Education of a Knife
The third-year medical student held the intravenous catheter, poised to insert it into a patient's vein. Suddenly the patient asked, "Have you done this before?" As the student later recounted to me, a long period of silence fell upon the room. Finally, the student's supervising resident, who was also present, said, "Don't worry. If she misses, I'll do it." Apparently satisfied, the patient let the student proceed.
Breaking this type of uncomfortable silence is the goal of Complications: A Surgeon's Notes on an Imperfect Science by Atul Gawande, a surgical resident and a columnist on medicine for The New Yorker. As Gawande's collection of stories reveals, fallibility, mystery and uncertainty pervade modern medicine. Such issues, Gawande believes, should be discussed openly rather than behind the closed doors of hospital conference rooms.
Complications is surely well timed. In 2000, the Institute of Medicine published "To Err Is Human," a highly charged report claiming that as many as 98,000 Americans die annually as a result of medical mistakes. In the wake of this study, research into the problem of medical error has exploded and politicians, including then-President Bill Clinton, have proposed possible solutions. The message was clear: The silence that has too long characterized medical mistakes is no longer acceptable. Yet while Gawande's book provides great insights into the problem of medical error, it also demonstrates how there can be no quick fix.
What may be most remarkable about the recent obsession with medical error is just how old the problem is. For decades, sociologists have conducted studies on hospital wards, perceptively noting the pervasiveness of errors and the strategies of the medical profession for dealing with them. As sociologist Charles Bosk has shown, doctors have largely policed themselves, deciding what transgressions are significant and how those responsible should be reprimanded. Within the profession, then, there is much discussion. Yet the public was rarely told about operations that went wrong or medications that were given in error. Residents joining the medical fraternity quickly learned to keep quiet.
Indeed, when one of those young physicians decided to go public, he used a pseudonym, "Doctor X." In Intern, published in 1965, the author presented a diary of his internship year, replete with overworked residents, arrogant senior physicians and not a few medical errors. In one instance, a surgeon mistakenly tied off a woman's artery instead of her vein, leading to gangrene and eventual amputation of her leg. Doctor X pondered informing the woman about the error, wondering "just exactly where medical ethics come into a picture like this." But his colleagues convinced him to remain quiet.
One whistleblower willing to use his own name and that of his hospital, New York's Bellevue, was William Nolen. In The Making of a Surgeon, published in 1970, surgeons swagger around the hospital, making derisive comments about patients and flirting relentlessly with nurses. (Not the least of reasons for being nice to nurses was the expectation that they would help cover up young doctors' mistakes.) Interestingly, Nolen was subsequently excoriated both by surgeons, who believed he had betrayed the profession's secrets, and by the lay public, who felt he was celebrating the "callousness and prejudice" of surgeons toward vulnerable patients.
Perhaps the peak of this genre of scandalous tell-all accounts occurred in 1978, with the publication of The House of God, written by the pseudonymous Samuel Shem. Although fictional, the book draws on the author's raucous and racy experiences as a medical intern at Boston's Beth Israel Hospital. To Shem, medicine's whole approach to patient care was misguided. The book's hero, the Fat Man, teaches his trainees a vital lesson: "The delivery of medical care is to do as much nothing as possible."
Today it has become more fashionable than rebellious for physicians to describe the trials and tribulations of their training. Dozens of doctors (and some nurses) have published such accounts. Gawande is a prime example of this more mainstream type of physician-author. Even though he describes very disturbing events in his articles for The New Yorker (some of which have been reprinted in Complications), he uses his real name and that of his institution: Boston's Brigham and Women's Hospital.
Gawande, however, has taken the art of physician narrative to a new level. He is a deft writer, telling compelling stories that weave together medical events, his personal feelings and answers to questions that readers are surely pondering. Most important, Gawande paints with a decidedly gray brush. There are few heroes or villains in Complications, just folks doing their jobs. Although some readers, perhaps those who have felt victimized by the medical system, may find Gawande's explanations too exculpatory of doctors, he has documented well the uncertainties and ambiguities that characterize medical practice.
Take, for example, his chapter "When Doctors Make Mistakes." With great flair, Gawande describes a case in which he mistakenly did not call for help when treating a woman severely injured in a car accident. Although Gawande could not successfully place a breathing tube in her lungs, he stubbornly kept trying rather than paging an available senior colleague. Eventually, Gawande clumsily attempted an emergency procedure with which he had little experience, of cutting a hole in her windpipe and attempting to breathe for her. It was only through good fortune that the patient did not die or wind up with brain damage. An anesthesiologist, called in very late in the game, managed to sneak a child-size breathing tube into her windpipe, enabling the patient to obtain adequate oxygen.
With typical candor, Gawande lists the possible reasons that he did the wrong thing: "hubris, inattention, wishful thinking, hesitation, or the uncertainty of the moment." All doctors, he is arguing, experience these very human feelings as they tend to their craft. The fact that lives are at stake may make physicians--as compared with other professionals--even more prone to such emotions.
Gawande also details how the surgery department addressed his error. The case was presented at the weekly morbidity and mortality (M & M) conference, where physicians discuss deaths and other bad outcomes. "The successful M & M presentation," Gawande perceptively notes, "inevitably involves a certain elision of detail and a lot of passive verbs." This clearly occurred during the discussion of Gawande's case, where, remarkably, no one ever asked him why he did not call for help sooner. Rather, his blunder was later addressed through another ritual, a private discussion between Gawande and the senior attendant he had not called. Games with language and secret conversations: These are the reasons Gawande has written his book.
In another chapter, Gawande provides a more provocative explanation for the type of mistake he made. Gaffes, he argues in "Education of a Knife," are part of how surgeons--and other physicians--must learn their craft. (After all, physicians don't perform medicine, they practice it.) In an anecdote resembling that of my third-year student, Gawande describes how he routinely caused complications when learning to place dangerous central-line catheters into the necks of seriously ill patients. Expertise, he explains, does not just happen. Physicians in training must victimize a certain percentage of patients to acquire the skills they will need to become competent doctors. Should we consider these events to be mistakes or business as usual? Deciding how to define a medical error is not the least problem.
In such learning situations, the necessary experience is best attained by keeping quiet. Using the "physician's dodge," patients are told "You need a central line" but not "I am still learning to do this." One ramification of this type of learning, Gawande notes, is the victimization of poor, less educated patients, who are often incapable of questioning doctors. Medicine's inclination to learn on "the humblest of patients" becomes especially apparent with Gawande's candid admission that he himself chose a more senior physician--rather than a more attentive cardiology fellow--to care for his son's heart problem.
Mistakes may be made not only by physicians but by patients. In the chapter "Whose Body Is It, Anyway?" Gawande asks what physicians should do when patients seem to make bad decisions. One especially compelling story, which I often use to teach medical students, involves a man who absolutely refused to go on a breathing machine after experiencing a complication of gall bladder surgery. Although the doctors explained that artificial ventilation would only be temporary and would likely save his life, the patient continued to object.
When the man passed out due to lack of oxygen, Gawande was faced with a devastating quandary. Does he abide by the man's wishes, which is what doctors are supposed to do, or immediately put him on the ventilator? Gawande chose the latter. I love to ask students what they think the man said when, a few days later, Gawande triumphantly took him off the machine. Invariably, half of the students predict that the man said, "Call my lawyer." But the other half, who guess that he said "Thank you," are correct. Gawande had surely averted a mistake in this case, but he was left without clear guideposts for approaching similar cases in the future.
Complications is filled with other stories demonstrating the capriciousness of medicine. For example, Gawande once detected a case of the rare, often fatal infection necrotizing fasciitis (flesh-eating bacteria) because he happened to have seen a case a few weeks before. He ultimately saved the patient's life, not through hard, scientific evidence but through a gut feeling and a willingness to submit a patient to possibly unnecessary surgery. "Medicine's ground state," he concludes, "is uncertainty." Other chapters examine why the medical profession so often hides the mistakes of impairedphysicians, and the questionable use of an operation to help morbidly obese patients lose weight.
In the wake of the Institute of Medicine report, experts have proposed numerous remedies for the problem of error. Most attention has focused on a "systems approach," which would produce a "culture of safety" similar to that of the airline industry. In such a scheme, sophisticated computerized systems would be put in place to detect impending errors, such as wrong medication doses, sloppily written prescriptions and dangerous drug interactions. This emphasis aims to revamp the current approach to medical error, which encourages finger-pointing and malpractice lawsuits.
Gawande's book demonstrates both the advantages and limits of such a systems model. On the one hand, by discouraging the stigmatization of medical mistakes, physicians may be more willing to reveal their own errors and those of their peers. The notion that the case of the obstructed airway could be discussed in an open and nonjudgmental environment, rather than couched in secrecy, is altogether welcome.
On the other hand, there is a reason decades of exposés like Complications have not led to significant change. Defining errors and ascertaining their causes is a tricky business.
So is dealing with the issue of blame. Gawande is willing to admit that he screwed up when he did not call for immediate help for his deteriorating trauma patient. "Good doctoring is all about making the most of the hand you're dealt," he writes, "and I failed to do so." But many physicians remain reluctant to come quite so clean.