The Problems of Medicine

Atul Gawande wrote Complications: A Surgeon's Notes on an Imperfect Science. It is a riveting book, and a blurb on the back cover says "Gawande is arguably the best nonfiction doctor-writer around...He's prescient and thoughtful...the heir to Lewis Thomas' humble, insightful, and brilliantly crafted oeuvre." (from Salon.com)

Well, I like Lewis Thomas. And I really like Atul Gawande. His style is simple, but not dull. He doesn't assume the readers to have complete medicine knowledge or to be up to date on the lingo, so he helpfully provides that.

The problem of medicine, Gawande begins to argue in the chapter Education of a Knife, is that "We want perfection without practice." This is ridiculous, because we cannot attain perfection without practice. World-renowned doctors are, well, world-renowned because they are good at what they do. They have been at their job for so long, they have instincts about what to do in dire situations. But people often forget that doctors are human too. They are still fallible and make mistakes.

"We call such doctors "incompetent", "unethical", and "negligent". We want to see them punished. And so we've wound up with the public system we have for dealing with error: malpractice lawsuits, media scandal, suspensions, firings. There is, however a central truth in medicine that complicates this tidy vision of misdeeds and misdoers: all doctors make terrible mistakes."( pg. 55-56)

I also find it interesting, and partly true, how Gawande realized that half the deaths of patients under a doctor are not the doctor's fault. Circumstances (or fate, he might say) led to the point that no matter what the doctor did, because of previous events, the patient would die.

"The British psychologist James Reason argues, in his book Human Error, that our propensity for certain types of error is the price we pay for the brain's remarkable ability to think and act intuitively - to sift quickly through the sensory information that constantly bombards us without wasting time trying to work through every situation anew. Thus systems that rely on human perfection present what Reason calls "latent errors" - errors waiting to happen. Medicine teems with examples. Take writing out a prescription, a rote procedure that relies on memory and attention, which we know are unreliable. Inevitably, a physician will sometimes specify the wrong dose or the wrong drug. Even when the prescription is written correctly, there's a risk that it will be misread. (Computerized ordering systems can almost eliminate errors of this kind, but only a small minority of hospitals have adopted them.) Medical equipment, which manufacturers often build without human operators in mind, is another area rife with latent errors: one reason physicians are bound to have problems when they use cardiac defibrillators is that the devices have no standard design. You can also make the case that onerous workloads, chaotic environments, and inadequate team communication all represent latent errors in the system. ...The one attending trauma surgeon available gets stuck in the operating room. When things go wrong, it is usually because a series of failures conspires to produce disaster." (pg. 63-64)

Here's one last quote about practice. It's impressive for surgeons specifically to keep at what they do, even when they are not absolutely sure that what they are doing is the best thing. Their many years of practice give them ability to be mostly sure, but not completely. The will to keep doing surgery is impressive, and is what sets them apart.

"Indeed, the most important talent may be the talent for practice itself. K. Anders Ericsson, a cognitive psychologist [apparently, Gawande likes psychologists] and expert on performance, notes that the most important way in which innate factors play a role may be in one's willingness to engage in sustained training. He's found, for example, that top performers dislike practicing just as much as others do. (That's why, for example, athletes and musicians usually quit practicing when they retire.) But more than others, they have the will to keep at it anyway." (pg. 20)