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Uncertainties of a profession

Atul Gawande's compulsion to write the book under review arises from `not just unexpected turns that can result in medicine but also from concern with the larger uncertainties and dilemmas that underlie what we do.'

THERE is always a reluctance to pick up a book that will freshen the wounds inflicted during a lifetime of being a surgeon. Complications are a part of the making of a surgeon. The only reason for a doctor to read such a book would be to see if the writer has also gone through similar horrid experiences. Atul Gawande, a second generation American and the son of doctor parents, is eminently suited to write this book. His compulsion to write it arises from "not just unexpected turns that can result in medicine but also, and more fundamentally from concern with the larger uncertainties and dilemmas that underlie what we do."

He neatly divides his study into three parts — fallibility, mystery and uncertainty.

A doctor's fallibility can spell disaster. The American system of training has been refined over the years and at no time is a trainee left unsupervised. Yet the doctor needs to learn decision-making and to practise incessantly. Where else would a trainee surgeon practise other than on patients (mostly without consent)? Even the standard process of putting in a central catheter in one of the major veins of the body can be trying and frustrating. Beside the risk of failure there can be life-threatening complications like puncture of the lung or internal bleeding. The importance of repetitive action even in surgery is highlighted by Gawande's reference to the Shouldice Clinic where only hernia operations are performed by a group of doctors, of whom some are not even qualified surgeons. Yet the results are three times better than any other group in the United States. This is not boring — "Perfection is exciting."

The Harvard Medical Practice Society reviewed 30,000 admissions and found that four per cent suffered from complications as a result of errors. Death due to negligence occurred in one per cent of this group. "Doctors make terrible mistakes", Dr. Gawande admits. He discusses how good doctors "go bad". Colleagues often ignore the problem and much later cover up. Delays as long as seven years take place before action is taken. The need for professional assistance programmes for doctors "gone bad" has now been recognised.

Genuine errors lead not to guilt but to shame. Error experts claim that errors are a process and not a single event. Litigation rarely reduces medical error rates. The only way these repeated errors are prevented is by having Morbidity and Mortality (M&M) conferences where, instead of individualising the problem, it is discussed in an open forum. In the U.S., such proceedings are protected from legal discovery and cannot be used in malpractice suits. Unfortunately, such a practice is sorely lacking even in premier teaching institutes in India.

The author goes on to write on mysteries of medicine where science has not been able to clearly outline the management of certain problems. Chronic pain without physical findings, unexplained blushing, obesity and control of nausea are discussed in detail with lucid examples and case presentations. The explanations are fascinating and some of the techniques of management are very imaginative; even so the outcome may lead to major emotional disturbances as has been mentioned in the case of the "blushing TV anchor-person".

In the final section, "Uncertainty", the need for autopsy and the need to analyse the management of end stage disease has been thoroughly discussed. There is also a fascinating chapter detailing cases where, in the end, intuition more than science has helped to save a life.

The book, on the whole, is good reading and well researched. Some of the case presentations bring forth vividly the problems of good patient management. For the non-professional, it may, at times, be morbid reading but in the end, it is undeniably a book which is thought provoking and worth discussing amongst friends and colleagues.

Complications: Notes from the Life of a Young Surgeon, Atul Gawande, Penguin India, p.272, Rs. 250.

Goutam Sen is a cardiac surgeon.

GOUTAM SEN

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