Ben Pederson's Reviews > Complications: A Surgeon's Notes on an Imperfect Science

Complications by Atul Gawande
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's review
Feb 04, 2008

did not like it
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 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.
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Elena I'm not certain, but it seems to me that at the time he wrote this book (long time before you read it in 2008) it was not the case that "fallibility is hot right now." I think the power of this book WAS in his use of anecdotes, concrete examples that could be discussed and brought the issue to light. I haven't read his other books, but I also believe he followed up with suggestions on how to improve upon these issues in other texts. Maybe the problem is your expectations for the book in the context of 2008 vs when the book was written.

Tony London His personal accounts are the whole points of his book. The anecdotes are his evidence for the various complications seen within medicine. He's commenting on the field through his own experience and backing up the commentary through anecdotes from his own personal life. To say that he is ridiculous for being anecdotal is ridiculous in of itself. The accounts of successful practices, what makes them successful, etc... is what makes this book an excellent commentary on the field of medicine. By no means does this book deserve one star. It should be required reading for every pre-medical student along with his commentary on geriatrics in "Being Mortal."

Brian I don't know about required reading but I would agree more with Elena that the book was written at the turn of the century when anecdotes were out of fashion. Seems as though he might have brought about a lot of other books and now because of that his book seems that way. I can agree with you though anecdotes of books all seem to be the same with doctors like they almost can't talk about anything else because that's all they know. But back in 2002 I'd be more likely to say he started the trend than just being merely apart of it. Not that he was the first one but if you see his acknowledgements there was a lot of apprehension about it.

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