Complications: A Surgeons Notes on an Imperfect Science

by Atul Gawande
Picador, 2003

Reviewed by Carilee Moran
So, you didn't want to read Complications because you've read enough agonized doctors' tell-alls full of gory surgical anecdotes and weeping relatives? Put those thoughts aside. This is, at heart, an engineer's book. It is about a system (the medical system) and its component parts (hardware -- tools, firmware -- practitioners' hands, and software -- practitioners' minds). It is about how that system works, how it learns, how it fails, and its limits of reliability. It is written with dispassionate compassion. Atul Gawande's writing evinces compassion, but not the cloying variety. He dissects his profession honestly but kindly, and in the process taught me, a prospective patient, something about what it is realistic to expect from the medical profession. The book covers a range of topics from medical error to gastric bypass surgery. The sections of the book seemed to have no logical connection to each other until I learned that they were compiled from essays he had written for The New Yorker magazine.

I asked a friend of mine, a retired surgeon from Boston, to read Complications. He had this to say:

I know (Gawande) from the Brigham hospital as a talented young surgeon. His essays point to a man who has command of the language. He reminds me of the late Lewis Thomas, who ultimately finished his career as Dean of the Yale School of Medicine. Both of these men, Thomas and Gawande, seem to be able to take a subject, rotate it 90 degrees and look at it from a totally different perspective.

From the first of Gawande's essays, he's written about subjects that usually aren't discussed in any detail, e.g. end of life issues, the operations done by embryonic surgeons (and the safeguards), and of course the mistakes. I read both this book and Gawande's more recent book, Better: A Surgeon's Notes on Performance, finding it hard to stop. There were so many incidents that brought back events in my own professional life.

Gawande spends quite a bit of time on the question of what makes the best surgeons best. His answer is that it is not raw talent, but rather, practice. But how can surgeons gain experience if the patients demand that only the already-experienced operate on them? Gawande answers this question for us: the learning is "stolen," hidden from sight as part of a team's operation, or by providing services in areas where the attentions of an inexperienced doctor may be the only care available.

This notion of "practice makes perfect" was described in relation to a Canadian hospital identified as a "hernia repair factory." At that hospital, achieving perfection with the one type of surgery was, in and of itself, the exciting part of the work. Still, I thought I heard warning bells ringing when I read later in the book about how good doctors go bad. One of the ways seems to be beginning to feel bored about doing the same procedure for the gazillionth time.

You're wondering where the engineers come into it. Take this quote: "other industries ... simply wouldn't countenance error rates like those in hospitals." Gawande describes some pioneering efforts to bring engineers into the process of medical care delivery, with information technology, with systems engineering and with new machine technology. Enterprising engineers, take note: there is still a lot of low-hanging fruit out there. Caregivers had better be prepared to push back where it makes sense, though. Engineers will ensure that your IV drip rate is correct, but they haven't invented any automatic pillow-fluffers or forehead-strokers yet. In this book, Gawande shines a light on some of that fruit, and points out some of the efforts to harvest it. You can't solve a problem unless youâre willing to name it. And that's what Gawande has done in this book rated at 4.5 stars by the SWE Book Club.

4.5 stars out of 5

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