however, and this is amply shown by the stupendous results at the Shouldice Hospital, Canada. Here surgeons restrict themselves to performing only hernia operations, take from 30 to 45 minutes per operation, and have a recurrence rate of 1%. In contrast, most general surgeons would take about 90 minutes per case, yet have a relapse rate of 10% to 15%.
Gawande takes a dig at medical conventions—and at medical morals—when he refers to chintzy freebies (golfballs, fountain pens, canvas bags) being lapped up by six-figure surgeons who should be immune to such petty bribery. There are also essays dealing with everyday medical problems such as nausea, pain, and blushing. Although Gawande expands on the current thinking on the pathophysiology, the focus is on the unanswered questions. He examines the role of sentiment and gut feeling, which is often the sum total of our experiences in a world of evidence based medicine. Importantly, he also boldly questions the blind acceptance of patient autonomy as an absolute truth.
Gawande adopts an interested third person approach—like, say, an Isaac Asimov, rather than an involved, treating physician like Richard Selzer. He confirms Somerset Maugham's belief that the best “training for a writer [is to] spend some years in the medical profession.”