Review: Complications: A Surgeon's Notes on an Imperfect Science by Atul Gawande

Oh how I loved this book. It might be because I was just relieved to read something, anything, that wasn't Armada, but I don't think that would be doing Atul Gawande justice. This book is beautifully written, occasionally heart-warming and so much more than one of those generic 'horrific tales from A&E' memoirs. 

Summary: Gently dismantling the myth of medical infallibility, Dr. Atul Gawande's Complications: A Surgeon's Notes on an Imperfect Science is essential reading for anyone involved in medicine--on either end of the stethoscope. Medical professionals make mistakes, learn on the job, and improvise much of their technique and self-confidence. Gawande's tales are humane and passionate reminders that doctors are people, too. His prose is thoughtful and deeply engaging, shifting from sometimes painful stories of suffering patients (including his own child) to intriguing suggestions for improving medicine with the same care he expresses in the surgical theater. Some of his ideas will make health care providers nervous or even angry, but his disarming style, confessional tone, and thoughtful arguments should win over most readers.

I should begin by saying that this relates directly to my day job - I advise and defend Doctors and other health professionals who are the subject of legal claims due to an alleged negligence. I've worked on neurosurgery, retained objects and delayed diagnosis claims, amongst others, so this book has a certain amount of interest for me.

Complications is far from merely a collection of anecdotes about 'when things go wrong,' however, and I do think it would interest everybody. Instead, Dr Gawande examines the concepts of surgery itself and discusses the different theories behind why things go wrong and the difficulty of actually implementing improvements. It's absolutely fascinating.

Two things really got me about this book - 1) the beauty of the writing, and 2) the humanity behind it. I propose to deal with them in turn, if I may. The prose in Complications is amazing though. He doesn't just write well 'for a surgeon,' Atul Gawande has a style that any author would be proud of. I've seen how surgeons write, and usually you're lucky if they've managed to spell the patient's name correctly. Mr Gawande is eloquent, articulate and patient as he guides us through the unforeseen conundrums of what surgery actually entails.

However, he doesn't beat the reader over their head with his qualifications. Obviously he references his job fairly often, as well as anecdotes that have come from his colleagues. What impressed me though, is that he also refers to his personal life and isn't above admitting fallibility when it comes to personal, medical decisions. There's a chapter that discusses the need to train new surgeons v providing the best possible care for patients. Trainees need to 'practice,' but who really wants an inexperienced student cutting into them? Mr Gawande refers to his own experience, in which he was asked whether he minded a surgical trainee performing his son's operation. Despite all his logic to the contrary, he refused. 

This is the uncomfortable truth about teaching. By traditional ethics and public insistence (not to mention court rulings), a patient's right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden, behind drapes and anaesthesia and the elisions of language. Nor does the dilemma apply just to residents, physicians in training. In fact, the process of learning turns out to extend longer than most people know.

The book is divided into three parts, called Fallibility, Mystery and Uncertainty. The first section deals with the topics I've touched on - the best way to train surgeons, when/why good doctors go bad, the lessons learned from surgical conferences, etc. 

The second part, Mystery, was my least favourite, although still interesting. Essentially it discusses three cases and the conceptual issues that arose from those particular matters. There's a TV presenter that undergoes surgery to control her chronic blushing, for example, and Mr Gawande touches on the judgement she's since received since her surgery was performed. They're interesting, but I personally preferred the more abstract chapters.

The Uncertainty chapters swing back into the discussion, dealing with topics like the inevitable requirement to take chances when performing surgery, the extent to which patients should be given control over their own care and whether human instinct or computers are better at providing accurate diagnoses.

Complications is perfectly accessible for a layperson. Every term and every abbreviation is seamlessly explained within the text, without the need to flick back to a glossary or consult a footnote. There are only one or two places that the mildly squeamish may balk at, but you can see them coming so it would be easy to gloss over them if necessary.

I hadn't realised that this was published way back in 2002 - it's just recently been rereleased in a pretty cover to match his other, newer books, Better: A Surgeon's Notes on Performance and Being Mortal: Illness, Medicine and What Matters in the End. Still, as the focus is on conceptual discussion more than particular treatments, I wouldn't think Complications is horrendously out of date. I just know I'm already desperate to read his other books. This one is perfect.'

Visit Mr Gawande's website here.