Product Description

In gripping accounts of true cases, surgeon Atul Gawande explores the power and the limits of medicine, offering an unflinching view from the scalpel’s edge. Complications lays bare a science not in its idealized form but as it actually is—uncertain, perplexing, and profoundly human.

Product Details

• Amazon Sales Rank: #2667 in Books
• Published on: 2003-04-01
• Original language: English
• Number of items: 1
• Binding: Paperback
• 288 pages

Features

• ISBN13: 9780312421700
• Condition: NEW
• Notes: Brand New from Publisher. No Remainder Mark.
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Amazon.com Review
Gently dismantling the myth of medical infallibility, Dr. Atul Gawande's Complications: A Surgeon's Notes on an Imperfect Science is essential reading for anyone involved in medicine--on either end of the stethoscope. Medical professionals make mistakes, learn on the job, and improvise much of their technique and self-confidence. Gawande's tales are humane and passionate reminders that doctors are people, too. His prose is thoughtful and deeply engaging, shifting from sometimes painful stories of suffering patients (including his own child) to intriguing suggestions for improving medicine with the same care he expresses in the surgical theater. Some of his ideas will make health care providers nervous or even angry, but his disarming style, confessional tone, and thoughtful arguments should win over most readers. Complications is a book with heart and an excellent bedside manner, celebrating rather than berating doctors for being merely human. --Rob Lightner

From Publishers Weekly
Medicine reveals itself as a fascinatingly complex and "fundamentally human endeavor" in this distinguished debut essay collection by a surgical resident and staff writer for the New Yorker. Gawande, a former Rhodes scholar and Harvard Medical School graduate, illuminates "the moments in which medicine actually happens," and describes his profession as an "enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line." Gawande's background in philosophy and ethics is evident throughout these pieces, which range from edgy accounts of medical traumas to sobering analyses of doctors' anxieties and burnout. With humor, sensitivity and critical intelligence, he explores the pros and cons of new technologies, including a controversial factory model for routine surgeries that delivers superior success rates while dramatically cutting costs. He also describes treatment of such challenging conditions as morbid obesity, chronic pain and necrotizing fasciitis the often-fatal condition caused by dreaded "flesh-eating bacteria" and probes the agonizing process by which physicians balance knowledge and intuition to make seemingly impossible decisions. What draws practitioners to this challenging profession, he concludes, is the promise of "the alterable moment the fragile but crystalline opportunity for one's know-how, ability or just gut instinct to change the course of another's life for the better." These exquisitely crafted essays, in which medical subjects segue into explorations of much larger themes, place Gawande among the best in the field. National author tour.

Copyright 2002 Cahners Business Information, Inc.

From The New England Journal of Medicine
Atul Gawande's voice has become familiar through the articles he has published in the New Yorker over the past several years. With these and other pieces collected in Complications: A Surgeon's Notes on an Imperfect Science, his varied interests and anecdotes cohere into a fascinating meditation on medicine as a human endeavor -- a meditation not only on the state of medicine today, with its controversies, jumps in knowledge and practice, and very real limitations, but also in some ways on the intrinsic complexities and paradoxes of the profession. Gawande writes about the whole enterprise of learning surgery -- and by extension, of learning any kind of medicine -- by practicing, in both senses, on human beings. And so the discussion extends from his own experience in learning how to put in a central line to the question of why and how repetition -- practice and more practice -- brings expertise and smoothness, and then beyond to the moral dilemma of teaching medicine to new learners: "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." After this introductory section about his own initiation into surgical technique, Gawande brings home the idea that everyone in medicine always needs to face questions of judgment, competence, and decision making. He looks at whether computers can read electrocardiograms more reliably than cardiologists and whether a team of nonsurgeons who perform only hernia operations, day in and day out, will do better by their patients than highly trained general surgeons. And then, inevitably, he takes on the issue of medical mistakes, both the error in judgment or technique by the otherwise reliable doctor and what happens to a doctor who makes mistake after mistake. He argues not only that uncertainty and some possibility of error come with the territory but also that many mistakes can be caught and prevented by applying lessons learned from other professions and other ways of thinking. But after all the discussion of how changing complex systems can reduce human error, Gawande, in telling the story of his own inability to obtain an airway in a trauma patient, is left with the truth that medicine remains a human endeavor, with responsibility and even blame to be assigned accordingly: "Good doctoring is all about making the most of the hand you're dealt, and I failed to do so. . . . Whatever the limits of the M&M [morbidity and mortality conference], its fierce ethic of personal responsibility for errors is a formidable virtue. 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." In his discussion of mysterious syndromes, of severe blushing, chronic pain, obesity, and nausea, Gawande confronts issues both at the limits of medical understanding and also, not coincidentally, at the intersection of mind and body. The sufferers he describes -- a woman who wants to be a TV anchorwoman but endures debilitating blushes, an architect with years of chronic back pain, a construction contractor who weighs 194 kg (428 lb) -- speak vividly through his clear and sympathetic writing, showing and telling how their lives have been damaged and circumscribed and even defined by these medical conditions. And yet there is always the nagging question of whether they are somehow "complicit" in their own destruction, whether the blushing problem is some compound of self-consciousness and vanity, whether the pain is "all in his head," whether the weight represents moral weakness. And in following some of these people through surgery -- an endoscopic thoracic sympathectomy to cure the blushing, a Roux-en-Y gastric bypass for the weight -- Gawande leads us to a fascinating surgical perspective. It is almost as if the more this surgeon becomes practiced and comfortable with the astonishing intimacies of surgical technique, with all possible invasions and manipulations of the human body, the more intrigued he becomes by the intricacies of the mind and the spirit and their power over the body and its progress, in sickness and in health. A beautifully written essay on autopsies includes an unforgettable image of a surgeon watching the much less gentle and elegant cutting done on the body after death: "Surgeons get used to the opening of bodies. . . . Nevertheless, I couldn't help wincing as she did her work: she was holding the scalpel like a pen, which forced her to cut slowly and jaggedly with the tip of the blade. Surgeons are taught to stand straight and parallel to their incision, hold the knife between the thumb and four fingers, like a violin bow, and draw the belly of the blade through the skin in a single, smooth slice to the exact depth desired. The assistant was practically sawing her way through my patient." The point of the essay is the necessity of autopsy and the high likelihood of discovering a different cause of death than had been assumed -- a misdiagnosis or complicating condition -- and by extension, the continuing presence of uncertainty even when decisions must be made and action taken and even though human beings cannot be completely understood by algorithm and experience. In the closing essay, Gawande confronts intuition -- what it is, how it works, and how it plays out in medical practice -- by taking us through the remarkable story of his "great improbable save," a 23-year-old woman who came in with what looked like a cellulitis of her leg and who turned out to have necrotizing fasciitis -- a diagnosis Gawande raised early in the course of her illness partly because he happened to have seen another case of it recently. When you are through with your initiation, when the systems work to support your practice, how do you finally make your decisions? When does inconsistency in how patients with the same problem are treated reflect problems in the system or bad doctoring, and when does it reflect tiny but real differences in human presentation or in instinct and choice on the part of well-trained experts and a willingness to live with the necessary degrees of fallibility, mystery, and uncertainty? Given the nature of the questions, of course, and the nature of the problems, there can be no resolution and no answers, but this book is a wonderful tribute to the complexity itself and to the intellectual, personal, and professional consequences of taking it on. Perri Klass, M.D.
Copyright © 2002 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.

Customer Reviews

Too Talented for the OR
Dr. Gawande's essays are thoughtful and very well written, and it blows my mind that he was able to be such a prolific writer while doing a residency (let alone a surgical residency). I read these essays one at a time originally when they appeared in the New Yorker during my pre-med and med school days, and I enjoyed rereading them recently, now that I'm a resident myself. It is always refreshing to see honesty when it comes to the imperfections of the medical profession. His stories about dealing with his own children's medical problems are very compelling, struggling with when to relinquish control to other doctors and when to step in and advocate. I also currently find myself much more interested in the cognitive science of decision making, having to make potentially life-altering decisions in a split second, balancing multiple confounding variables along with personal styles, experiences and instincts. Another topic given well deserved scrutiny is the phenomenon of physician burnout and how the profession deals with, and often fails to deal with, "good doctors gone bad."

Dr. Gawande comes across as the type of person I wouldn't expect to enjoy working with the typical surgeon colleagues. In fact, I would love to see him address this topic in his future writings. It would take a writer of his skill to explore the stereotypical personalities and cultures of the different specialties. No one wants to over-generalize, but medical students from various schools will have very similar descriptions of the types of O.B. residents versus psychiatrists versus pediatricians versus orthopedists that they worked with. The broad, simplified version of this is along the lines seen on the TV show Scrubs, with surgeons being the jocks and internists being the geeks. That is too generalized but not entirely untrue. It's an interesting question, what perpetuates these sub-cultures, whether it is the type of person drawn to a specialty or whether people pick their careers based on who they want their colleagues to be.

In the end, even with all the discussions of mistakes, burnout, and imperfections, I found this book to be affirming about the medical profession. Affirming both as a physician and as a sometimes patient or family member of a patient. Medicine doesn't always work like it should, and doctors should not be placed on pedestals. There are real problems in the system, but there are also plenty of very dedicated, hard-working, medical professionals doing their best to overcome those problems, working to provide the best care possible to their patients, to make the best decisions possible given the limitations of our knowledge. In times of crisis, you just have to take a deep breath and then put your faith in the system.

Confident With Him As My Surgeon
"Complications", by Dr. Atul Gawande is a very gutsy and honest discussion about medicine in general, and surgeons in particular. The book is also unique, for unlike others of its type it is written by a surgeon that is starting his career, and not looking back upon it. I would imagine that the book caused some consternation amongst his peers. The book does nothing to minimize the skills and accomplishments of the men and women who can reach in to the body and do some pretty spectacular work. The book does portray them as human beings that come with all the normal traits that any of us do. The pressure they must deal with is that when they make a mistake, it can irreparably harm or cause the death of the patient they are trying to help.

The vast majority of careers that people practice does not involve decisions that can cause the outcomes I mention above. And few occupations require of their practitioners near perfection, that if not delivered has a major legal industry prepared to hammer them with lawsuits. Incompetent or negligent doctors should be punished and removed from practice, but what about a human error, or a doctor that makes every single decision that is correct and appropriate for the patient he or she sees, and misses the 1 in 250,000 cases where doing everything correctly can cause a patient to die. The final chapter of this book deals with exactly those type of odds. Whether those odds are beaten often depends on the instincts of the physician. And these intuitive feelings they may or may not act upon are certainly helped by experience, but younger doctors without the years that familiarity brings can often make a decision largely because they are so new. Dr. Gawande makes clear that all the sophisticated technology available does not replace the one on one interaction with the patient.

If we ever need a surgeon we want a person we perceive as experienced, a person we are literally willing to risk our health and our lives with. The problem is that virtually no one wants to be part of a new surgeon learning his craft even with very experienced surgeons standing right at the table, watching and even directing the path the surgery takes. Dr. Gawande also shares his feelings when his children are ill and the contradictions he deals with as a parent, even as he is often on the other side with people judging him and his youth.

The statistics say that a surgeon will make a given mistake once every 200 times he or she performs a surgery that is described in the book, and that is also fairly common. If the mistake is made the results range from terrible to potentially terminal. The author does a great job of sharing what it feels like to be told that you will make the mistake, that doing the task 99.5% of the time without error can still cost a life.

A person who decides to become a general surgeon will study and practice until their mid 30's before they are able to operate on their own. That type of commitment is rare, and recent articles have said that less men and women are willing to devote that much of their lives before beginning their chosen career.

We want these people to be perfect when it is either we, or someone we care about that is to be operated on. They are not perfect, although those that are excellent can statistically come very near perfection. I would trust Dr. Gawande for he is a man that is clearly skilled, but is also acutely aware of how fine a line he walks every moment of his day.

Essay Collection from Surgeon, New Yorker author
This book is basically a collection of essays Gawande has published in the New Yorker, where he is a staff writer, along with a few from Slate. His writing style is similar to that of Malcolm Gladwell, Jerome Groopman, and other New Yorker authors of the David Remnick era - intelligent and clear.

Gawande is a surgical resident, so he is experienced enough to have insight into the medical profession and practices of surgeons, but still new enough in the field to bring a keen critical mind and the clarity of a relative outsider's perspective. Also, his compassion is one of his distinct qualities and shines through in the writing.

If you are a regular New Yorker reader, you probably have already read all of these essays. The brilliant essay about why doctors make mistakes is included, as well as memorable essays about when good doctors go bad, and how the practice of autopsy goes in and out of fashion. The only one that was new to me was the one about a surgeons' convention, which was entertaining but not crucial reading. It is nice to have them all in once place, but unless you are a completist or a rabid Gawande fan, I'd recommend getting it from the library or waiting for the paperback.