On Complications

I recently finished reading Complications – A Surgeon’s Notes on an Imperfect Science – by Atul Gawande.

Below are key excerpts from this book that I found particularly insightful:

The thing that still startles me is how fundamentally human an endeavor it is. Usually, when we think about medicine and its remarkable abilities, what comes to mind is the science and all it has given us to fight sickness and misery: the tests, the machines, the drugs, the procedures. And without question, these are at the center of virtually everything medicine achieves. But we rarely see how it all actually works. You have a cough that won’t go away—and then? It’s not science you call upon but a doctor. A doctor with good days and bad days. A doctor with a weird laugh and a bad haircut. A doctor with three other patients to see and, inevitably, gaps in what he knows and skills he’s still trying to learn.

I am a surgical resident, very nearly at the end of my eight years of training in general surgery, and this book arises from the intensity of that experience…But more than anything, this book comes from what I have encountered and witnessed in the day-to-day caring of people…The book’s title, Complications, comes not just from the unexpected turns that can result in medicine but also, and more fundamentally, from my concern with the larger uncertainties and dilemmas that underlie what we do. This is the medicine that one cannot find explained in textbooks but that has puzzled me, sometimes troubled me, sometimes amazed me, as I’ve joined the profession’s ranks.

There is a saying about surgeons, meant as a reproof: “Sometimes wrong; never in doubt.” But this seemed to me their strength. Every day, surgeons are faced with uncertainties. Information is inadequate; the science is ambiguous; one’s knowledge and abilities are never perfect. Even with the simplest operation, it cannot be taken for granted that a patient will come through better off—or even alive.

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.

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.

With repetition, a lot of mental functioning becomes automatic and effortless, as when you drive a car to work. Novel situations, however, usually require conscious thought and “workaround” solutions, which are slower to develop, more difficult to execute, and more prone to error. A surgeon for whom most situations have automatic solutions has a significant advantage.

The British psychologist James Reason argues, in his book Human Error, that our propensity for certain types of error is the price we pay for the brain’s remarkable ability to think and act intuitively—to sift quickly through the sensory information that constantly bombards us without wasting time trying to work through every situation anew. Thus systems that rely on human perfection present what Reason calls “latent errors”-errors waiting to happen.

This sort of burnout is surprisingly common. Doctors are supposed to be tougher, steadier, better able to handle pressure than most. (Don’t the rigors of medical training weed out the weak ones?) But the evidence suggests otherwise. Studies s show, for example, that alcoholism is no less common among doctors than among other people. Doctors are more likely to become addicted to prescription narcotics and tranquilizers, presumably because we have such easy access to them.

In the end, it is sometimes not science but what people tell us that is the most convincing proof we have.

In recent years, we in medicine have discovered how discouragingly often we turn out to do wrong by patients. For one thing, where the knowledge of what the right thing to do exists, we still too frequently fail to do it. Plain old mistakes of execution are not uncommon, and we have only begun to recognize the systemic frailties. technological faults, and human inadequacies that cause them, let alone how to reduce them. Furthermore, important knowledge simply not made its way far enough into practice.

In the absence of algorithms and evidence about what to do, you learn in medicine to make decisions by feel. You count on experience and judgment. And it is hard not to be troubled by this.

It is because intuition sometimes succeeds that we don’t know what to do with it. Such successes are not quite the result of logical thinking. But they are not the result of mere luck, either.

A highly recommended read in the areas of medicine and decision making.

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