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.