Good doctoring is all about making the most of the hand you’re been dealt” - Atul Gawande

Atul Gawande, Complications: A Surgeon's Notes on an Imperfect Science

Atul Gawande a surgeon, from Harvard University, started writing as a staff writer for the New York Times in 1998, and has since gone on to write this book; Complications: A Surgeon’s Notes on an Imperfect Science. The book is pretty much that, notes on an imperfect science, imperfect as it is meant literally, imperfect as in the risks involved in surgery. In his book Atul looks at the imperfect science and the risks that it produces, and questions what in the science is imperfect, why it is imperfect and analysis’s ways in which the risk of this imperfection can be eliminated or more realistically minimised. The book contains three parts and in each part are between 4 and 5 chapters. The first part is called Fallibility and explores the simplicity of the risk involved with surgery, why humans are not perfect and are just learning the practice of medicine the same way someone would learn the practice of playing a musical instrument, and that mistakes can be made during this learning curve. The second part, Mystery, Is about the lack of knowledge in the medical profession in relation to many common conditions which are experienced by growing numbers of people. This lack of knowledge of the condition consists of the cause and the cure. The Third part Uncertainty, analysis’s the way in which to minimise the risk through better systems of decision making, better discovery methods for more effective treatment and better use of technology.

Fallibility

In the first chapter Atul reminisces what it was like when he was first starting out as a surgeon and how amazed he was that he was allowed and able to perform the things that any surgeon is expected to perform. In this chapter Education of a Knife, Atul outlines a situation where he finds himself poking around in a patients chest with a 3 inch needle not being 100 hundred percent sure where the needle should be going. After failing to find the location for the needles purpose after three attempts the chief resident took over and completed the task in no time. After which she told Atul that he’ll “….get it” and that “It just takes practice”. Atul was also intrigued with the idea that a surgeon could “…press a scalpel to someone’s body and open it like fruit” also “…that a mere person would have the confidence to wield [a] scalpel in the first place”. Now he was a surgeon and trained to do so, however inexperienced he was he was expected to fulfil patients requirements and function as any normal surgeon would have to.

It did not matter how out of his depth he felt, the patients didn’t sign up for an amateur they signed up for a surgeon and it is a surgeon they were expected to get. Like in anything practice makes perfect and as Atul states “In surgery, as in anything else, skill and confidence are learned through experience – haltingly and humiliatingly”. This is normal for anything, no one is expected to play guitar like Jim Hendrix given the first strum they make, it takes time and practice, however Atul makes a very good point when he says there is one difference to practice makes perfect in medicine compared to other disciplines and that is that “…it is people we practice upon”. However after a while the “conscious learning becomes unconscious knowledge”, it is the mere issue that a doctors “…learning curve…” may jeopardise a patients safety, however there seems no other way around it.

Knowing this Atul found him self in tricky situation when his 11 day old son went into congestive heart failure, he had to tell the young physician who had been looking after his son, that he would prefer to have a more experienced “cardiologist in chief” to mind his sons unusual problem. He understood that the young physician needed the experience however he did not want to let his son be that experience. He felt bad he knew the only way the young physician would learn, the same way he learnt was through learning from doing. Atul put it that, the learning that young physicians must undertake is stolen, the idea that “Learning must be stolen”, from the safety of patients.

In 1996, a Swedish man named Hans Ohlin went head to head with a computer, both trying to correctly process medical data and the competition was to see which fielded the best results. The data was EKG’s (electrocardiograms), the EKG data is collected through electrodes that are placed on the skin, and they pick up low-voltage electrical pulses. The idea with the EKG’s is that they can be read to understand heart attacks. Ohlin and the computer where both given 2240 EKG’s to analysis and were to report as whether a heart attack was occurring at the time the EKG had taken place. The record of accomplishment of doctors shows that “…between 2 and 8 percent of heart attacks who are seen in emergency rooms are mistakenly discharged”. This is due to doctors misreading EKG’s. In The Computer and the Hernia Factory, the results showed that”Ohlin correctly picked up [620]…while…The computer picked up [738]. The machine beat man by 20 percent”.

The idea that Atul believes is behind achievement in hospitals as it is in most disciplines is the idea to be perfect, to act as a machine, Atul believes that “human beings, under some circumstances, really can act like machines”. Atul provides an example of Shouldice Hospital in Toronto, where hernia operations take from 30 to 45 minutes (usually up to 90 minutes), their reoccurrence rate is 1 percent (usually 10 to 15) and the cost of the operation is about half of what it is elsewhere. The reason Shouldice’s hernia achievement rate is so good is that the surgeons at the hospital do Hernia operations and nothing else. Atul believes that “…the Shouldice example suggests that physicians should be trained to act more like machines” doing the same things over and over they becoming like machines when performing them.

Some doctors are however sceptical about this way of treating patients, they believe that “…diagnosis can’t be reduced to a set of generalisations”, they believe are more personal approach must be taken. Atul agrees that this is necessary but he also understand that a doctor’s intuition can on occasion be wrong, maybe there needs to be some middle ground that is found so that the best of personalised intuition and generalised systems can be utilised. Atul ends the chapter with the idea that “maybe machines can decide, but we still need doctors to heal”, the middle ground found?

Given the previous two chapters, it becomes quite evident that mistakes do happen from time to time, When Doctors Make Mistakes analysis’s why mistakes occur and what is done to minimise the mistakes that do occur. Atul starts with an example of a mistake that he made while operating a patient. In the situation it turned out that Atul was the most experienced surgeon in the emergency room to deal to the particular patient, but he had only ever been the assistant to the surgeon before, never actually being in charge of the operation. After having an experienced surgeon come down and save the day Atul realises where is mistakes formulated. He was ill prepared, he panicked and given that he had already started making mistakes the mistakes snowballed to the situation where he had to call for a more experienced doctor. This is a situation shows complications do occur during surgery, but what if the complications cause mistakes and patients suffer. Mistakes like a surgeon leaving a “large metal instrument in the patients abdomen, where it tore through the bowel and the wall of the bladder”. This is just one case where a patient suffered complications at the hands of a surgeon. Do we sue these doctors?, the patient with the ripped bowel would defiantly contemplate it, but the truth is that doctors make mistakes, just like anyone else makes mistakes. Atul points out that in the US “…upward of forty-four thousand patient die each year at least partly as a result of errors in care”. Atul also points out that all doctors will make serious mistakes and commit acts of negligence, and doctors don’t get worked up about press reports of the horrors of the medical world, because they know that one day “that could be me”.

In another study Atul refers to it is found that “…research as consistently failed to find evidence that litigation reduces medical error rates”. By this book it seems that medical risk is inevitable through the incidence of mistakes and complications, so doctors have found away in which to manage this risk.

Doctors have found that talking candidly bout mishaps that have occurred and discussing what went wrong and how to remedy this is an effective way with dealing with the mistakes and complications. The meeting that takes place to discuss these issues is called the Morbidity and Mortality Conference, or just M&M. The proceedings are all confidential and protected from legal discovery, and occur once a week in “…nearly every academic hospital in the [US]”. For example when Atul’s case (briefly discussed in this paragraph) came before the M&M, the mistakes were identified and a remedy was put in place so that the process could be performed better next time.

One thing however Atul points out that isn’t taken into account in M&M’s is that mistakes usually come about “because a series of failures conspires to produce disaster”. The M&M just looks at the errors occurring to cause the mistake. “Error experts therefore believe that it’s the process, not the individuals in it, that requires closer examination and correction”. To fix this idea Atul believes a man by the name of Jeffery Cooper holds the answer. Cooper was the lead author of the book “Preventable Anaesthesia Mishaps: A Study of Human Factors”. In writing the paper Cooper decided to use a technique called “critical incident analysis”, a system used to “analyse mishaps in aviation”. This system is similar to the one used today by the Federal Aviation Administration (FAA), which has had “…enormous success in improving airline safety…” There are two “cornerstones” with the system that allow for the system to work effectively. The first is that “Pilots who report an incident within ten days have an automatic immunity from punishment” …and the second is that… “Reports go to a neutral, outside agency, NASA which has no interest in using the information against individual pilots”. Atul saw this work by Cooper as a major break through for the practice of medicine and the Anaesthesiologists started to find what was wrong with their methods and how to fix them by using a similar system to that of the FAA. Atul believes that anaesthesiology is only the first to be reformed and believes that “Surgery, like most of medicine, awaits its Jeff Cooper”

Mystery

The second section entitled Mystery focuses on the lack of knowledge in the medical profession. This lack of knowledge has implication on doctors as they struggle to explain reason for symptoms which have no obvious cause and in turn find a cure to help their patients. This section uses five case studies to show it different examples of this. I have chosen to use the two of the five case studies; the first case study is on chronic pain; and the second is about nausea. In both these case studies there is no apparent cause or cure to the symptoms.

The first case study focus on a man named Rowland Scott Quinlan and his struggle with chronic pain. He was a Boston architect who loved to go sailing. In 1988 he fell off a plank and dislocated his shoulder which required several operations to be fixed, he did not how ever hurt his back in any major way. A couple of months later when he had returned to work he got his first back spasm. The pain at first was bearable and the attack where not that frequent but as time went on he could no longer work as he could not work for longer than two to three hours a day. He got x-rays which revealed nothing to the cause this pain, so he was sent to a pain specialist who injected steroids through a big needle into his back. They worked for a little while but soon became useless. With no reason for this pain the doctor dismissed it. “When doctors encounter a patient who has chronic pain without physical findings to account for it – and such patients are exceedingly common – we tend to be dismissive”.

The question was asked “Are you faking it?” He had handicap licence plates, financial security and no pressures of running a business and if he didn’t feel like doing anything he could just say his back hurt. When his wife is questioned about this she answers that this is ridiculous. He is humiliated every day by not being able to carry the groceries in to the home to not being able to get to the toilet in time as a result soiling himself. She does find the pain to have aspects that she doesn’t understand. “She notices when he is anxious or irritable, the pain is worse and that when he is in a good mood or is simply distracted, the pain can disappear”. The cause of the attacks could be bought on by a mood a thought rather than physical. This is typical of chronic pain suffers.

The explanation of pain which dominates the medical profession and society was crated by Rene Descartes over three hundred years ago. “Descartes proposed that pain is a purely physical phenomenon – That tissue injury stimulates specific nerves that transmit an impulse to the brain, causing the mind to perceive pain”. We see this in every day society we complain of a pain we go see a doctor they find a cause, broken bone, tumour or cut. There have been limitations to this definition for quite a while now though. In WW2 men who had serious injuries would not respond to them as they should. The thought was they where so happy to survive the fight their brain counteracted the pain signal sent from the brain.

In 1965 Rene Descartes explanation of pain was changed by Ronald Melzack and Patrick Wall. They argued that pain didn’t just travel from the damaged nerves to the brain but went through the spinal cord first where it was either sent up to the brain or down, not to the brain. They suggested that other inputs effected pain like emotions. Studies have proved this, comparing dancers to university students, dancers can with stand pain much more, extroverts have a higher pain tolerance that introverts, drug users have low pain threshold. The best study to show that outside influences effected pain was a dental trail which used 500 subjects, some were given a placebo drug and told it would help with the pain while others were given the placebo and told nothing and others where given anaesthetic and told nothing. Those who had the placebo drug and where told it would have good effects experience the less pain out of the three groups, even those with the actual drug. This theory still suggest that there is damage tissue it just how much pain is felt, so it did not explain Roland Scott Quinlan pain as there is no injury nor does it explain the condition termed phantom-limb pain which is felt by people who limbs have been loss but the patients still feel if the limb is there by the sensation of pain.

Then in 1994 a DR. Frederick Lenz preformed an operation on a man who chronic hand pain who also had panic attacks. He found a section in the brain which seemed to trigger both of the conditions. When he concluded his work he came to the conclusion that all pain is in the head, no physical injury is needed to make the pain system in our heads go haywire. The fact is that the brain causes the pain sensation and that it doesn’t need external inputs to do so. “For the solution to chronic pain may lie more in what goes on around us than in what is going on inside us. Of all the implications of this new theory of pain, this one seems to be the oddest and most far reaching: it has made pain political”.

This case study shows that a perception of pain is not as good as we may think. Pain is a sensation which everyone experiences from time to time and the most complained about sensation to physician. To have such a lack of knowledge about how it is created is shows a lack of science in today’s society.

The next case study involves a woman named Amy Fitzpatrick, who was pregnant with twins and her struggle with nausea. In the beginning she experienced mild nausea, the same type of nausea which is very common in everyday pregnancy, also referred to as morning sickness. She experienced it for the first time when she was driving to work travelling on a motorway at 60 mph, the effects of the nausea made it hard to drive with blurred vision and a terrible stomach ache. She pulled over and threw up. When nausea occurs a person stomach is pulled up through their diaphragm and into their chest. Then vomiting occurs, this has two stages in itself. The retching phase, “involves a few rounds of coordinated contractions of the abdominal muscles, the diaphragm and the muscles of the respiratory inspiration. During this stage nothing comes out. The second stage is named the expulsive stage in this stage “the diaphragm and the abdomen undergo a massive, prolonged contraction, generating intensive pressure in the stomach; when the oesophagus relaxes, it’s as if someone had taken the plug off a fire hydrant”. Causing food and liquid in the stomach the be dislodged from the body. This normally makes a victim feel better but this was not the case for Amy. She drove home and went straight to bed.

That weekend was Easter and Amy and her husband drove to see Amy parents in Alexander. Over that weekend her nausea got worse, she could not hold down water or any food. On the Monday she went into hospital and got an IV drip to help her replenish her self with all the fluid and solids she had lost. The doctors reassured her that this was all part of pregnancy and there was nothing to worry about. Amy did not get better; this meant she could not handle the drive home to New York so she ended up staying at her parent’s house. Over the next couple of weeks she threw up around 6 times a day and lost around 12 pounds, this obviously was not good when pregnant, epically with twins. She couldn’t handle the blandest of smells and going in the car was one of the most harrowing things for her to go through. “The worse of it was she was losing control of her life”.

Nausea doesn’t get much attention in the medical world even though it is the second most frequent complaint from patients to physicians (the first being pain). 60 to 85% of women experience it during pregnancy. While also a third of them complain it’s so bad they take time off work for it. In Amy case she has a rare condition of it termed hyperemesis of pregnancy, this is where the women lose weight and instead of putt it on, only 1 in every 200 women who get nausea get this syndrome. The pain of nausea for pregnant women is so bad that women recall the pain of it long after their pregnancy, they fell it is worse than the child birth itself and is the reason that many women won’t have children again. This is shown in the movie a clockwork Orange, when the authorities try to make people stop doing crimes by making them nausea when they have bad thought, rather than the feeling of pain.

In a 1992 paper written by Margie Profet she pointed out that a reason for pregnant women to have nausea may be due to the fact that many things which are non toxic to adults are to embryos. This may show why Ireland has the world’s highest rate of neural defect, like spina bifida due to their mass potato consumption. Also those women with some sort of morning sickness compared to those that don’t are less likely miscarriages.

Amy was losing weight so her doctors decided to give her some drugs to help her put on weight by stopping the nausea. She tried many drugs and none help her get any better. The problem was that her nausea wasn’t getting better as doctor presume would happen the opposite was happening she was getting worse. She had dropped 16lbs by the fourth month of the pregnancy. Many doctors thought that it was a mentally caused, the Freudian theory, that is she didn’t want to have her baby and she caused these symptoms at an unconscious level. Doctor suggested abortion but this was not an option as she wanted the baby and also she was Catholic. Doctors could not find a cure for Amy. After 6 months of the pregnancy she stopped all therapies. She continued having nausea, but by the 7 and half month she found she could eat a few selections of food and was able to hold down a protein drink. On the 8 month she went into labour, one month premature surprisingly the babies where born a respectable 4 pound 12 ounces and five pounds not the expect 3 pounds. After the birth she threw up one more time but this was the last time.

This case study shows that when dealing with the symptom nausea, that there is little known about the causes and even less about a cure. It has major effects on pregnant women and causes such pain that many leave their jobs and refuse to have more children. Science has no real answers in the case of nausea.

These case studies show two common symptoms which are experienced by a great number of the population. Their knowledge about these symptom is lacking and makes you think if they don’t know much about the two most complained about symptoms to doctor what do they know about not so common symptoms which one day you might come down with? Science is not perfect in the medical profession, even when dealing with common everyday medical problems.

Uncertainty

Once routine and now rarity an autopsy is what is referred to as the Final Cut, in this chapter Atul examines Autopsy’s and their place in medicine today. Where once autopsy’s were used to unearth the cause of death, given the limitations of the primitive tools used at the time to help treat people. Autopsy’s can be gruesome operations for some, everyone knows what they are and the thoughts that go through someone’s head when an autopsy is mentioned are the same for everyone that is why hard for a doctor to bring up the issue of an autopsy with the deceased’s families.

Autopsies were once very few, due to the involvement of the church, even after the church had loosened up its stance on autopsies, people still were sceptical to allow for their deceased family members to be autopsied. Some doctors autopsied “…patients immediately after death, before relatives could turn up to object”. However some doctors went further by waiting until the bodies were buried, digging them up and then performing autopsies on them. After a while night time guards were posted on some graveyards to protect corpses from graveyard robberies, this where the term “graveyard shift” originates. Further yet a company in Ohio in the late 19^th Century, sold “torpedo coffins” where coffins were equipped with pipe bombs to deter robbers.

In the beginning of the 20^th Century prominent physicians “…began popular support for the practice of autopsy”. The physicians defended autopsy as a “tool of discovery” which had already found “…the cause of tuberculosis, reveal[ed] how to treat appendicitis and establish[ed] the existence of Alzheimer’s disease”. Autopsy’s were used to find the cause to a patient’s death to “…provide families with answers”, and by the end of the Second World War “…the autopsy was firmly established as a routine part of death in Europe and North America”.

There has been a decline in autopsies in more modern times, where the fault is not with people rejecting them these days (permission is given up to 80 percent of the time) but with Doctors not wanting to do them. Two reasons have been given to the decline in doctors not wanting to give autopsies, one is that maybe hospitals are trying to save money, as insurers do not cover autopsies and so don’t get paid for them, the other reason is that autopsies give evidence of malpractice, evidence of malpractice that doctors to not want or need. Atul however believes there is another reason, he thinks its due to “…medicines twenty-first-century, tall-in-the-saddle confidence”. Doctors believe they know how a patient died, given the extreme increase in technology that grants doctors the ability to better understand the cause of a patients death. However, three studies were performed in 1998 and 1999 and found that in about 40 percent of cases, misdiagnosis of death was found after performing an autopsy. The figure 2 out of 5 deaths misdiagnosed is the same figure that it was way back in 1938, there has been no advance forward given all of this technology, so maybe autopsies are necessary.

More times than not a patient will get to a situation during their health care where a decision must be made as to which treatment to undergo if any at all, Whose body is it anyway examines who should be allowed to decide which treatment if any a patient should take. Sometimes one of the options of treatment maybe so bad that treatment is ultimately bypassed. Atul provides the example of patient X who had the option of undergoing risky spinal surgery just to add an extra few months to his life. The surgery did not have a high chance of succeeding but still it offered and alternative to the dire situation. The decision is this case was given to patient X. This would not of been the case in the past, where doctors would have “…consult[ed] patients about their desires and priorities, and [would] routinely with[hold] information”.

Patients in most cases were also “…forbidden to look at their own medical records; it wasn’t their property doctors said”. Patients at this time “…were regarded as children: too fragile and simple minded to handle the truth”. Atul describes how in the 1970’s and 80’s men would come to his father (also doctor) requesting a vasectomy and “he routinely refused to do the operation if the men were, unmarried, married but without children, or “too young””. These days however almost no one is turned away from a vasectomy, giving the patient more freedom to decide their own fate.

If however you offer two options to a patient, and they choose one which you believe is a very bad decision, “…should you simply do what the patient wants? The current medical orthodoxy says yes”. Atul believes that in patient X’s case he chose badly but it was his decision, although the decision did not render the results that he was looking for the results came from a decision he made.

Maybe then, there may an issue with the communication of the risks between the doctor and the patient. It would seem quite important that the patient fully understand the risks involved. However many patients “…don’t want the freedom…” that they are given to make the tough decisions. In fact in one study it was found that “…although 64 percent of the general public thought they’d want to select their own treatment if they developed cancer, only 12 percent of newly diagnosed cancer patients actually did want to do so”.