Complications: A Surgeon's Notes on an Imperfect Science (review)

Atul Gawande. Complications: A Surgeon's Notes on an Imperfect Science. New York: Metropolitan Books of Henry Holt and Company, 2002. 269 pp. Hardcover, $24.

Atul Gawande's bravely self-reflexive, exquisitely candid, agilely argued book, published as he nears the end of his surgical residency, is remarkable. His fourteen narrative essays, clustered into three sections, "Fallibility," "Mystery," and "Uncertainty," are model ethical interrogations of ordinary medical encounters. Although many of these writings were published separately in The New Yorker and Slate, read together, the essays create a coherent vision of the complexities of practicing medicine Gawande sees with the fresh perceptions of a novice. Unlike many physicians' narratives, however, Gawande's essays do more than tell a doctor's story.

In "Education of a Knife," for instance, Gawande begins writing as a novice anxiously learning from his chief resident how to insert a "central line." He lets us watch him nervously direct a "fat three-inch needle on a syringe" under the clavicle, insert the needle into the vena cava (the main blood vessel to the heart), widen the opening into the vein, and thread the catheter (the central line) into the blood vessel, all the while trying not to puncture the beating heart or the nearby lungs (p. 12). He silently wonders whether his imperiled patient realizes that he is his doctor's object lesson. A few pages later, Gawande is a father whose newborn son has a cardiac emergency. When the baby is discharged, a young doctor, who skillfully oversaw a team of surgeons and trainees during the hospitalization, expectantly offers Gawande his card and a follow-up appointment for the child. Gawande politely refuses both. Still a trainee himself, he selects for his child's care the hospital's expert associate cardiologist-in-chief. Her young colleague will practice on another patient.

Without excusing himself from the troubling inconsistencies his stories expose, Gawande aligns them with a central paradox of medicine: medicine demands practice; yet the need to practice counters "the imperative" to give each patient the best care (p. 24). Moreover, the errors that accompany practice are silenced. Almost twenty years ago, David Hilfiker memorably confessed several painful clinical mistakes, wishing to be released, and to release others, from "the yoke of perfection." ¹ Gawande's essays in "Fallibility" both advocate breaking the silence about errors and express doubt that it will be broken in the clinic, where "elisions of language" prevail (p. 24). These elisions disguise the potential harm to patients, who allow their bodies to be opened to the world when a resident says, "You need this procedure" without adding "I'm doing it for the first time." Gawande's book powerfully makes these clinical disguises visible to patients and others. Rather than releasing physicians from perfection, however, Gawande asks them to make perfection a habit. At the same time, he admits that perfection is problematic. A Harvard study of medical learning that he cites draws the easily convincing conclusion that improvements in training physicians are possible, but even accomplished practitioners fail before becoming experts. Without turning to scientific studies, Hilfiker hoped that doctors could face their mistakes through "confession, restitution, and absolution," a remedy that plangently concentrates on the ethical status of the physician. ² Gawande's discussion of medical error asks us to look unflinchingly at the whole complex medical system.

He invites the ethical reflection not only of doctors but also of their patients. Self-reflexively skeptical about patients' willingness to share the risks that medical training requires, Gawande imagines a stark structural remedy for such unfairness. "If choice cannot go to everyone," he concludes, "maybe it is better when it is not allowed at all" (p. 33). Such "cold hearted machinery," he believes, will both support learning and distribute risk justly (p. 32). His program for distributing risk makes those not practicing medicine but saturated with expectations for it—patients, families, oversight agencies, policy makers, funding...