Complications: A Surgeon's Notes on an Imperfect Science

by Atul Gawande

There is, however, a small medical center outside Toronto, known as the Shouldice Hospital, where none of these statistics apply. At Shouldice, hernia operations often take from thirty to forty-five minutes. Their recurrence rate is an astonishing 1 percent. And the cost of an operation is about half of what it is elsewhere. There’s probably no better place in the world to get a hernia repaired. What’s the secret of that clinic’s success?

Fascinating. Why don't all medical centers specialize if the success rate is so great?

In virtually all cases, statistical thinking equaled or surpassed human judgment.

What accounts for the superiority of a well-developed computer algorithm? First, Dawes notes, human beings are inconsistent: we are easily influenced by suggestion, the order in which we see things, recent experience, distractions, and the way information is framed.

Second, human beings are not good at considering multiple factors. We tend to give some variables too much weight and wrongly ignore others. A good computer program consistently and automatically gives each factor its appropriate weight.

many EKGs are in the gray zone, with some features suggesting a healthy heart and others suggesting a heart attack. Doctors have difficulty estimating faithfully which way the mass of information tips, and they are easily influenced by extraneous factors, such as what the last EKG they came across looked like.

Yet compassion and technology aren’t necessarily incompatible; they can be mutually reinforcing.

while errors will always dog us—even machines are not perfect—trust can only increase when mistakes are reduced.

It was estimated that, nationwide, upward of forty-four thousand patients die each year at least partly as a result of errors in care.

Most surgeons are sued at least once in the course of their careers. Studies of specific types of error, too, have found that repeat offenders are not the problem. The fact is that virtually everyone who cares for hospital patients will make serious mistakes, and even commit acts of negligence, every year.

The deeper problem with medical malpractice suits is that by demonizing errors they prevent doctors from acknowledging and discussing them publicly. The tort system makes adversaries of patient and physician, and pushes each to offer a heavily slanted version of events.

Neff and his team saved hundreds of careers from destruction—and possibly thousands of patients from harm. Neff’s was not the only program of its kind. In recent decades, medical societies here and abroad have established a number of programs to diagnose and treat “sick” physicians. But his was one of the very few independent programs and more systematic in its methods than just about any other. Yet his program was shuttered a few months after my visit. Although it had attracted wide interest across the country and had grown rapidly, the Professional Assessment Program had

Given the evidence, he now says, we should stop thinking that pain or any other sensation is a signal passively “felt” in the brain. Yes, injury produces nerve signals that travel through a spinal-cord gate, but it is the brain that generates the pain experience, and it can do so even

According to the new theory, pain and other sensations are conceived as “neuromodules” in the brain—something akin to individual computer programs on a hard drive, or to tracks on a compact disc. When you feel pain, it’s your brain running a neuromodule that produces the pain experience, as if someone pressed the PLAY button on a CD player.

The new theory about the psychology of pain has, almost perversely, helped give direction to the pharmacology of pain. For pharmacologists, the Holy Grail of chronic-pain treatment is a pill that would be more effective than morphine but lack its side effects, such as dependence, sedation, and motor impairment.

an overactive neuronal system is the problem, then what one needs is a drug that will damp it down. That’s why, in what a decade ago might have seemed a strange development, pain specialists increasingly prescribe anti-epileptic drugs, like carbamazepine and gabapentin, for their most difficult-to-treat patients.

drug companies are hard at work on a new generation of similar “neuro-stabilizing” compounds.

a pain drug from the venom of the Conus sea snail

The Conus venom was known to kill by blocking specific pathways in the brain that are necessary in order for neurons to fire. With a few alterations, however, Neurex scientists created Ziconotide, a drug that only slightly inhibits those pathways. Instead of shutting brain cells down, it seems to merely mute their excitability. In initial clinical trials, Ziconotide effectively controlled chronic pain from cancer and from AIDS. Another new generation analgesic in development is Abbott Laboratories’ ABT-594, a compound related to a poison secreted by an Ecuadorian

ABT-594 proved to be as much as fifty times as potent as morphine in relieving pain. Companies have other pain drugs in the pipeline, too, including a class of drugs known as NMDA antagonists, which also work by reducing neuronal excitability.

indeed, Ireland’s heavy potato consumption may account for its having the world’s highest rate of neural defects, such as spina bifida.)

Overall, women with moderate to severe morning sickness have a lower rate of miscarriages than women with mild nausea or none at all.

The autopsy is in a precarious state these days. A generation ago, it was routine; now it has become a rarity.

Some doctors went ahead and autopsied hospital patients immediately after death, before relatives could turn up to object. Others waited until burial and then robbed the graves, either personally or through accomplices, an activity that continued

To deter such autopsies, some families would post nighttime guards at the grave site—hence the term “graveyard shift.”

By the end of the Second World War, the autopsy was firmly established as a routine part of death in Europe and North America. So what accounts for its decline? In truth, it’s not because families refuse—to judge from recent studies, they still grant that permission up to 80 percent of the time. Instead, doctors, once so eager to perform autopsies that they stole bodies, have simply stopped asking.

When I failed to ask Mrs. Sykes whether we could autopsy her husband, it was not because of the expense, or because I feared that the autopsy would uncover an error. It was the opposite: I didn’t see much likelihood that an error would be found. Today, we have MRI scans, ultrasound, nuclear medicine, molecular testing, and much more.

How often do autopsies turn up a major misdiagnosis in the cause of death? I would have guessed this happened rarely, in 1 or 2 percent of cases at most. According to three studies done in 1998 and 1999, however, the figure is about 40 percent.

Whoa!

Regardless of the decade, physicians missed a quarter of fatal infections, a third of heart attacks, and almost two-thirds of pulmonary emboli in their patients who died. In most cases, it wasn’t technology that failed. Rather, the physicians did not consider the correct diagnosis in the first place. The perfect test or scan may have been available, but the physicians never ordered it. In a 1976 essay, the philosophers Samuel Gorovitz and Alasdair MacIntyre explored the nature of fallibility.

Little more than a decade ago, doctors made the decisions; patients did what they were told. Doctors did not consult patients about their desires and priorities, and routinely withheld information—sometimes crucial information, such as what drugs they were on, what treatments they were being given, and what their diagnosis was. Patients were even forbidden to look at their own medical records: it wasn’t their property, doctors said. They were regarded as children: too fragile and simpleminded to handle the truth, let alone make decisions.

PaternaLim

One of the reasons for this dramatic shift in how decisions are made in medicine was a 1984 book, The Silent World of Doctor and Patient, by a Yale doctor and ethicist named Jay Katz.

It was a devastating critique of traditional medical decision making, and it had wide influence. In the book, Katz argued that medical decisions could and should be made by the patients involved.

Importan ce of Jay Katz

Surgeons almost uniformly attacked the idea that patients should be allowed to choose. As one surgeon asked, “If doctors have such trouble deciding which treatment is best, how can patients decide?” But, as Katz wrote, the decision involved not technical but personal issues: Which was more important to Iphigenia—the preservation of her breast or the security of living without a significant chance that the lump would grow back? No doctor was the authority on these matters.

The case for letting patients choose

But when you see your patient making a grave mistake, should you simply do what the patient wants? The current medical orthodoxy says yes.

But, as we explained to him, life was not what we had to offer. We could offer only a chance of preserving minimal lower-body function for his brief remaining time—at a cost of severe violence to him and against extreme odds of a miserable death. But he did not hear us: in staving off paralysis, he seemed to believe that he might stave off death.

People are rightly suspicious of those claiming to know better than they do what’s best for them. But a good physician cannot simply stand aside when patients make bad or self-defeating

decisions -- decisions that go against their deepest goals.

decisions—decisions that go against their deepest goals.

Very interesting point: I agree. Autonomy isn't respected by giving patients all the options, but rather by giving the options that further the patient's own goals. Too many doctors make a fetish of autonomy. It's a value for expressing the patient's important wishes, not for dumping information on them.

I had come into residency to learn how to be a surgeon. I had thought that meant simply learning the repertoire of moves 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.

if having control over one’s life is to mean anything, people have to be permitted to make their own mistakes. But when the stakes are this high, and a bad choice may be irreversible, doctors are reluctant to sit back.

the exercise of that autonomy means being able to relinquish it. Thus, it turns out that patients commonly prefer to have others make their medical decisions. One study 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.

Not only in Asian culture!

The uncertainties were savage, and I could not bear the possibility of making the wrong call. Even if I made what I was sure was the right choice for her, I could not live with the guilt if something went wrong. Some believe that patients should be pushed to take responsibility for decisions. But that would have seemed equally like a kind of harsh paternalism in itself.

Carl Schneider, a professor of law and medicine at the University of Michigan, recently published a book called The Practice of Autonomy, in which he sorted through a welter of studies and data on medical decision making, even undertaking a systematic analysis of patients’ memoirs. He found that the ill were often in a poor position to make good choices: they were frequently exhausted, irritable, shattered, or despondent.

Schneider found that what patients want most from doctors isn’t autonomy per se; it’s competence and kindness. Now, kindness will often involve respecting patients’ autonomy, assuring that they have control over vital decisions. But it may also mean taking on burdensome decisions when patients don’t want to make them, or guiding patients in the right direction when they do. Even when patients do want to make their own decisions, there are times when the compassionate thing to do is to press hard: to steer them to accept an operation or treatment that they fear, or forgo one that they’d pinned their hopes on. Many ethicists find this line of reasoning disturbing, and medicine

Autonomy isn't the only value.

Among patients recognized as having heart attacks, for example, it is now known that an aspirin alone will save lives and that even more can be saved with the immediate use of a thrombolytic—a clot-dissolving drug. A quarter of those who should get an aspirin do not, however; and half who should get a thrombolytic do not. Overall, physician compliance with various evidence-based guidelines ranges from over 80 percent of patients in some parts of the country to less than 20 percent in others. Much of medicine still lacks the basic organization and commitment to make sure we do what we know to do. But spend almost any amount of time with doctors and patients, and you will find that the larger, starker, and more painful difficulty is the still abundant uncertainty that exists over what should be done in many situations. The gray zones in medicine

In the absence of algorithms and evidence about what to do, you learn in medicine to make decisions by feel. You count on experience and judgment. And it is hard not to be troubled by this.

Three decades of neuropsychology research have shown us numerous ways in which human judgment, like memory and hearing, is prone to systematic mistakes. The mind overestimates vivid dangers, falls into ruts, and manages multiple pieces of data poorly.

Scary and brave of him to admit.

A variety of studies have shown physician judgment to have these same distortions. One, for example, from the Medical College of Virginia, found that doctors ordering blood cultures for patients with fever overestimated the probability of infection by four- to tenfold. Moreover, the highest overestimates came from the doctors who had recently seen other patients with a blood infection. Another, from the University of Wisconsin, found evidence of a Lake Wobegon effect (“Lake Wobegon: where the women are strong, the men are good-looking, and all the children are above average”): the vast majority of surgeons believed the mortality rate for their own patients to be lower than the average.

It is because intuition sometimes succeeds that we don’t know what to do with it.

Judgment, Klein points out, is rarely a calculated weighing of all options, which we are not good at anyway, but instead an unconscious form of pattern recognition.

Important point. if something feels off, go with your gut.

Klein identified two clues the lieutenant had taken in without even realizing it at the time. The living room had been warm—warmer than he was used to for a contained fire in the back of a house. And the fire was quiet, when what he had expected was the fire to be loud and noisy. The lieutenant’s mind appeared to have recognized in these and perhaps other clues a dangerous pattern, one that told him to give the all-out order. And, in fact, thinking very hard about the situation could well have undermined the advantage of his intuition.

My tendency is to reason, but sometimes intuition or pattern recognition is what's needed.

Yet as arbitrary as our intuitions seem, there must have been some underlying sense to them. What there is no sense to is how anyone could have known that, how anyone can reliably tell when a doctor’s intuitions are heading down the right track or spinning wildly off.