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Oct-Dec2002-10(4)
BOOK REVIEW
Many questions, no easy
answers
Dr Chandrika
Rao
Complications: notes from the life of a young
surgeon. Penguin India, New Delhi, 2002. ISBN 0-14-302845-6 Rs 250, pp
251. Paperback.
This is a book that any doctor, especially a
surgeon, can instantly identify with. Gawande's stories sound familiar, though
few surgeons would be honest enough to admit it. He has given an honest account
of the unforgettable, unexplainable and unexpected turns that 'simple' and
'routine' procedures can take. He elaborates on these stories in the initial
essays which are aptly labelled 'Fallibility'.
His style of writing is smooth and effortless,
whether it is an analysis of the element of human error resulting in
complications, or his analysis of impaired physicians in the essay entitled
'When good doctors go bad.' The story of the once-successful orthopaedic surgeon
describes how a highly respected, and much sought after surgeon has his licence
taken away - a decade of busy practice, name, fame and respectability lost
forever. I am sure many surgeons have similar experiences. Why do priorities go
haywire? Alcoholism, burnout, addiction to narcotics and tranquillisers are
taking their toll on medicine. Hospitals all over the world should have a
programme like the one at Abbot Northwestern, where the orthopaedic surgeon
practised, to deal with doctors under stress. The stresses of practice have
created many impaired physicians - truly a scary thought. We need to weed out
these doctors so that they do not do harm to themselves or their patients.
Medicine is a profession with high stakes, tremendous risks - and no margin for
error.
Gawande writes, "We drug people, put needles and
tubes into them, manipulate their chemistry, biology and physics, lay them
unconscious and open their bodies. We do so out of an abiding confidence in our
profession. What you find when you get in close however - close enough to see
the furrowed brows, the doubts and missteps, the failures and the successes - is
how messy, uncertain and also surprising medicine turns out to be."
The dilemmas and ethics involved in letting a
trainee surgeon loose with the knife - even under supervision - are analysed
well. 'Practice makes perfect,' goes the age-old adage, and it is reassuring to
know that teaching hospitals - ironically - have better outcomes than other
hospitals. It is not practical to do all your surgical training by using virtual
reality, or by letting robots operate. Nor is it practical, always, to have
hospitals where one particular operation is practised, as exemplified in 'the
hernia factory', the Shouldice Hospital in Canada.
It is interesting to read about what can affect the
learning curve - the planning and organisation of an operation and going over
the steps methodically, with juniors as well as with scrub nurses. Having the
same team - though not always possible - makes so much difference to the
outcome. The experience of the Great Ormond Street Hospital, London, is
described. Surgeons changed the procedure for doing the operation for
transposition of the great arteries (from Senning procedure to the switch
operation) to give patients better quality of life into adulthood. The price of
learning this was appalling, with a high mortality in the initial cases - but
with time, the mortality rate reduced.
One can endlessly debate whether greenhorns should
practise on patients just because the latter cannot 'afford' to be fussy. Which
of us will entrust our near and dear ones to the care of a junior colleague? By
Gawande's own admission, the ideal "When it comes to my child, I demand the
best," should apply to all patients.
Many doctors are skeptical, like Gawande, about the
benefits of conventions and conferences. They feel the same about the role of
pharmaceutical companies in organising these events, and in sponsoring research.
Instead of trying to influence doctors with their gifts, companies should reduce
the costs of life-saving drugs.
Part two of the book deals with mysteries in
medicine. The stories of the architect with the excruciating backache, and of
the pregnant woman with the pathological hyperemesis, are told well. Again, he
emphasises the unpredictabilities faced in the day-to-day practice of medicine.
The final section of the book describes the dilemma and uncertainty involved in
decision making - whether it is for an autopsy or for organ donation. For one
patient, his decision to undergo surgery despite the risks involved proved fatal
for him. For another, her decision not to undergo surgery for an aortic aneurysm
proved to be correct, as she was alive and well one year later.
Time and again, we learn that medicine is not a
mathematically exact science, even with all the hi-tech investigative
modalities. As Gawande says in the introduction, "As pervasive as medicine has
become in modern life, it remains mostly hidden and often misunderstood. We have
taken it to be more perfect than it is and less extraordinary than it can be."
How true. This book is a 'must read' for all doctors, especially surgeons and
trainees in surgery. Patients would also do well to read the book. They will
realise that doctors are just human beings and should not be expected to perform
miracles.
Dr Chandrika Rao, Paediatric Surgeon, Manipal Hospital, Bangalore 560 017 . Email:chandrikabsgblr@yahoo.com