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520 reviews for:
Complications: A Surgeon's Notes on an Imperfect Science by Atul Gawande
Atul Gawande, Atul Gawande
4.21 AVERAGE
520 reviews for:
Complications: A Surgeon's Notes on an Imperfect Science by Atul Gawande
Atul Gawande, Atul Gawande
4.21 AVERAGE
Interesting and insightful look at healthcare and doctor-patient relations from the perspective of a surgeon.
My fascination for all things related to the health care industry probably spurred my love of this book. The book focuses a great deal on root cause analysis, and spends the 1st section discussing the moral dilemma that as humans we are imperfect, yet imperfection is unacceptable in the medical field. It's a great blend of science, and philosophy.
Gawande is an incredibly observant and eloquent writer. I haven't had this much fun reading nonfiction in a long time.
Gawande is an incredibly observant and eloquent writer. I haven't had this much fun reading nonfiction in a long time.
I found the medicine bits a little boring (because I'm too familiar with them), but I love the way Gawande writes. The larger questions about appropriate use of medicine and of surgery, of the ethics of what doctors do, were thought provoking. Interesting case studies.
Complications impact every aspect of our life. We believe that we’ve got life all figured out, but then come the pesky complications to our orderly, perfect world. Atul Gawande speaks about medical complications in Complications: A Surgeon’s Notes on an Imperfect Science while simultaneously exposing the inner struggle that surgeons – and, indeed, anyone who provides care to another person – must struggle with. I’ve reviewed two of Gawande’s more recent books The Checklist Manifesto and Being Mortal – both are good and different from each other. They’re the reason I picked up Complications.
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Click here to read the full review
Great vignettes. Interest in medical field at all will help you appreciate these short stories. Overall, like a surgeon friend carefully giving you his view on things.
As a PT in training, especially interesting given our complicated relationship with surgery.
As a PT in training, especially interesting given our complicated relationship with surgery.
This was fascinating and really resonated with me. Dr. Gawande’s writing is very accessible and I think any reader will take away something valuable from reading this book.
informative
reflective
medium-paced
I wasn't sure how to rate this book. On one hand, ‘many chapters originated as articles’ and you can tell. It’s a set of essays that, although as pleasant to read as any of Gawande’s work, felt more like a random collection than a cohesive whole.
On the other hand, I have rarely read something that made me literally stop reading and go ‘yes, yes, oh my goodness he’s saying it exactly, oh wow he gets it, he has put words to what I’ve been feeling’ as the ‘Education of a Knife’ chapter, which details the paradox of medical learning: that the only way to learn practical skills is to practice on real people, and the sheer internal angst that produces. Reading it as a clinical medical student was a visceral experience. Gawande doesn’t provide any answers (I mean are there any?) but I have rarely felt so seen.
Gawande describes his first time putting in a central line. Forgetting steps. Trying to hide your inexperience from the patient. Missing it. Having to have the supervisor take over. Now I’ve never attempted a central line but I have still been there many times over.
John Green said ‘speak the truth even if your voice shakes’ or something very like that. In medicine it seems like a bad idea to ‘make the incision even if your hand shakes’ but that is what we have to do. I still cringe at the memory of my first suture on a real person. To begin with I messed up the local anaesthetic injection, something I didn't realise was even possible to get wrong. The A&E doctor let me do a single stitch but the angle was completely different to the flat, perpendicular pieces of plastic skin I’d practiced on and I couldn’t figure out how to hold the needle while leaning over the patient, stretched awkwardly almost on tiptoes over the bed, my body twisted. I still remember seeing my gloved hand shake as I did the stitch and being unable to stop them. I didn’t manage to go in and out twice like you’re supposed to. I literally forgot how to knot (the sheer panic actually made me lose the ability to tell what was forward and what was back and I had to be talked through it). It was not fun. My skin crawls at the memory.
Now I could’ve done more practice stitches on raw meat. But at some point I would have to have tried on a real person. And there is no guarantee that the prep will be enough. In fact, it probably won’t be. But I still have to learn. But I don’t want to learn on real people (and they sure as anything don’t want me learning on them either). But I don’t have a choice!
Gawande also writes of his third attempt at a central line ‘Again, it was stick, stick, stick, and nothing.’ He could be writing about my attempt at cannulas or taking blood. Pre-clinical years I assumed that taking blood was easy. Hey, no matter where you cut me I bleed (I must have vaguely known you aim for a vein but I think part of me thought ‘mosquitos seems to hit blood no matter where they land’ and extrapolated from there). But it turns out it’s actually a skill you have to learn to be able to do? And the only way to get better is to practice on real people?! Get outta here.
Atul Gawande lays out what Matt McCarthy calls the ‘black-comic paradox of becoming a doctor: How do you learn to save lives in a job where there is no practice?’ so, so well in this chapter. It’s the choice between ‘the patient should have the experienced person do the procedure’ and ‘if the unexperienced person never does a procedure all the people with experience will die and the medical profession will be over’ which is really not much of a choice at all. I always I want to land on the side of that patient right in front of me and not do the procedure. I’m scared. And, more than that, I’m bad at that thing. Of course I am, I’ve never done it before on a real person. But this real person right in front of me is unwell so it doesn’t really seem fair to land them with this as well.
Wait, what do you mean this is medicine, they’re all sick?
Of course, the senior can pick a patient who is an easy candidate for that procedure (nice big veins, textbook anatomy, etc) but even on the perfect person it’s your first time doing it and you are not the optimal choice.
Gawande writes that ‘In surgery, as in anything else, skill and confidence are learned through experience –haltingly and humiliatingly. Like the tennis player and the oboist and the guy who fixes hard drives, we need practice to get good at what we do. There is one difference in medicine, though: it is people we practice upon.’ How is that okay? How is that possibly a good system? Well, because there is no choice but to do it that way. But it’s awful! For both the patient and me agonising over it. And it felt very precious to me to have that articulated by someone else, to have someone put the words to the gut wrenching feeling that turns my stomach every time someone asks me if I want to try a practical procedure and I think ‘well, not really, but I haven’t got a choice.’ The only way to the other side where competence lies is through the valley of incompetence, but that process is emotionally painful for me, and physically painful for the poor person at the other end of my needle or NG tube or catheter.
‘If I had a clear idea of what I was doing wrong, then maybe I’d have something to focus on. But I didn’t.’ says AG. Imagine just sticking a needle in someone and hoping for the best. Welcome to my experience. I want to get better! I am not enjoying this any more than the patient (it feels very wrong to say even less, but when you fail at venepuncture it may only mean one more scratch for them but I have cried actual tears. Maybe I’ll leave it at we’re both suffering, in different ways.) What is harder is that the learning curve is not merely up. You make some movements forward, but then you fail again. You hit the vein and then you don’t. You don’t know what you did differently between patient X and Y but X worked and Y didn’t. And then Z didn’t either. It’s discouraging.
I can hope this gets better in the future with better models. We do have plastic arms we can practice venepuncture on before hitting the wards but it is not perhaps surprising that even though the arms look realistic from a distance, the texture of plastic with some tubing inside is not all that similar to flesh. But medical engineering continues and no doubt someone will come up with some (probably prohibitively expensive and single use) bio-plastic that is just like the real thing. That would genuinely go some way to addressing this inevitability.
But for now, there just isn’t that. So I just have to deal with that? (I mean, the patients too, but how many people say directly ‘yo man, this is my first time’? Not many, me included.) So I have both the heavy guilt of knowing the patient is getting a sub-par experience but the pressing weight of ‘you have to take opportunities because in not too long it will be you alone with no guidance having to do this and imagine that poor patient then.’ It is not a comfortable place to sit. I don’t know how I’m meant to balance these two things. Either I become hardened to the patient before me to protect my own feelings or I remain too soft and never learn how to be a doctor. Obviously I should land somewhere in the middle, but no matter where on that spectrum I land I am uncomfortable. It feels like the train track problem. This patient here before me (and, let’s be real, probably many more until any level of competence is achieved) vs the many theoretical future patients. Immediacy vs impact.
Atul Gawande lays this problem out so, so well in this chapter. Quotes that will stay with me regarding this were:
-‘We find it hard, in medicine, to talk about this with patients. The moral burden of practicing on people is always with us, but for the most part unspoken’… ‘Not to worry. I just assist,’ I say…. Yet to say I just assisted remains a kind of subterfuge. I wasn’t merely an extra pair of hands…I was there to help, yes but I was there to practice, too.’
-‘In medicine we have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm through supervision and graduated responsibility… Studies generally find teaching hospitals have better outcomes than non-teaching hospitals…But there is still no getting around those first few unsteady times a young physician tries to put in a central line, remove a breast cancer or sew together two segments of colon. No matter how many protections we put in place, on average these cases go less well with the novice than with someone experienced. …. This is the uncomfortable truth about teaching. … a patient’s right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden, behind drapes and anaesthesia and the elisions of language.
-‘By the 1980s [it was] possible to do a switch operation safely. In 1986, the Great Ormond Street surgeons made the changeover, and their report shows that it was unquestionably a change for the better. The annual death rate after a successful switch procedure was less than a quarter…resulting in a life expectancy of 63 instead of 47. But the price of learning to do it was appalling. In their first 70 switch operations, the doctors had a 25% death rate compared with just 6 percent with the [previous] procedure. (18 babies died, more than twice the number of the entire Senning era.) Only with time did they master it: in their next hundred switch operations, just 5 babies died. As patients, we want both expertise and progress. What nobody wants to face is that these are contradictory desires. In the words of one British public report, ‘There should be no learning curve as far as patient safety is concerned.’ But that is entirely wishful thinking.’
I cannot tell you how validating that chapter felt to me. Even if there are no answers to the problem, to know you are not alone in your feelings is a precious gift. It is the magic of books, and I have rarely felt it so acutely as I did reading this chapter. It was as if someone had taken my ill-formed anxieties swirling round in muddled confusion and laid them out neatly on a page. For that reason, I give the book five stars.
On the other hand, I have rarely read something that made me literally stop reading and go ‘yes, yes, oh my goodness he’s saying it exactly, oh wow he gets it, he has put words to what I’ve been feeling’ as the ‘Education of a Knife’ chapter, which details the paradox of medical learning: that the only way to learn practical skills is to practice on real people, and the sheer internal angst that produces. Reading it as a clinical medical student was a visceral experience. Gawande doesn’t provide any answers (I mean are there any?) but I have rarely felt so seen.
Gawande describes his first time putting in a central line. Forgetting steps. Trying to hide your inexperience from the patient. Missing it. Having to have the supervisor take over. Now I’ve never attempted a central line but I have still been there many times over.
John Green said ‘speak the truth even if your voice shakes’ or something very like that. In medicine it seems like a bad idea to ‘make the incision even if your hand shakes’ but that is what we have to do. I still cringe at the memory of my first suture on a real person. To begin with I messed up the local anaesthetic injection, something I didn't realise was even possible to get wrong. The A&E doctor let me do a single stitch but the angle was completely different to the flat, perpendicular pieces of plastic skin I’d practiced on and I couldn’t figure out how to hold the needle while leaning over the patient, stretched awkwardly almost on tiptoes over the bed, my body twisted. I still remember seeing my gloved hand shake as I did the stitch and being unable to stop them. I didn’t manage to go in and out twice like you’re supposed to. I literally forgot how to knot (the sheer panic actually made me lose the ability to tell what was forward and what was back and I had to be talked through it). It was not fun. My skin crawls at the memory.
Now I could’ve done more practice stitches on raw meat. But at some point I would have to have tried on a real person. And there is no guarantee that the prep will be enough. In fact, it probably won’t be. But I still have to learn. But I don’t want to learn on real people (and they sure as anything don’t want me learning on them either). But I don’t have a choice!
Gawande also writes of his third attempt at a central line ‘Again, it was stick, stick, stick, and nothing.’ He could be writing about my attempt at cannulas or taking blood. Pre-clinical years I assumed that taking blood was easy. Hey, no matter where you cut me I bleed (I must have vaguely known you aim for a vein but I think part of me thought ‘mosquitos seems to hit blood no matter where they land’ and extrapolated from there). But it turns out it’s actually a skill you have to learn to be able to do? And the only way to get better is to practice on real people?! Get outta here.
Atul Gawande lays out what Matt McCarthy calls the ‘black-comic paradox of becoming a doctor: How do you learn to save lives in a job where there is no practice?’ so, so well in this chapter. It’s the choice between ‘the patient should have the experienced person do the procedure’ and ‘if the unexperienced person never does a procedure all the people with experience will die and the medical profession will be over’ which is really not much of a choice at all. I always I want to land on the side of that patient right in front of me and not do the procedure. I’m scared. And, more than that, I’m bad at that thing. Of course I am, I’ve never done it before on a real person. But this real person right in front of me is unwell so it doesn’t really seem fair to land them with this as well.
Wait, what do you mean this is medicine, they’re all sick?
Of course, the senior can pick a patient who is an easy candidate for that procedure (nice big veins, textbook anatomy, etc) but even on the perfect person it’s your first time doing it and you are not the optimal choice.
Gawande writes that ‘In surgery, as in anything else, skill and confidence are learned through experience –haltingly and humiliatingly. Like the tennis player and the oboist and the guy who fixes hard drives, we need practice to get good at what we do. There is one difference in medicine, though: it is people we practice upon.’ How is that okay? How is that possibly a good system? Well, because there is no choice but to do it that way. But it’s awful! For both the patient and me agonising over it. And it felt very precious to me to have that articulated by someone else, to have someone put the words to the gut wrenching feeling that turns my stomach every time someone asks me if I want to try a practical procedure and I think ‘well, not really, but I haven’t got a choice.’ The only way to the other side where competence lies is through the valley of incompetence, but that process is emotionally painful for me, and physically painful for the poor person at the other end of my needle or NG tube or catheter.
‘If I had a clear idea of what I was doing wrong, then maybe I’d have something to focus on. But I didn’t.’ says AG. Imagine just sticking a needle in someone and hoping for the best. Welcome to my experience. I want to get better! I am not enjoying this any more than the patient (it feels very wrong to say even less, but when you fail at venepuncture it may only mean one more scratch for them but I have cried actual tears. Maybe I’ll leave it at we’re both suffering, in different ways.) What is harder is that the learning curve is not merely up. You make some movements forward, but then you fail again. You hit the vein and then you don’t. You don’t know what you did differently between patient X and Y but X worked and Y didn’t. And then Z didn’t either. It’s discouraging.
I can hope this gets better in the future with better models. We do have plastic arms we can practice venepuncture on before hitting the wards but it is not perhaps surprising that even though the arms look realistic from a distance, the texture of plastic with some tubing inside is not all that similar to flesh. But medical engineering continues and no doubt someone will come up with some (probably prohibitively expensive and single use) bio-plastic that is just like the real thing. That would genuinely go some way to addressing this inevitability.
But for now, there just isn’t that. So I just have to deal with that? (I mean, the patients too, but how many people say directly ‘yo man, this is my first time’? Not many, me included.) So I have both the heavy guilt of knowing the patient is getting a sub-par experience but the pressing weight of ‘you have to take opportunities because in not too long it will be you alone with no guidance having to do this and imagine that poor patient then.’ It is not a comfortable place to sit. I don’t know how I’m meant to balance these two things. Either I become hardened to the patient before me to protect my own feelings or I remain too soft and never learn how to be a doctor. Obviously I should land somewhere in the middle, but no matter where on that spectrum I land I am uncomfortable. It feels like the train track problem. This patient here before me (and, let’s be real, probably many more until any level of competence is achieved) vs the many theoretical future patients. Immediacy vs impact.
Atul Gawande lays this problem out so, so well in this chapter. Quotes that will stay with me regarding this were:
-‘We find it hard, in medicine, to talk about this with patients. The moral burden of practicing on people is always with us, but for the most part unspoken’… ‘Not to worry. I just assist,’ I say…. Yet to say I just assisted remains a kind of subterfuge. I wasn’t merely an extra pair of hands…I was there to help, yes but I was there to practice, too.’
-‘In medicine we have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm through supervision and graduated responsibility… Studies generally find teaching hospitals have better outcomes than non-teaching hospitals…But there is still no getting around those first few unsteady times a young physician tries to put in a central line, remove a breast cancer or sew together two segments of colon. No matter how many protections we put in place, on average these cases go less well with the novice than with someone experienced. …. This is the uncomfortable truth about teaching. … a patient’s right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden, behind drapes and anaesthesia and the elisions of language.
-‘By the 1980s [it was] possible to do a switch operation safely. In 1986, the Great Ormond Street surgeons made the changeover, and their report shows that it was unquestionably a change for the better. The annual death rate after a successful switch procedure was less than a quarter…resulting in a life expectancy of 63 instead of 47. But the price of learning to do it was appalling. In their first 70 switch operations, the doctors had a 25% death rate compared with just 6 percent with the [previous] procedure. (18 babies died, more than twice the number of the entire Senning era.) Only with time did they master it: in their next hundred switch operations, just 5 babies died. As patients, we want both expertise and progress. What nobody wants to face is that these are contradictory desires. In the words of one British public report, ‘There should be no learning curve as far as patient safety is concerned.’ But that is entirely wishful thinking.’
I cannot tell you how validating that chapter felt to me. Even if there are no answers to the problem, to know you are not alone in your feelings is a precious gift. It is the magic of books, and I have rarely felt it so acutely as I did reading this chapter. It was as if someone had taken my ill-formed anxieties swirling round in muddled confusion and laid them out neatly on a page. For that reason, I give the book five stars.
This book was excellent. Well-written and so interesting (if you're into medicine and surgery). His honesty on doctors, medicine/surgery and patients made for a great read.
emotional
informative
inspiring
reflective