Insights from Complications

Atul Gawande’s Complications is a tour of the medical system through the lens of a series of case studies. The cases are interspersed with semi-philosophical commentary. The prose is easy to read. Here are some insights that the book gave me (note that the book is from 1999, so some of this stuff might be false):

• Some part of being a doctor is solving body-based engineering problems. Patients will have various issues (“there is lots of fluid where it shouldn’t be”), and doctors will have to solve them (“if we put a piece of tubing into that place, then the fluid will go away”). Since the number of possible medical problems is large, this solving must happen even in cases where there is a known “best practice” because there are too many problems for doctors to know all the best practices.
• There is a tragedy of the commons type problem for surgical education. Learning how to do surgery involves practice, but people who are practicing are less good at the surgery than people who have lots of experience. People getting surgery only want surgery from the most experienced people, but everyone is better off if surgeons learn to do surgery by practicing. The way that this is solved is that the hospitals just have the students practice and patients aren’t given much of a choice. When a doctor’s family needs surgery, there are probably going to only be experienced surgeons. Quoted surgery complication rates are often for experienced practitioners, which the particular people doing that surgery might not be.
• Various medical facilities specialize in particular surgeries. The Shouldice Hospital outside Toronto specializes in fixing hernias. Usually, this surgery takes 1.5 hours and fails with more than 10%. At Shoudice, it takes 45 minutes and fails with 1 percent. The probable reason for this is that surgeons at Shouldice do more hernia surgeries a year than most surgeons do in their lifetimes. [Insert comment about how the lack of such specialization in the current medical system more broadly seems insane, but whatever]
• Anesthesiology used to have a high death rate because it was insane. For example, different machines administering anesthetics used to raise or lower the dose upon turning the dial clockwise. Also sometimes people got their breathing tube put into their stomachs instead of their lungs and they died. These problems were eventually fixed when some engineer named Pierce made a fuss to standardize instruments and also checking blood oxygen levels to see if you put the breathing tube in right. This isn’t specific to anesthesiology. The rate of surgery done on the wrong side of the body was lowered when people started initialing the correct side with a marker. [AHHHHHHHHHHHH]
• There is a surgeon convention with ten thousand surgeons about once a year. The schedule is over 300 pages. There are about 5000 salespeople at this convention. This convention has its own daily newspaper.
• Nausea might be for your body getting rid of toxins. Morning sickness (when pregnant women get nauseous easily) is explained by babies being particularly susceptible to small doses of toxins. Nausea from things like rollercoasters and other weird movements is explained by the perception of weird movements being a common effect of toxin hallucinogens.
• Autopsies reveal that a large number of diagnoses were incorrect (one study said 40%). We don’t really do them that much anymore. We also don’t really keep detailed records on what diagnoses were wrong and why. [why does nothing work at all?]
• Morbidity and mortality (M&M) conferences are small weekly conferences held by hospitals to discuss medical mistakes that were made and how to make less of them. Proceedings are kept confidential by law. [yay]
• Being a doctor involves a bunch of soft skills like talking patients through choices. Patients are allowed to make their own choices about treatment, but doctors often try to encourage various choices through persuasion. [not sure how I feel about this one. clearly the person doing the persuading shouldn’t be the same person doing all the other stuff though]

Here are some quotes that I liked:

As one professor of surgery put it to me, given a choice between a Ph.D. who had painstakingly cloned a gene and a talented sculptor, he’d pick the Ph.D. every time. Sure, he said, he’d bet on the sculptor being more physically talented; but he’d bet on the Ph.D. being less “flaky.” And in the end that matters more. Skill, surgeons believe, can be taught; tenacity cannot.

I asked Byrnes Shouldice, a son of the clinic’s founder and a hernia surgeon himself, whether he ever got bored doing hernias all day long. “No,” he said in a Spock-like voice. “Perfection is the excitement.”

The first documented postmortem examination in the New World was actually done for religious reasons, though. It was performed on July 19, 1533, on the island of Espanola (now the Dominican Republic), upon conjoined female twins connected at the lower chest, to determine if they had one soul or two. The twins had been born alive, and a priest had baptized them as two separate souls. A disagreement subsequently ensued about whether he was right to have done so, and when the “double monster” died at eight days of age, an autopsy was ordered to settle the issue. A surgeon, one Johan Camacho, found two virtually complete sets of internal organs, and it was decided that two souls had lived and died.

Please note that some of the links referenced in this work are no longer active.