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

We're angry when a surgeon makes a preventable error. Even a malpractice suit doesn't seem to be sufficient. We want the bad doctor to be thrown out of the profession.

We've got it all wrong, says Boston's resident surgeon, Atul Gawande. The problem of bad doctors who make mistakes is a minor factor. The major problem is that good doctors make mistakes. All doctors make mistakes. We're going to have to reform standard procedures, and resist our impulse to punish surgeons for being fallible humans.

When some manufacturers of anesthesiology equipment used dials that turned clockwise to turn up the gas or oxygen, and other manufacturers used dials that turned counterclockwise to turn up the gas or oxygen, human error on the part of anesthesiologists killed a number of patients. When the equipment dials were standardized among all manufacturers (and it was an engineer, not a doctor, who recommended it), the number of patients who died during surgery dropped.

Likewise, when the nationwide procedure was for an anesthesiologist to rely on a stethoscope to determine how well a patient was breathing, a number of patients died during surgery, or suffered brain damage, due to insufficiency of oxygen. When it became the standard for hospitals to have the expensive equipment to monitor the patients' oxygenation, that problem was fixed.

These two reforms were fought for, and won, by Dr. Ellison Pierce, when he was elected vice president of the American Society of Anesthesiologists in 1982. A study found that these two reforms alone resulted instantly in a 95 percent decrease in the number of surgery patients who died from what is called human error on the part of the anesthesiologist. [pages 64-68] Clearly, the approach of punishing people was ineffective; what was effective was to fix the system.

More recently, we have continued to hear new reports of orthopedic surgeons operating on the wrong arm or leg. Our response is typically, "How could an M.D. confuse right and left?" However, it wasn't until 1998 that the American Academy of Orthopedic Surgeons called for it to be standard practice to use a marker to label the body part, and to do so before the patient or the surgeon go to the operating room. [69] In retrospect, everyone will ask, "Why didn't I think of that?"

Beyond adopting new standards and procedures, there continue to be errors that result from doctors losing their concentration, or making bad decisions. Dr. Gawande tells the story of the time he had to perform an emergency tracheotomy (placement of a breathing tube into an incision in the neck) on a car accident victim brought in by an ambulance. While first trying a tube in the patient's mouth and throat, to see if it restored breathing, he should have immediately told the staff to get out the tracheotomy kit, in case he needed it. He waited until he needed it before he called for it. Then he waited until he had a problem with the "trache" before he called for the assistance of another doctor who had much more experienced with the procedure, and was available elsewhere in the hospital. Before he even began, he should have put out a call to see if the other doctor was available. With seconds to spare, it was the other doctor who saved the patient's life. [48-54]

Very helpful here is a mandatory weekly meeting held in every academic hospital in the U.S. It is called the Morbidity and Mortality Conference, nicknamed M & M. The doctors and their supervisors frankly discuss their own mistakes, with the intention of becoming conscious of what should be done better the next time. Because there are no patients, lawyers or reporters present, the doctors are frank with themselves and each other. In fact, most states have laws exempting the M & M from legal discovery. [57-62]

Inviting ever more constructive self-criticism is a vastly better way to protect patients than a pervasiveness of lawsuits. Generally, I might add, in any industry which employs fallible human beings, a policy of punishing errors is the surest way to prevent an open discussion of how best to prevent errors. Unfortunately, as Gawande points out, we tend to feel that it's "paradoxical" [62] to resolve that we won't make errors in the first place, and at the same time, have weekly scheduled meetings about our errors, the very existence of which meetings implies that some of these errors, which we resolve not to make, are going to be inevitable. We can resolve the apparent paradox by recognizing what British psychologist James Reason calls "latent errors." [63] All complex human systems include errors just waiting to happen.

We don't see bimodal distribution pointing to the existence of "good" and "bad" doctors. What we actual have is a normal bell-shaped distribution of the number of times doctors make serious errors or bad decisions. The bad doctors, then, are those who are located at the "bad" tail of the normal distribution. Gawande held several conversations with one of them, former orthopedic surgeon Hank Goodman, whom a hospital eventually fired.

Discussing one of several cases that went wrong, "Goodman told me that he should have done ... a total hip replacement. But it had already been a strenuous day, and he couldn't endure the prospect of a longer oparation. He made due with pins." [91] The author explains, "Medicine requires the fortitude to take what comes; your schedule may be packed, the hours late, your child waiting for you to pick him up after swimming practice, but if a problem arises you have to do what is necessary. Time after time, Goodman failed to do so."[93-94]

Here I would have liked Gawande to acknowledge that we have a social planning problem, directly or indirectly an economic problem. If, for example, society had twice as many orthopedic surgeons, then each of them would carry half the load, and perhaps Dr. Goodman wouldn't have been so fatigued that he decided to "made due with pins." For that matter, another problem mentioned above, the pre-1982 problem of anesthesiologists failing to have on hand the expensive equipment necessary to monitor a patient's breathing (one device that measures blood oxygen levels, and a second device that measures carbox dioxide exhaled) was also indicative of an economic problem. The author doesn't render an opinion on the controversial issues of politics and economics. I would have thought that the connection is a natural one.

Complications is a deeply humanistic book about surgical problems, free from any tendency to cover up embarrassing facts. Asserting that good doctors make serious mistakes, Gawande describes several that he has made, and those of his friends, whose real names are given. This honesty combines with easy readability to result in what will be certainly recognized as one of the best nonfiction books of the year.

Reviewed by Mike Lepore for crimsonbird.com