Dear friends and readers,
Another blog where I’m turning my lecture notes into a blog for my students and in the hope other readers involved in some aspect of medicine (and which of us is not?) will find them of interest.
I begin with Gawande’s Complications: A Surgeon’s Notes on an Imperfect Science, his introduction, a summary and exemplification of his book’s major arguments: Medicine is a strange and disturbing business: it is messy, uncertain and surprizing. Is that true of other sciences? Yes. Are there other applied uses of science where what happens is very often unpredictable? We have had one this term: the NASA shuttle. John Harrison’s invention of watch that could tell what longitude a shiop is at. We see him aboard ship showing how hard it is to cope with knowing this abstract placement.
Gawande opens with anecdote (pp. 3-5). The doctors were frightened, meant to help a young man shot through the buttocks, cut him open, what damage was done was done by them; they couldn’t explain how it happened. Then the case of boy in danger of death. He, Gawande, had to guess. They didn’t know how gravity would affect what they were doing (p. 6). Lee Tran. They guessed right.
Medicine is an imperfect science, diagnosis and offering medication are ways of investigating what’s wrong with someone (p. 7). The stories in a sense all exemplify this idea. Book’s sections organized thematically to highlight sub-points he wants to make: doctors are fallible: they have to learn and on patients and they “go bad.” Much mystery and many unknowns in medicine and struggles of what to do about these (back pain with no physical explanation that drives a person wild; nausea won’t go away and is literally killing her): we see that evolution has made a creature at odds with the demands of our modern lives and society. Then uncertainty itself driving the whole experience, shaping it.
The major flaw in book: “While people continue to bear the high cost of medical care, negligence and over-commercialization, Gawanade offers analysis of intangible though important dimensions dimensions through stories and leaves out of his discussion any ethical burden on the above issues affecting the nation and society: our attitudes towards one another because of race, sex, ethnicity, and the kind of illness we show up with.” “He prefers to throw dust away from medical profession by called medical science ‘imperfect’.” It could be called a distraction.
The candid stories conceal a biased and conciliatory analysis that favors a gainful status quo of practitioners; the way medicine is practiced today (in the US and elsewhere) where good health benefits are distributed like cookies to certain high incomes and luckily placed people and age groups.”
On the other hand they are candid and for many they open up cracks in our own attitudes towards medicine and doctors that are unreal and dangerous. He is smart, learned, and gives us a chance to think. What medicine is despite the plethora of programs remains mostly hidden and misunderstood.
Part 1: Fallibility
Essay 1: Education of the Knife (pp. 11-34): it’s people doctors must practice upon.
He is frank about how hard it is to learn. I’ve read this kind of thing where the doctor/nurse/medical technician shows him or herself trying to put in an IV. What makes this different is he shows himself trying to put in a scalpel, in the center of someone’s body. The reader pays attention.
What are the motives of someone who does this? Enjoyment of power. Darwin was originally going to be a doctor; his father sent him to one of the best medical schools on the earth at the time, at the University of Edinburgh (also good were Paris, some in Italy). He shuddered in horror: no anesthesia; he found it particularly hard to take how the poor were treated and also children, particularly the children of the poor. Gawande gaps in awe (p 15), exhilarating the power (p 16)
Real experience daily is of ordinary things all the time: someone gets a screw in her leg from a chair and can’t wrest herself free, (p 18)
He doesn’t tend to see hand-eye coordination genes per se as central. What you need is the ability to practice, practice, practice. The genius or talent is the one which leads you to practice (pp. 18-21)
It is hard to talk to patients about this (p 23) People won’t let you learn on their family or friends if they know about it (pp. 29-30). He didn’t let a resident learn on his child. Truth is the wealthy and well-connected wriggle out; he’s for setting up a system insofar as you can, where choices are offered or born equally (p. 33) How much should trainees be allowed to participate? (Is there anyone in the classroom who feels or knows that a physician-in-training did something and the result, while not fatal, is not so good?)
Introduces important theme or insight which carries throughout the book: the way to eliminate errors is not to demonize individuals; it’s to study a system, a practice, a habit, a group and see what patterns of errors happen and then see how to eliminate them. Everyone makes mistakes, everyone. No matter how hard you try not to. Gawande shows they tend to be of the same kind: like misreading the machine which puts someone under anesthesia because the companies put the controls on the front differently; like copying out prescriptions.
What to do? Get after the companies; make doctors use preset prescriptions in computers (that is shown to work better because then they are not misread, another systemic problem). We want to believe in some hero and then we sue him; he’s just another “flawed human” being in a team, in a subculture.
We see the team that learns quicker and does better, is one where people cooperate, are not competitive or domineering, and we see why: they are really a team (p 29): trust, getting people to do their best in security.
It is hard for someone to adjust to and face your own fallibility.
Essay 2: The Computer and the Hernia Factory (pp. 35-46): what makes for needed excellence
Gawande begins with examples of how approaching medicine from a systemic point of view, relying on machines can help eliminate certain kinds of errors. The problem: people are mistakenly discharged; one reason is misreading the computer printout. Machine is better at it (p. 37).
Well, there are hospitals where doctors do nothing but hernias. They get good at it. Repetition changes the way you think. Is that to be better? Depends, maybe in the case of this sort of operation. Doctors do rely on intuition too; a lot of doctoring is sizing you up. Do we eyeball our groceries to determine how much they should cost us?
The problem in the book of celebrating technical virtuosity. Is Gawande too much into this technical virtuosity? Our films (Wit, The Doctor) stress the need for humanity. Jason a technique freak; so too Kelekian; alas so too was Vivian Bearing when she taught poetry. All avoiding the human. The human is so painful and so uncertain. It’s hard to make friends. I’m one of those who goes to the library and finds books as friend.
Essay 3: When Doctors Make Mistakes (pp 47-74): again doctors must learn on people and how to bring down the number of mistakes
Gawande is concerned to show us that medical error is not fundamentally a problem of bad or crooked or inadequate or corrupt doctors. He tells the story of his bad judgement is one that has been excerpted again and again. It’s brave of him; it also probably precludes some other person getting very mad at him (he can’t make enemies telling of his own failure).
I talk a lot to my dentist. Dentists are doctors. For about 15 years, maybe a bit more I’ve had very bad troubles with my teeth. He’s a nice man, honest, a good dentist. When I told him about this book and quoted the line, “It was a clean kill” (p. 61), he said to me people he knows have said this to him. One surgeon says you are unlikely to carry on through a life doing surgery without killing someone. I said, “is that true, do you think?” Well, he said, he’s lost people’s teeth when they didn’t need to lose them. He feels bad when people lose their teeth unnecessarily.
Gawande’s pride was at stake. He wanted to do it himself
While I don’t think suit prevents errors, and agree that fear of suit can make errors, I disagree with the inference some may take away from this chapter that we ought not to have suit (pp. 55-58).
It’s the only place we as patients have to fight a lack of autonomy. It’s a crude highly fallible mechanism which is screwed up by the adversarial court system (and you get money for pain and injury, not from mistakes; juries award much bigger sums when outcome back regardless of whether there was a mistake or some egregious misconduct as in the stories Gawande tells in the essay called “When Good Doctors Go Bad.”
I lived in England for a time where you can’t sue; patients have less rights in custom; custom and norms are more significant in determining how people behave than law. Laws forbid things; they don’t tell us what to do, but what not to do. The language is sometimes phrased as the law allows you this or that, but it’s felt as what is not permitted. Scotland you have to prove a tort; here only pain and injury.
Would they discuss their errors if we didn’t have lawsuits? I don’t think so (p 58). Nonetheless, I agree demonizing errors is a bad idea. As doctors are not gods, so they are not demons.
M&M: Mortality and Morbidity: with all its evasions, it’s what they have and it needs to be protected. Let us remember lawyers make money from suits. He agrees it’s inadequate and shabby. The individuals don’t take responsibility; the doctor does not want to see himself as part of team or system. There’s the problem of collegiality and the problem that you fear someone will accuse you of bad or poor practice. But they do look into errors; the person is known to have made it, and his or her career is on the line.
Probably the most important part of this book is the argument that “people err frequently and in predictable patterned ways.” We know this but do not act upon it except when something seems singularly risky: like airplane flight. People don’t have wings. He tells the case of anesthesiology where error was brought down to a tiny percentage of what it had been when the systems and patterns of behaviors were studied (pp 64-67).
I notice that one cause of the young woman’s death can be said to be an unwillingness to spend money on new machines that make no money. It cost to replace the monitors with better ones (p 67). That takes money out of the budget which individuals can glom up. City of Alexandria is always very unwilling to replace a stop sign with a red/green light. They say people don’t like red/green lights, but they also often add the $90,000 bill or so these things cost. Only after a number of accidents at bad corners, do you see a red/green light go up.
Doctors should still work to utter capacity; bodily harm at stake. Effort makes; diligence, attention, care (p 73).
Gawande did err; he did not make the most of the hand of cards he’d been dealt with. Not always easy to see what is the best thing to do.
Essay 4: Nine Thousand Surgeons (pp. 75-86): people go to conferences to be with their tribe.
A considerably lighter essay. Time our for a little humor that teaches us something. What do professionals go to conferences for? A good question. Feynman distrusts conferences. He says they are mostly for display, political networking, personal aggrandizement. There are things sold which are worthless; little original research or ideas for real anywhere. Maybe so. Still people go and he went too. Anyone here ever gone to a convention or conference of people engaged in the same endeavor or having the same interests?
You go to be validated; to talk to people in your community like you. To share feelings and thoughts. The conversations on the bus. You are among your particular tribe. A tribe not linked by genes or biology. If nothing original, a lot of development. You are in for conning of course and have to figure out what’s valuable and what hype, what personal aggrandizement sheerly and what interesting.
You can experience the occasional illuminating or just so moment: the telling paper, film, procedure, encounter. For him it was the man with the real books of thought (pp. 81-82) in the midst of frivolous nonsensical gadgets and freebee give-aways.
Essay 5: When Good Doctors Go Bad (pp. 88-106): the problem of inadequate means to stop bad doctors from practicing; the lack of help for them.
Story of Hank Goodman is memorable: he began as intensely caring and ambitious and became “burned out.” Had had enough.Surprisingly common and no one with the power to do anything acted (p. 95). Gawande says there is an honorable reason: “they don’t have the heart.” Well what about the patients. He does not include how people fear for themselves. He says the intentions of everyone are good. Are they? (p. 95). Goodman was depressed. Most whitewashing moment in the book.
People just beneath this doctor in the best position to know (p. 96). Some brave enough to steer patient away.
But it’s brave and decent of Gawande to bring this up; to tell this story and how the man who started this effective clinic could not get monetary support. We should look to what someone does and not what they didn’t do altogether.
He names 4 types of abusive behavior, p 100: persistent poor anger control or abusive behavior; bizarre or erratic behavior (which people get away with when in high positions); transgression of proper professional boundaries (ditto — mostly having to do with sex); and the familiar marker or sign of a disproportionate number of lawsuits or complaints.
What we really are: 32 percent of general population has some serious mental disorder (1/3) be it depression, mania, panic, psychosis or addiction.
Gawande would like readers to stop being ready to view doctors as sociopaths; they are struggling human beings too. I wonder if we are able to look at ourselves.
Do you think people prefer a system of don’t ask, don’t tell? Well which people. Doctors may prefer it, but do patients? (P. 103) There are people who don’t want to know about their sickness, who don’t want to be asked to participate in the decision-making process for real. I don’t prefer don’t ask, don’t tell. But this is a character trait with me. I want to know. I feel stability and safety can only rely on truth. I may be wrong. In life I’ve seen where I have been.
Part 2: Mystery
Essay 6: Full Moon Friday the Thirteenth (pp. 109-114): our intuitive thinking wrong
People see patterns and meanings where there is none; do a study and discover that our intuition is wrong. There is no connection, but as we experience the misery or trauma, we persist in remembering the previous time we experienced it and its details and trying to find some pattern.
Essay 7: The Pain Perplex (pp. 115-129): suffering because and out of things outside our control.
Have you ever had a pain and everyone said “it’s in your head”? Gawande is here to agree it’s in your head but that does not make it any the less real. Have you ever had a pain and no one could find an explanation for it and dismissed your pain? Gawande writes of the common condition of ” a patient who has chronic pain without physical findings to account for it.”
It’s common for doctors to dismiss them as cranks, not real, needing psychiatric care (“whinging”). Such people go to acupuncturist and alternative medicine.
Gawande is here to believe you and say there are some other scientifically medical people who will try to help you. The story of Rowland Scott Quinlan (pp. 115-118). Story not atypical but common.
Theoretically the problem is the mechanistic theory we adhere to about medicine. We have to find a physical agent to push something
before we will believe it’s been pushed. Gawande leaves out psychology: people don’t want to allow this; it’s inconvenient; they only want to take seriously what is physically there.
Underlying this story is an argument that psyche is as real and significant as soma, e.g., panic disorder. It’s real. But it gets no respect. It’s hard to get an etiology. Gawande is for resorting to drugs if they work — and also operations. After all, he’s a surgeon. Health is a complicated state. People aren’t faking it if misery in the job or marriage or wherever is giving them acute pain (P. 128).
Gate-control theory of pain has been replaced by a new theory which seems to be accurate: the brain is not a bell you pull with a string, and the idea of to stop the bell from reacting to the pull (that is find distractions and other things to make you ignore pain, though it’s true that people in certain professions and situations will ignore pain longer: ballet dancers and men who escaped with their lives from battle even with terrible maiming injuries.
Pain comes from the brain, and it doesn’t need a physical stimulus necessarily. This makes pain political because it demonstrates the source is social arrangements. If we want to eliminate the pain, we need to change the social arrangements.
Essay 8: A Queasy Feeling (pp. 130-145): the uses of nausea.
A woman friend has told me that there are people who “don’t believe” in this condition of a woman during pregnancy; they deny that near fatal vomiting can occur in some pregnancies.
Parents have an adversarial as well as supportive relationship with children. There is a conflict between the interests of the mother and child when it comes to childbirth. Nature does not care for the individual but species. Until 20th century childbirth was often fatal; it’s still dangerous. Explanation comes from evolution: pelvus we walk on is not quite big enough to accommodate large brain which developed a little later. We are claptrap machine. Horses have trouble too.
So here is a place where natural selection has developed erratically: some foods safe for adults are unsafe for embryos; pregnancy sickness may be evolved to reduce an embryo’s exposure to natural toxins. Common morning sickness does usually end by the end of the first trimester. It’s said that women who are pregnant naturally prefer bland foods; I can say that when I was pregnant the second time I stopped drinking wine – and other liquors. I couldn’t. They just made me sick. This unhappy state ended upon giving birth.
I don’t know that motion sickness is relevant here; he does not want to go into the adversarial nature of the symbiosis.
Story of how woman endured this killing pregnancy: she did have someone to care for her; she had money and health care; many women would not and many would not endure this. They’d have an abortion. It was advised but she said she was Catholic. The doctors also attached her to a device that made her hear a heartbeat much louder than it really was. I wonder if the nurse did that voluntarily or was it imposed on this woman (p 139)
Gawande goes into the phenomena of nausea and tries to explain why people dislike it so. Our understanding of this is primitive. Pharmaceutical companies make millions of dollars selling drugs. Best way to cope is start treating the condition when it’s mild. So habit comes in here
Larger interesting issue about suffering Do we do enough about suffering? The problem is when we see someone suffering we look at it as something to test and then look to see if there is a practical thing we can do. Instead of trying to cope with the suffering. Nausea is one condition where we are forced to deal with the suffering itself because people really dislike nausea.
Essay 9: “Crimson Tide” (pp. 146-161): the blush
This one interesting because physiology is clearly intertwined with someone’s character. They are not separate facets of existence which people might tend to think. Blushing useful. You signal you are embarrassed, you self-deprecate; you are kowtowing to group, confessing anxiety.
Essay 10: The Man who Couldn’t Stop Eating (pp. 162-183): eating disorders.
I. The story of Vincent Caselli and his Roux-en-Y gastric-bypass operation. This one too has evolutionary implications. All of the essays in this section do: be it the one about blushing or how we impose patterns on things (which we are skipping) we have evolved in reaction. So our bodies work hard to keep our calories going safely in our bodies.
Story of Caselli includes much detail which tells you he is working class: the way it’s done makes me a wee bit uncomfortable: it’s stigmatizing. Both he and wife good at business: he construction, she assisted-living. He ate a lot, big portions and everything on his plate. We eat out of habit too: it’s time so we eat.
So history of weight-loss one of unremitting failure (pp. 169-70). We are built to survive starvation, not deal with abundance. If you diet, your metabolism goes slower to compensate. So it can be a terrible battle to lose weight.
People who have this operation seems mostly to chose not to overeat anymore, to eat less. Though not all. Alas Vincent is eating less because he is forced to, not because of operation. He is not a thoughtful fellow and it may be it’s hard to sink in that this operation has endangered him so that if he overeats he’s at risk. Gets rid of diabetes.
I’m glad to see this emphasis on weight problems through this operation: most of the time you get stories about anorexic women which show little sympathy and less understanding (p. 182): “how can you let yourself look like that?” (see “Girls Want out” by Hilary Mantel, at London Review of Books)
I’m glad to see that Gawande expresses concern at merely plump people opting for this serious operation.
Very recently a study was published which showed our awareness that we are overweight can be attributed to strong advertising on the part of the weight-losing industry. The claim is that some of this distaste for the least fat on women in commercials and films is a product of advertising. Some of the “worry” about obese children in particular may be a construct of advertising campaigns.
Part 3: Uncertainty
Essay 11: Final Cut (pp. 187-202): the need for autopsies to continue.
An intelligent argument on behalf of autopsy. He thinks its decline is due to doctor hubris — not money or distaste of families of dead patients who give in if pressured. He says that people have always protested autopsy so that it’s unlikely that a new religious motive is coming in here.
How do others feel about autopsy? Why is it in decline? You don’t have to be religious to be emotionally attached to the corpse of the person. Perhaps also a distrust and dislike of hospitals and doctors. Don’t want the body cut up. Final cut.
Gawande shows long history of medicine demonstrates the importance of autopsy in learning about the human body. A corpse can be treated more aggressively. He felt he didn’t need to do autopsies until he discovered a bad mistake.
A long history of misdiagnosis continues (pp. 197ff): 40% in 1998 and not getting better. Why? the nature of fallibility. The tests shows accurate results, but the physician doesn’t call for the right test. People are somewhere between being like hurricanes and ice cubes. Remarkable that he thinks he can come up with what’s wrong with Charlotte Duveen.
Essay 13: Whose Body Is It, Anyway (pp. 208-27) autonomy and having to choose
This essay revolves around the question of asking the patient for their input? Gawande seems to think our communities have begun asking too much of patients to hand them the responsibility?
This is a complete switch-around from earlier practice: much hidden and patient not consulted; treated like a child or someone of a lower class. Gawande says the current medical orthodoxy says let the patient decide.
Is that your experience? Mine is the mildly dominating doctor with a pretense of consulting me.
Case of man who chooses badly (Lazarus, symbolic name) because he can’t face that they don’t have life to offer him but continued near death and misery and yet more misery to sustain that (p 215)
Gawande makes a strong case that patients are themselves emotional, confused, don’t know enough, can’t hear: exhausted, irritable, shattered or despondent (p 222). Gawande preferred to have decision made for him; Dr K saved the life of the man who didn’t want “another machine.”
What is really needed is kindness. That’s the real task (p. 222). Autonomy is but one value among others, but it is an important one. He’s not saying don’t get a second opinion, don’t ask questions, but that ethicists have gone overboard. But Gawande too strong on the side of the doctor deciding. Just about all his stories have patients succumbing to doctors and ending up better off. As usual, he forgets corrupt, indifferent, and bad-choosing doctors.
To sum up: There’s a direct conflict of interest between the pregnant female and the fetus in the sense that childbirth endangers her life and her body; there is the problem that people cannot always hear the truth about anything and make bad decisions, a result of naivety, misinformation and inability to take in the hard reality.
I suggest the man who chose the horrific operation because he couldn’t accept there was nothing doctors could do for him and the woman who had naive ideas about childbirth (knew nothing of history) may be taken as conflicts of interest. We don’t treat suffering itself; we go after what we think we are supposed to care so much about yet do we care about it?
Essay 14: The Case of the Red Leg (pp. 228-52).
Gawande falls into sensational mode: here are these heroic doctors cutting cutting cutting to save. Here we see how Gawande falls into technical virtuosity. Is Gawande too much into this do you think?
Our films, Wit and The doctor stress the need for humanity. Jason a technique freak; so too Kelekian; alas so too was Vivian Bearing when she taught poetry. All avoiding the human. The human is so painful and so uncertain. Wit is about the human condition seen through the prism of illness: how hard to make contact with one another.
For Gawande’s later essays, see comments: Bell Curve; The Score; The Way We Age Now.
Atul Gawande recently withd Jack Cochran, a high official at Kaiser Permanente
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