Atul Gawande's ‘Complications’

[X-Posted at SM]

I recently picked up Atul Gawande's Complications: A Surgeon's Notes on an Imperfect Science in a bookstore in Philly. While I thought I already had a favorite Indian doctor-writer in Abraham Verghese, Gawande gives him a run for his money here.

Complications is essentially a warts-and-all portrait of the field of medicine in the U.S. for lay readers. It's built on extensive research and interviews as well as Gawande's own experience as a surgeon at Harvard. Gawande's overarching interest is in what can be done to improve and reform the practice of medicine from within. It's fitting that Malcolm Gladwell has a blurb on the back of the book, since Gladwell's detail-oriented, problem-solving method closely resesmbles Gawande's in many ways.

Complications has been a success -- it was a National Book Award Finalist. In 2003, Gawande was invited to do the commencement address at the Yale School of Medicine, which is a pretty remarkable honor for a young doctor. He's also published a number of times in the New Yorker (try here and here), as well as the New England Journal of Medicine, where he published an influential article about casualty rates in the ongoing Iraq war.

Professional humility is the starting point for many of Gawande's examples. He writes, with nail-biting fluidity, about a potentially catastrophic mistake he himself made as a young surgical resident (he masks some details, presumably to protect himself from liability). It turns out that another doctor was able to save the situtation, but one sees that it easily could have gone the other way. Gawande mentions it to illustrate one of his central points -- that all doctors inevitably make mistakes:

There is . . . a central truth about medicine that complicates this tidy vision of misdeeds and misdoers: all doctors make terrible mistakes. . . . If error were due to a subset of dangerous doctors, you might expect malpractice cases to be concentrated among a small group, but in fact they follow a uniform, bell-shaped distribution. Most surgeons are sued at least once in the course of their careers. Studies of specific types of error, too, have found that repeat offenders are not the problem. The fact is that virtually everyone who cares for hospital patients will make serious mistakes, and even commit acts of negligence, every year. For this reason, doctors are seldom outraged when th epress reports yet another medical horror story. They usually have a different reaction: That could be me. The important question isn't how to keep bad physicians from harming patients; it's how to keep good physicians from harming patients.

Note that he's not just pointing out that "all doctors make terrible mistakes" to try and let them off the hook. Rather, he wants to acknowledge the fact and deal openly with the mistakes that are most commonly made so as to reduce their frequency.
Though Gawande doesn't come out strongly on the question of tort reform in Complications, it's clear that he doesn't think that a strictly legal response to failures and mistakes by doctors (or the system) is likely to improve how well doctors do. He states it well in this New Yorker interview:

What is the toll of malpractice on doctors?

The financial toll is under one per cent of our expenses. The real toll, I think, is in two places. One is in hindering our ability to honestly address injuries to patients from complications. There are two or three per cent of patients who will be hurt by serious complications in care; about half of those will be the result of error. And because these cases have the potential to become all-out battles in court, we often lose our human instincts to apologize, to grieve, to still be doctors for our patients. The other cost is in our ability to improve. Almost every case, when it’s settled, is sealed, and it can become hard to know what the patterns of failure in medicine are. In the airline industry, if there’s an accident, they can do an investigation and share information and figure out when there are certain patterns that suggest what things can be done to improve safety. We really haven’t been able to do that. (link)

Instead of simply turning it over to the law, Gawande is interested in expanding the processes that doctors themselves have evolved for analyzing their mistakes and fostering a sense of accountability via feedback networks and candid self-criticism (he's big on surgical "M&M" meetings, for instance).

While the first half of Complications deals more with surgery, the second half is more general -- case studies and interesting problems that have cropped up in recent years. One involves a patient suffering from chronic pain, and explores some of the recent advances in pain-psychiatry that have been made; another tells the story of a pregnant woman who had extremely severe nausea (hyper-emesis); and a third deals with a television newscaster who had a severe case of uncontrollable blushing. These case studies generally go beyond the mere "human interest" angle; in each case, Gawande uses the example to discuss some recent advances in the science.

Medical malpractice reform is a complex issue, and as an outsider I'm far from well-equipped to say "here is what should be done." So here are some starter links.

1) One recent study has questioned the claim (common among those who favor caps) that frivolous malpractice litigation has reached crisis proportions.
2) Another study has questioned whether introducing "pain and suffering" liability caps would actually significantly reduce costs.
3) And another study I came across suggests that the current system encourages doctors to be so defensive that they order lots of unnecessary tests, which increases insurance costs and makes the whole system more expensive.
4) Finally, a bill has been introduced in the U.S. Senate (S.22) that would put caps on Pain and Suffering (non-economic) damages; Senator Ted Kennedy has given his detailed response, which makes a number of good points. [UPDATE: The bill was defeated.]