Tuesday, December 1, 2009

Complications – Notes from the life of a young surgeon by Atul Gawande

Baala Joshiyam. Virudha vaidheedam” – says a Sanskrit lore.
It means if you have to consult an astrologer or a fortune-teller, find the youngest person possible. Logic is that, he is yet to learn the subtleties of psychology and owing to his inexperience he is likely to tell what is most probable that would happen no matter how unpleasant it may be, rather than saying what you want to hear. On the other hand, when you go to doctor, choose the eldest possible since he would have done many experiments with so many folks that his diagnosis is likely to be better than a younger one.

So, with that frame of mind, “young surgeon” was more a warning than a reassurance for me.
Add to that, from childhood, I am always used to the jokes on doctors in the vernacular magazines.
(For example, patient is asking the doctor, “Is this operation so difficult doctor?”. Doctor replies, “Oh, no, it is dead easy”). Well, I was in for a pleasant surprise. It is a serious and an impressive read.

This book contains three broad sections. (1) Fallibility (2) Mystery (3) Uncertainty, each containing four or five cases. The title “Complications” comes not just from unexpected turns that can result in medicine but also the underlying dilemmas in what we do. Author says “medicine, we have taken it to be both more perfect that it is and less extraordinary than it can be”.

Fallibility section has five good chapters. I am picking up “The computer and the Hernia factory” where he specifically talks about the Shouldice Hospital near Toronto. The recurring rate is an awesome 1% where as rest of country or anywhere in the world is way above that. Since this is a hospital that focuses one and only one on hernia operations, staffs are better trained; the infrastructure is designed very well to support this kind of surgery in large volumes and so on. A defining trait of experts is that, they move more and more problem solving in to an automatic mode.
In basket ball game, they call it as muscle memory - That is, you practice so much, instead of head, hand remembers how to pocket the ball.
Reading about this hospital makes me wonder, if doctors have to be trained very early for some specific super specialty. It also gels with the observation made by one of the very leading surgeon here at Bangalore- When he was interviewed as to why he assigns relatively very young personnel for such complicated surgeries, he responded with confidence that, “it is a question of experience, that is, number of exposures a person has had. Here, we do so many operations per day, such expertise comes much early in their lives than our counter parts elsewhere”.

Mystery section reminds me of the oft heard quote “just because your doctor has a name for your condition does not mean he knows what it is”. It has five neat stories and I am picking up “The pain perplex”. He talks about a person who was very physically fit, but after a fall in the construction site developed a kind of uncontrollable pain. It was so much that, he could not work for more than 2 or 3 hours a day. He would suddenly develop pain hence sustained working was impossible. After CT-scans, countless X-rays etc source and cause could not be figured out. After that, he was directed to meet Dr Ross who is a pain specialist. Dr Gawante makes a keen observation about Dr Ross’s waiting hall. Most of the testimonies he has put up hardly talks about the cure but they are testimonials of serious “Thank You Doctor” types for simply taking the patient’s pain seriously. It looks like recognition and acknowledgement of pain for an undetected cause is an issue. Dr Gawante talks about some interesting experiments we can do by ourselves in the pain area. He also talks about RSI rise and fall in Australia. It seems to me pain as a phenomenon is yet to be understood clearly even by medical fraternity, quite so because, it is complex concoction of physical, physiological, psychological and a bit a faking or ‘making up” by brain.

Uncertainty section has 4 stories. I would pick “whose body is it, anyway?” as a sample. He talks about a sober case of a patient called Lazaroff who had extensive cancer in liver, bowel and all the way to spine. The choice was to do nothing and have a peaceful death. The second option was to attempt a spine surgery which again had low probability of success and even so it would not cure him. Mae West would say, ”Whenever I'm caught between two evils, I take the one I've never tried”. Lazaroff has not tried both and the end is sure either way but a question of time. He chose surgery. 14 days past surgery, during which time he always had life system support, finally, Dr Gawande leans towards him at bedside and informs him (just in case if he can hear) that breath tube would be taken out of his mouth. 13 minutes later Larzaroff had died. Post that the case, author delves about patient’s autonomy which leaves you thinking deeply. While autonomy is fine, I also intuitively feel that, as he also says, patients prefer choices. Yet, when it comes to making decisions on critical medical choices, they prefer some near & dear and the doctor to take that decision rather than by themselves. He neatly says “Just as there is an art of being doctor, there is an art of being patient – You must choose wisely when to submit and when to assert”. I wonder when physical condition is in bad shape, weighing the alternatives would be an appropriate possibility at all. To me, it is an equation between difficulty-in-understanding versus the-danger-of-trust. When age crosses certain watermark which is of course individual specific, one is better off on the trust side!

One of Dr Gawante’s remarks caught my attention: “It is a reality in medicine that choosing to NOT do something – to not to order a test, to not to give antibiotic, to not to take the patient to the operating room – is far harder than choosing to do it”. I could not help recalling Software testing side. G.M.Weinberg, one of the software gurus, ask us to imagine having a buffet plate and load it the way you want – except that, the number of trips to the table is limited to two or three and so would be the number of plates and its size. In short, what you include in the plate would determine the sagacity as a test leader since there is so much to choose from. Is medicine is based on “exclusion” and software testing is based on “inclusion”?.
Nobel Physicist Murray Gell-Mann once proposed an interesting question.”Imagine how complex physics would be if atoms can think”. Well, the answer may be the practice of medicine from the complexity standpoint.
This is a must read for anyone who, like me, has no clue about the field of medicine yet want to story based start! Hats off to Doctors!
Thanks a lot for reading this far…..