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…..
Regards,
madhu

13 comments:

பகலவன் கிருஷ்ணமூர்த்தி said...

Madhu-san,

As usual, a very interesting narration of the book. I liked the anecdotes such as "between two evils, I choose the one that I have never tried.."

Surprisingly, a week ago, I was discussing during a weekend hiking session, how do doctors choose the "correct approach" (as the last option) on critically ill patients. While I do agree that "correct approach" is subjective, I always wonder whether it will be mentally disturbing the doctor (at all?) who chose the approach that did not work and caused the eventuality.

Another interesting point is the comparison between medical practice and software debugging. I concur with you about "exclusion" being the focal point in medicine.

A good review. I enjoyed it.

Thanks,
-Pags

Mohanakrishnan said...

Madhu,

Interesting note on a very interesting book. Now I want to read it too. :-)

padmini ranganathan said...

Nice summary Madhu. You may also want to read 'Better' by Dr.Gawande. Interesting concepts discussed like 'Washing hands' by doctors...he goes on to reminiscence on 'The choices a doctor makes are necessarily imperfect but they alter people's lives....because of that reality, it often seems safest to do what everyone else is doing - to be just another white-coated cog in th emachine....but a doctor must not let that happen.." He ties it to why no one who takes on risk and responsibility in society should not let that happen. Am sure you'll enjoy that as much as this one...

Mukund S said...

Interesting article, indeed - I recently heard a commentary on CBC Radio about how the BC (British Columbia) province is noticing a huge decline in the prescription of a very expensive medication, the moment the government started sponsoring it instead of the private insurance. Logical thought suggests that practitioners would be more than happy to prescribe the expensive option to patients knowing that they didn't have to bear the brunt of the cost. But rather, what's happened is that the doctors being reimbursed directly by the province meant that the margins on the medications were dictated by the government. So, now that the margins were lower on the expensive medication, most practitioners chose the cheaper option, and indirectly, the number of people having serious complications from the medication also came down. A stunning discovery, and right down the alley you are referring to!

Ramesh N Raghavan said...

Madhu-san,
As usual, an excellent review.. I enjoyed all your analogies and having read this book in full I could relate very well to them.
I am reminded of one of the conversations I had with a Doctor a couple of years back. For some pain in the rib area, he had prescribed some generic pain killers. I asked him what is the reason for the pain. He was quite matter of fact. They had taken an X-Ray which did no show much.. He just said, "human body is very complex, and often we don't exactly know what is going on. Since X-Ray doesn't show anything specific, let us assume it is just some muscular pain and try treating it. If it goes away, we are all happy, and if it doesn't or aggravates we can go to the next step". I was slightly taken aback when he was so candid, but after reading Dr. Gawande, I could better relate to what he said.
With respect to your comment about how medical decisions can change with age, I have a recent experience where despite some tests being available, the doctor did not recommend them for my Dad. His point was that the tests are quite painful for the patient, and even if they show something, he was of the opinion it is not going to help much for him at his age.. It will purely be an academic exercise to try and understand what is causing the condition, but with no benefit to the patient and so he discouraged me from trying to put him through the process".. I am not sure in which book, but Dr. Gawande also talks about similar dilemmas when treating severely wounded soldiers whom we are now able to save and keep alive, but he wonders how as a society we can deal with people who are quite crippled and are quite dependent on continuous medical interventions or others to survive.. I think those are quite relevant questions for which again there are no simple answers, and each patient/Doctor has to take a call or make some choices which are often fraught with risk..
Also interesting was Dr. Gawande's assertion that contrary to popular belief a surgeon is not necessarily a person born with very dexterous hands. He says it is just years of practice as you have also mentioned with respect to the Hernia speciality hospital. His opening chapter where he describes how he got inducted into inserting a Central line into patients and how it is only after several misfired attempts he could get it reasonably right is very nicely written. I often remember that passage and console myself when nurses struggle to get a vein in my Dad's hand to draw a blood sample. Often it requires multiple exploratory attempts before they give up and try a visible, but smaller vein in the forehand.. Clearly a case of not having enough "experience". The fact that the human body is unique in every person and no two individuals arteries/veins are exactly in the same spot/shape makes such simple tasks quite difficult at times..
Thanks for your review and keep posting!!
Best Regards,
N.R. Ramesh.

prataprc said...

The blog is becoming a "quotes factory". Adding to the list of quotes, another one,

Best writing is writing less, like in mountains, the shortest way is from peak to peak, for those who have long legs

Madhu Parthasarathy said...

Hello Pratap:

Thanks for the interesting feedback.
I would divide your feedback in to two.
(1)About quotes
(2)About being short

Now about quotes.....

=>If Some wise person who travelled that path much ahead of me in time, said very wisely....then,why would I want to miss that?
As a software fellow, I see that as "great re-use block" which is fully tested and waiting to be integrated :-)

=> I for one, atleast believe, I quote only to express myself better

=> I don't claim to be a wide reader, but except Drucker, I have seen most of them do quote.Even he occasionally quotes the 14th century Rabi

Now about being short...

=> I have made it a point not to cross 2 pages in the word document before I upload it in the blog
.... if it crosses, trust me, I will reduce the font size :-)

=> Saint Francis of Assisi(1181-1226) says "Preach the Gospel and if necessary use words".
I am afraid, I would have to use both words and also quotes, because for me both seem to be essential.

=> As per your quote,I really wish,I had such a long leg :-)

=> Finally, most of the visitors to the JuJubax blog may not be impressed if they see two white blank pages, much less understand me.

So, net<>net, I may admire your feedback but unlikely to implement.
Thanks for your understanding.

regards
madhu

vivisa said...

Am reading this review, first thing in the morning Madhu-san. Some of the one liners took me back to jbx days. Please keep reading and reviewing. I'll come back for more :) -- sAgar

vivisa said...

Madhu-san, just in case you / any of your readers click on my blogger profile - it is outdated; I've moved to Posterous.
http://vsagarv.posterous.com/

Thanks. -- sAgar

ESR said...

In this context, you will find books by Dr Andrew Weil very interesting, especially the first one: "Health and Healing". One lighter comment on the side: Atoms seem to be able to think , at least at 'sub-particle' levels. Example: Paired particles change their spin status depending on each other even if separated by light years.

jaga said...

I haven't read the book but your notes have made me curious. Will try to get the book ...

bama said...

madhuma
It was an interesting read.Probably,I can talk more than write to you!Asuusual great sincerity displayed in every line.
Great going!

Madhu Parthasarathy said...


another interesting read by the same author

Annals of Medicine: Slow Ideas, by Atul Gawande. Some innovations spread fast. How do you speed the ones that don’t? http://nyr.kr/17qKMXn