Complications by Atul Gawande
The medical profession has always seemed so mysterious to me. You get sick, you go see a doctor and usually you come out well again, or at least on the road to recovery. I've always thought, especially when I was younger, that doctors are the closest thing that we have to wizards in modern society. They perform a certain magic on their patients which is miraculous and mysterious in equal parts. To be sure, they are not infallible. I know people who have suffered at the hands of careless doctors just as I know people who have made incredible recoveries. All of this is just to say that I've always had a fascination with the realities of working in medicine. It was in this spirit that I picked up “Complications” by Atul Gawande.
I knew little about Dr. Gawande when I bought “Complications”. I expected the book to be a sort of memoir documenting his education and professional opinions. This turned out to be true only in the most general sense. Instead, it is a sort of guide to the medical world for those of us who've never been able to see behind the curtain. And aside from its practical value, it was the best sort of book, both pleasurable and empowering.
“Complications” is divided into three parts, each of which describes a different collection of issues which complicate the medical field, both for patients and doctors. Entitled Fallibility, Mystery and Uncertainty, each section is composed of a pleasant combination of anecdotes, statistics and personal opinions. Gawande makes no attempt to speak for the profession as a whole, but his comfortable writing style and easy incorporation of statistical data make his work feel authoritative without coming off as pushy or dry. Indeed, I found the text incredibly easy to read. I finished it in two days.
The book begins with a section entitled Fallibility. Here, Gawande describes the process by which the slow change from medical student to doctor occurs. The agent for this change is simple. Practice. The difference between a student and a doctor is the amount of practice and the collection of experience. This sounds entirely reasonable for nearly any other profession, but in the case of the doctors, the notion of practice seems unconscionable because the subject is a person, not a computer chip or a novel. It hardly seems ethical to submit unknowing patients into the hands of an inexperienced resident. And yet, Gawande makes a good point. There is no way to practice most medical techniques without a living example to study. And without such examples, and therefor without practice, there would be no new doctors.
I constantly felt myself challenged by suggestions of this sort. Many of the things Gawande describes are scary, or contradict the way I've grown up thinking about doctors. I struggled to feel comfortable with his assertions that all doctors are fallible and that they all make mistakes. Even though I've always known that intellectually, it's hard to accept knowing that at some point in my life I'll be forced to trust a doctor, potentially with my life on the line. This tension between his admissions of weakness against his confident acceptance of the facts and optimism in the face of them kept me turning page after page, despite my unease. It feels strange to be privy to a surgeons vulnerabilities, particularly when the cases he discusses could easily be you or someone you know, but it also felt oddly empowering. In pulling back the curtain, I felt more equipped to deal with doctors in the future.
While the first part primarily examined things from the surgeon's point of view, part two, entitled “Mystery”, is organized a bit differently. Primarily, it follows a series of case files, describing the course of a patient's medical experience from diagnosis to present. For example, a man suffering chronic pain after a fall and a woman with an extreme case of nausea. The cases presented each concern specific diagnoses for which there is little known definitively. Each is unique and acts as a complete narrative. Gawande's descriptions are vivid and full of life, and I became quite attached to some of the patients. However, this section is my favorite of the book for a more subtle reason. Underlying each narrative are examples of mistakes, unanswered questions and ignorance within the medical community, gently underscoring the suggestions made in Fallibility. However, there are also examples of outstanding doctors who possess compassion, quick wit and ingenuity. I came away with the sense that on each of these mysterious fronts, progress is being made.
Last, Gawande concludes the book in a section called Uncertainty. Here he brings together the narratives of doctor and patient to discuss the lines where they intersect. This might be the most educational section of all, in that it discusses issues such as patient autonomy and the importance of autopsy. Perhaps it is a little less flashy than the story of a woman with crippling blushes, but it is also more useful. It explains a good deal about doctor-patient communication and lays out sensible guidelines for when and how it is appropriate to contradict or agree with a doctor's decision. It is not a step by step guide, but it does reveal the inner workings of a doctor's decision making process. Lest I sell it short, I'll also point out that all of this advice is delivered through anecdotes, and peppered with numbers and facts. It comes together surprisingly well, into a narrative which feels natural and complete.
This book is not the sort of book you might take to the beach for a pleasant summer read. It is very direct and honest, sometimes gruesomely so, about medical and ethical issues which are uncomfortable for most people to think about. What should you do when you're sick? How trustworthy are your doctors? However, as I read it, I was consistently entertained and could hardly put it down. Despite the subject matter, it wasn't a grim or depressing read. I came away feeling better educated and prepared to deal with medical issues than I was before. And for that reason alone, I think it's a worthwhile read. Aside from that, it's also well written and full of entertaining stories. It also doesn't hurt that it was a finalist for the National Book Award. What more could you ask of a book?