Goodreads | Complications: A Surgeon's Notes on an Imperfect Science

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Lorenzo's Oil	1	8	08/14/2008 11:50AM

reabdimation rated it:

03/29/08

Hmmm... I love surgery, it means.. when a handy book of more-humanity-and-less-cut of surgery was published.. how can i resist?

Well.. for being honest, it makes me feel bored when i've red the middle-part. it turns 'in' again in a few last chapter. I agree to middle-rating, (in Indonesia means, lumayanlah.. bukan buku sampah) of this book. but i truly disagree when sumone gave only one star rating to this stuff. (Cari deh di tinjauan lain. Huh. You make me angry dude.. pelit amat sih. Gue ng...more Hmmm... I love surgery, it means.. when a handy book of more-humanity-and-less-cut of surgery was published.. how can i resist?

Well.. for being honest, it makes me feel bored when i've red the middle-part. it turns 'in' again in a few last chapter. I agree to middle-rating, (in Indonesia means, lumayanlah.. bukan buku sampah) of this book. but i truly disagree when sumone gave only one star rating to this stuff. (Cari deh di tinjauan lain. Huh. You make me angry dude.. pelit amat sih. Gue nggak tahu ada penulis laen yang pernah, bisa, dan berhasil bikin tulisan tema ini) Nevertheless, Atul gawande deserve for sum appreciation, and He already had..

the Most interesting part from me.. is a chapter when Atul writes about "the curve of learning". He statistically showed about transision safety rate of "great artery transposition" surgery, between the convensional and the latest method. Now, Using the latest method, a child who has born with "great artery transposition" can reach the age of 40. But, when its was first introduced, the safety rate was really low. (i forget about its number.. hmm 8 survivals against 100 operations? sorry, i forget the number)

Then, surgeons keep practicing, keep using the latest method, do a preparation surgery, training the nurse, using a team who spesialized on its procedure, maintain the team.. then.. the safety rate increase. Like i said before, these days, a child with "great transposition artery" can celebrate his or her 40's birthday..

It means, we can never resist a failure. A medical student can never resist a failure..

Too bad, people dont care about it. A simple or even hard failure of a medical student (physicians is a life-long medical students, right?), is a condition that makes them an expert someday. But, people dont care.. they never care

Haah.. tiba2 gue kepikiran soal pendidikan di kampus gue..
= |

Oya, buku ini salah satu favorit gue (biarpun cuma 3-bintang) karena punya "kenangan" tersendiri. ^_^ huehehe...
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Patricia rated it:

11/12/08

Read in November, 2008

Atul Gwande's Better: A Surgeon's Notes on Performance is a collection of essays that probe skillfully and poignantly into the depths of medical ethics and the performance of doctors. He is a fine researcher and an astute observer who carefully delineates many facets of each issue that he explores, be it washing hands, malpractice concerns, or the Apgar score.

As a non-fiction writer, I was acutely aware of how adept Gawande is at using narrative to illustrate and discuss complex moral...more

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Ben rated it:

02/04/08

bookshelves: have-read

Read in January, 2007

This book wss filled with about 25 anecdotes flimsily tied together by Gawande's less than inspiring reflections. I have the book in front of me at the moment and I am paging through rereading sections that I noted along the way:

"I had come into residency to learn how to be a surgeon. I had thought that meant simply learning the repertoire of move and techniques involved in doing an operation or making a diagnosis. In fact, there was also the new and delicate matter of talking patients...more This book wss filled with about 25 anecdotes flimsily tied together by Gawande's less than inspiring reflections. I have the book in front of me at the moment and I am paging through rereading sections that I noted along the way:

"I had come into residency to learn how to be a surgeon. I had thought that meant simply learning the repertoire of move and techniques involved in doing an operation or making a diagnosis. In fact, there was also the new and delicate matter of talking patients through their decisions - something that sometimes entailed its own repertoire of moves and techniques." pg 217

Next to this paragraph I had written "NO SHIT!"

The book is full of these minor, pseudo-epiphianic moments that come off as weak aphorisms. However, given the audience of this book (everyone) he does well to treat people about how uncertain medicine really is and how it really comes down to the tricky nature of making decisions and how they should be made in the medical setting:

"But the conundrum remains: if both doctors and patients are fallible, who should decide? We want a rule. And so we've decided that the patients should be the ultimate arbiter. But such hard and fast rule seems ill-suited both to a caring relationships between docotr and patient and to the reality of medical care, where a hunderred decisions have to be made quickly... The doctor should not make all of these decisions, and neither should the patient. Something must be worked out between then, one on one - a personal modus operandi. Where many ethicits go wrong is in promoting patient autonomy as a kind of ultimate value in medicine rather than recognizing it as one value among others...(A)s the field grows ever more complex and technological, the real task isn't to banish paternalism; the real task is to preserve kindness." pg 223-4

This simply makes sense, nothing new here.

The best part of the book is the last two paragraphs (and is all you really need to read have said that you have read the book, in my opinion.):

"The possibilities and probabilities are all we have to work on within medicine...What we are drawn to in this imperfect science, what we in fact covet in our way, is 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. In the actual situations that present themselves, however, [...:] we can never be sure whether we have such a moment or not. Even less clear is whether the actions we choose will prove either wise or helpful. That our efforts succeed at all is still sometimes a chock to me. But they do. Not always, but often enough." pg 251-2

In a way, the whole thesis of this book (which I think is summed up in the sentence in bold above) is pretty remarkable. There is so much talk about the fallibility and humanity in medicine right now... fallibility is so hot right now. However, as is apparent in this book, the medical community is only at the stage of recognizing this fallibility. Gawande doesn't do what I thought he would: suggest what we should do given the increase visibility of the fallibility of the practice of medicine. He really doesn't have any good ideas. In all his articles, he seems to be advocating a technocratic answer (using checklists etc.). The biggest problem I have with the book is the way Gawande seems to view the profession medical community of independently-acting people, who, in the aggregate, are not too of an impressive lot. In this, Gawande is entirely old-school. He fails to recognize the possibility of alternative ways to approach patient care. In a way, I think that he is dangerously anecdotal. Maybe it is just me being tired of reading anecdotal medical non-fiction, but it just seems like a lame format (don't hold these words against me because I really don't know what I am looking for, or what type of book I would write). He treats them like data points. I believe that the book could be reduced by about 80% for someone like you or I who are as far in the medical field as we are.

However, I believe there to be value within this book. I am really really happy that millions of people (future patients) are reading books like this and Groopman's "How doctor's think" as it really does educate them to get real about what medical care is all about. It will serve to empower people and get them involved in their care and think about how they want it to go down. But, to me, I really did expect a lot more from this guy. The reviews that it got are ridiculous, they are way over the top! It is pretty incredible- it goes to show how easy it is to be heard once you have written for the New Yorker and got a MD from Havard. I will keep reading his books, though, for no other reason than that he is so hot right now, millions are reading him. I at least have to know other people are thinking about. ...less

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Elizabeth rated it:

10/24/07

Read in October, 2005

recommends it for: everyone

Complications is a book of anecdotes about a surgical resident’s experiences and impressions of the current health care environment. Gawande divides his stories into three sections: fallibility, mystery, and uncertainty. The fallibility section demonstrates that doctors can make mistakes. Some fallibility arises from there being a learning curve. For example, it is hard to do a central line correctly the first time. But for a doctor to learn how to do a central line, he must have a first ...more Complications is a book of anecdotes about a surgical resident’s experiences and impressions of the current health care environment. Gawande divides his stories into three sections: fallibility, mystery, and uncertainty. The fallibility section demonstrates that doctors can make mistakes. Some fallibility arises from there being a learning curve. For example, it is hard to do a central line correctly the first time. But for a doctor to learn how to do a central line, he must have a first patient to try it on. The concern then arises as to which patients receive care from the inexperienced versus the experienced. Yet fallibility occurs in even the most experienced doctors. Gawande reports on one doctor who became so careless that he was no longer allowed to practice. The frightening part of that story is how long his colleagues let him continue when they had concerns. (The Doctor also brings up this issue.) It is understandable that doctors are reluctant to come down too hard on their colleagues. They need each other as a support system and thus need to maintain trusting relationships. Furthermore, medicine is uncertain, and it can take a long time to see a pattern of truly irresponsible behavior as opposed to just having more complicated cases. Gawande makes the point that discipline of doctors works best when it done by a group outside the doctors peer group or employer because it is more objective. Then this outside group can propose a plan of action which the employer can implement. Unfortunately, this model has been too expensive to be much of a viable option.
The mystery section details stories of conditions that cannot be explained by current medical science, like blushing, pain, and nausea. In each of these cases, the doctors could not explain why the patient had the condition. Much of the time, the patient just wanted the doctors to believe them even though there did not seem to be a physiological source of the problem. It is interesting that the patient is more willing to accept that there is no medical explanation than the doctors. Yet the doctors are the ones with the training and have probably seen many more circumstances when they cannot make a diagnosis.
The uncertainty section deals with how to make the right diagnosis or judgment. There are several points in this section that have come up in the other literature reviewed for this independent study. First is the declining use of the autopsy. The autopsy is how doctors can determine what was actually wrong with the patient. It is the final way to get rid of uncertainty. Its purpose is to help the doctors recognize such conditions in the future. Yet autopsies are done less and less. (Although many times the family is opposed to the autopsy and will not allow it.) Another recurring point is the decision-making power of the patient. Patients have become more pro-active in their desire for decision-making ability, but they are much more ambivalent about actually exercising it. Especially in situations where there is uncertainty, patients do not feel comfortable or emotionally able to make the decision. Some do not think they can handle the responsibility if it turns out to be the wrong decision. Gawande notes that doctors also prefer to make the decision. One of the things he had to learn as a resident is how to persuade patients to the decision he thinks is best. As health care becomes more consumer-driven, the debate over the level of physician agency is likely to continue.

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Katie rated it:

08/10/07

Read in June, 2007

recommends it for: Everyone

An very well written book in which Gawande argues that surgery is an evolving and imperfect art. He begins by describing in compulsively readable detail some occasions during which it has failed its patients. An overarching theme in the book is an idea of what makes a good surgeon; Gawande points out that it's not about innate talent. It's about practice, commitment, a willingless to learn new things, a willingness to teach others, specialization, and perhaps attentiveness to the patient. (I...more

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Danae rated it:

05/22/08

Read in May, 2008

This was a fun and interesting book, full of little insights and things to think about. The author is a doctor, who also happens to have written columns for a couple of on-line magazines, and several of the chapters bagan as such columns-- which is about how the book reads. It's like sitting down and reading a fairly interesting magazine article, which you may find yourself thinking about later, or mentioning in a conversation, but the book itself doesn't really have any clear objective or age...more

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Lucy rated it:

(review of isbn 142720151X)

07/26/07

this was a very interesting book. i liked his writing style, too. it was far more engaging than the stupid tree book. isn't this author bio a bit sickening, though? "atul gawande, a 2006 macarthur fellow, is a general surgeon at the brigham and women's hospital in boston, a staff writer for the new yorker, an assistant professor at harvard medical school, and a frequent contributor to the new england journal of medicine. gawande lives with his wife and three children in newton, massachusett...more

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Andrea rated it:

04/10/08

Read in April, 2008

This was an interesting journey into the life of a surgeon. I learned a lot about what it is like to be a medical professional. I have long believed that we need serious medical reform in this country. So I particularly enjoyed the authors comments in that area. However, I didn't always agree with his conclusions.

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Beth rated it:

04/04/08

Read in April, 2008

recommended to Beth by: Amy
recommends it for: Krissi

This was like the best of all the case studies we ever saw in clinical lab science :), but with the added ethical, political, and physician's viewpoint all thrown in for a great read. This is the kind of book I love to read- I enjoyed reading it and kept wanting to get back to it, and I learned a lot from it as well.

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Polly rated it:

07/02/08

I loved this book about the medical profession (mostly surgeons). I was skeptical because it sounded dry and scientific, but it is really a wonderful and a true portrayal of how complicated medical care is today, and really always has been.
The stories of individual patients are gripping. Try it.

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Anna rated it:

10/28/08

bookshelves: non-fiction

Read in October, 2008

recommends it for: people who work at a hospital who are not doctors.

Very readable ruminations on medical and ethical situations in the world of doctors. I like it that Gawande seems to be writing in order to find out his own identity as an M.D. He writes the book as a surgical resident, which is interesting in itself, but he also moves outside of the teaching hospital to provide a bigger picture of the doctor/patient relationship. In some of the essays, Gawande pokes at the edges of medical knowledge, giving the reader a sort of medical mystery to follow. Ot...more

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Jo rated it:

09/01/08

bookshelves: biography--memoir, health, nonfiction, science

Read in September, 2008

I'm not sure if "liked" is the correct word, but it was fascinating - and somewhat disturbingthough there were positive aspect as well. It is a series of anecdotes by a resident doctor at a teaching hospital that illustrate how complicated medicine is, and the learning curve involved - a lifetime learning curve. It was sometimes hard to listen to for me sometimes. The first anecdote involved learning to put in a central line, which is learned by doing, on a patient, and when he describ...more

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Maura rated it:

(review of isbn )

08/07/08

Read in August, 2008

This book inspired me to consider Doctors in a new way. Having had a number of, well,suffice it to say 'challenging' expriences as a patient under the care of a doctor, I was able to consider the profession in a new way thanks to this book. Atul Gawande expertly humanized what I am now inspired to refer to as the ART of Medicine in the way he helped me recognized the absolutely impossible place these people put themselves in.
Doctors are always searching for the new, the better, the most advan...more

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dtjunkie rated it:

06/09/08

The old joke goes something like this:

A tourist is wandering around New York city and he is clearly lost. He walks up to a local and asks, “How do you get to Carnegie Hall?”. “Practice, Man, Practice” responds the local.

Despite the groans this joke elicits, there is sure to be a few wry smiles because of how true the statement is. If you want to be good at something you have to practice. Sure it helps if you have some natural talent, but the desire to be good at something and the wil...more The old joke goes something like this:

A tourist is wandering around New York city and he is clearly lost. He walks up to a local and asks, “How do you get to Carnegie Hall?”. “Practice, Man, Practice” responds the local.

Despite the groans this joke elicits, there is sure to be a few wry smiles because of how true the statement is. If you want to be good at something you have to practice. Sure it helps if you have some natural talent, but the desire to be good at something and the will to keep practicing is just as important. Chris Ballard writes of Kobe Bryant in a recent article in SI:

There’s a difference between loving basketball and liking basketball. There are only about 30 guys in the league who love it, who play year round. Allen Iverson loves to play when the lights come on. Kobe loves doing the shit before the lights comes on. This thing, this freakish compulsion, may be the hardest element of the game to quantify. There are no plus-minus stats to measure a player’s ruthlessness, his desire to beat his opponent so badly he’ll need therapy to recover. One thing’s for sure: You can’t teach it. Is so Eddie Curry would be All-NBA and Derrick Coleman would be getting ready for his induction ceremony in Springfield, Mass. But people know it when they see it

Despite similar levels of athletic ability, his ability to practice more and harder than anyone else is the reason that Kobe Bryant is the best player in the NBA. The importance of practice isn’t limited to sports. Atul Gawande, in his book entitled Complications: A Surgeon’s Notes on Performance states that studies have shown that the difference between the ability of elite performers (from violinists to chess players to athletes) and lesser performers is the amount of deliberate practice. In fact, Gawande cites a study by Ericsson who claims that the most important talent is the willingness to practice! Incredibly, elite performers hate practice just as much as their less able peers. However, they are somehow able to push through and will themselves to practice anyways.

Thus, if a person is to become exceptional at their profession, the best thing to do is to practice practice practice. This is obviously easy for Kobe Bryant; it just means more time in the gym. However, Gawande raises an important question: How do we teach surgeons? Obviously, to become an expert surgeon, one must have lots of hands on practice. However, how ethical is it to allow a surgical intern to practice on someone whose life is at stake? Study after study has shown that a patient is more likely to have a successful operation the more experienced a surgeon is. Yet the fact remains that as a society we need to train new surgeons. Additionally studies have shown that when new operating procedures are introduced, patient mortality increases in the short term (but decreases in the long term). How can we train surgeons on new procedures without putting patients at risk?

Gawande does a great job describing these problems and speaks of how he understands the need to train surgeons but he himself has refused to let an intern operate on one of his family members. I can see how much of an internal struggle this would be. I understand that we need to train new surgeons, but I sure as hell don’t want to be the first person a surgeon has ever operated on.

And all that thought was brought on by the first chapter! As usual Gawande’s writing stimulates the mind and the rest of the book is a quick read. Gawande discusses the problem of bad doctors, what should happen when a doctor makes a mistake (and every doctor will eventually make a mistake), the purpose of medical conferences, and a series of interesting case studies. I found the final chapter (about a young girl who may or may not have contracted the flesh eating bacteria) especially interesting. Gawande compared his successful diagnosis to the situations described inGary Klein’s work on firefighters in the field.

But the dilemma that stayed with me was how can we train surgeons without putting patients at risk? It is clear from studies of elite performers that the only way to become proficient in a profession is to practice practice practice. Yet who would want to be on the other end of the knife when a mere novice is holding the scalpel?...less

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Sara rated it:

08/29/08

Read in January, 2008

recommends it for: patients, doctors, surgical residents, surgical instructors and professors at medical schools

This is a fascinating and well written little book by a surgical resident at a Boston area teaching hospital, but it hit a little bit too close to my life just at the time I was reading it, a time when I was in the middle of having to subject myself to all kinds of torture at local Boston area teaching hospitals. So I kept picking it up and putting it down. It's not the fault of the book, but I kept experiencing frustrating gulfs between, on the one hand, this wonderfully compassionate and sel...more This is a fascinating and well written little book by a surgical resident at a Boston area teaching hospital, but it hit a little bit too close to my life just at the time I was reading it, a time when I was in the middle of having to subject myself to all kinds of torture at local Boston area teaching hospitals. So I kept picking it up and putting it down. It's not the fault of the book, but I kept experiencing frustrating gulfs between, on the one hand, this wonderfully compassionate and self-aware but practical analysis of the structure and the process and the point of teaching hospitals and specifically surgical residencies, and on the other hand the insulated and frequently self-serving attitudes of actual surgeons who were sometimes also tenured medical school professors working in the very same health care system as this author, and it was incredibly dispiriting.

When I could divorce it from my own situation, however, I could appreciate this book for its own sake, as a rare and thoughtful examination of the life of a surgeon from the viewpoint of someone just starting out his own life as one but who had already achieved, among other things, an advanced degree in public health. When was the last time you met someone that qualified to explore this subject matter intelligently, let alone to just sit still in a quiet room of your choosing and listen to him talk? Compelling, and also invaluable, really. In the end, though, it does feel like only a starting place, and not just a starting place in Dr. Gawande's life. It feels like the starting place for a very complicated conversation that will have to include all of us, awake and engaged, for the rest of our existence as creatures who require medical assistance.

I loved that the book was ultimately as much about patients as surgeons, as much about who patients are as doctors' responsibilities toward them. It also managed to address doctors' responsibilities toward themselves and each other, technically, sure, but also just as human beings. The "star" of the book isn't a person or, thankfully, an institution, but rather a process, the endless process of learning with everything that matters in life at stake for everyone involved. The patients' stories, especially the last one, and the things patients told Dr. Gawande about their journeys have stayed with me, and will stay with me for a long time, I expect. I also feel as though I picked up some practical tidbits for my own not especially brilliant or important life, a strategy for learning as a team which Gawande presents in the very first chapter, and also a few little things both statistical and anecdotal about the psychology of helping people. I hope they stick with me, too....less

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Leigh rated it:

10/13/08

Read in July, 2008

recommends it for: those who like Robert Sapolsky

Part-surgeon, part-author, part-idealist, Gawande manages to inject some humanity into the medical field with his honest and revealing account of life in the OR, ER, and ICU. Surprisingly, he's able to balance the defining perspectives between doctor and patient, and unearth where science and technology are on point and where the inevitable blind spots are in the medical community. His aim is to demystify the hippocratic and remind us, the public, that surgeons and specialsts are, after all, c...more

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Indrany rated it:

04/17/08

Read in April, 2008

recommended to Indrany by: Josh Curry
recommends it for: anyone who has ever been sick

This was amazing. As an aspiring doctor, I obviously found it fascinating and personally relevant. It's funny, though, reading reviews about how revolutionary his candid attitude about the fallibility of medicine is. Working in an ER as a patient advocate, I often explain to patients that multiple tests, time, etc are necessary. Doctors are human and the body is a complicated machine. Most of the time the explanation makes patients more understanding and patient with the ER physicians. Or ...more

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Mishl rated it:

02/07/08

Read in January, 2007

Atul Gawande began as a philosophy major and is now a surgeon, and you can see that background in the depth of his reflections and explorations around topics in medicine. As he writes in his introduction:

"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. . . . I have divided the book into three sections. The ...more

"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. . . . I have divided the book into three sections. The first examines the fallibility of doctors, asking, among other things, how mistakes happen, how a novice learns to wield a knife, what a good doctor is, how it is that one could go bad. The second focuses on mysteries and unknowns of medicine and the struggles with what to do about them. . . . The third and final section then centers on uncertainty itself. For what seems most vital and interesting is not how much we in medicine know but how much we don't -- and how we might grapple with that ignorance more wisely."

Sometimes it feels like we are afraid of uncertainty and failure, so it's refreshing to see someone searching for the truth, which can mean being willing to confront and explore failure and fallibility. I'm not in medicine, but in operations management as well, I think a lot about analyzing and minimizing errors, understanding and supporting systems (both official and informal), and then the whole uncertainty question, since the future is always uncertain, and even in the present, you never know the complete picture.

I enjoyed this book so much I lent it to my mom, who actually enjoyed it, too. Highly recommended, and fun to read even for non-doctors!...less

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Steve rated it:

01/23/08

Read in January, 2008

Since I myself am moving into a career in medicine, the idea of this book was intriguing to me - the honest thoughts and doubts of a surgery resident. In fact, the first part of the book, entitled "Fallibility," was just that. In his first chapter, "Education of a Knife," Gawande writes about the paradoxical endeavor of utilizing calculated violence in the OR to benefit a patient and the mental hurdles that must be overcome as a surgeon in order to do so. The description h...more

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Lindsey rated it:

01/24/08

bookshelves: must-reads

Read in January, 2008

I have read these stories on and off in the past year and as someone who is not involved in medicine but has three doctors (or to be doctors) in their family, I love this book. I will admit it, I have an academic crush on Gawande--I think he is a genius and writes what all of are curious about but that other doctors don't want us to know. Doctors don't want us to know that there is doubt, guess work, uncertainty, errors, etc. that goes on daily in medicine. We, in the U.S. look at our doctors...more

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Complications: A Surgeon's Notes on an Imperfect Science

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