I recently picked up Atul Gawande’s Complications: A Surgeon’s Notes on an Imperfect Science in a bookstore in Philly. I thought I already had a favorite Indian doctor-writer in Abraham Verghese, but Gawande gives Verghese a run for his money in this excellent, thought-provoking book.
Complications is essentially a warts-and-all portrait of the field of medicine in the U.S. for lay readers. It’s built on extensive research and interviews as well as Gawande’s own experience as a surgeon at Harvard. Gawande’s overarching interest is in what can be done to reform the practice of medicine from within. It’s fitting that Malcolm Gladwell has a blurb on the back of the book, since Gladwell’s detail-oriented, problem-solving method clearly resesmbles Gawande’s in many ways.
Complications has been a success — it was a National Book Award Finalist. In 2003, Gawande was invited to do the commencement address at the Yale School of Medicine, which is a pretty remarkable honor for a young doctor. He’s also written a number of times for the New Yorker (try here and here), as well as the New England Journal of Medicine, where he published an influential article about casualty rates in the ongoing Iraq war. Professional humility is the starting point for many of Gawande’s examples in Complications. He writes, with nail-biting fluidity, about a potentially catastrophic mistake he himself made as a young surgical resident (he masks some details, presumably to protect himself from liability). It turns out that another doctor was able to save the situtation, but one sees that it easily could have gone the other way. Gawande mentions it to illustrate one of his central points — that all doctors inevitably make mistakes:
There is . . . a central truth about medicine that complicates this tidy vision of misdeeds and misdoers: all doctors make terrible mistakes. . . . If error were due to a subset of dangerous doctors, you might expect malpractice cases to be concentrated among a small group, but in fact they follow a uniform, bell-shaped distribution. Most surgeons are sued at least once in the course of their careers. Studies of specific types of error, too, have found that repeat offenders are not the problem. The fact is that virtually everyone who cares for hospital patients will make serious mistakes, and even commit acts of negligence, every year. For this reason, doctors are seldom outraged when th epress reports yet another medical horror story. They usually have a different reaction: That could be me. The important question isn’t how to keep bad physicians from harming patients; it’s how to keep good physicians from harming patients.
Note that he’s not just pointing out that “all doctors make terrible mistakes” to try and let them off the hook. Rather, he wants to acknowledge the fact and deal openly with the mistakes that are most commonly made so as to reduce their frequency. Though Gawande doesn’t come out strongly on the question of tort reform in Complications, it’s clear that he doesn’t think that a strictly legal response to failures and mistakes by doctors (or the system) is likely to improve how well doctors do. He states it well in this New Yorker interview:
What is the toll of malpractice on doctors?
The financial toll is under one per cent of our expenses. The real toll, I think, is in two places. One is in hindering our ability to honestly address injuries to patients from complications. There are two or three per cent of patients who will be hurt by serious complications in care; about half of those will be the result of error. And because these cases have the potential to become all-out battles in court, we often lose our human instincts to apologize, to grieve, to still be doctors for our patients. The other cost is in our ability to improve. Almost every case, when it’s settled, is sealed, and it can become hard to know what the patterns of failure in medicine are. In the airline industry, if there’s an accident, they can do an investigation and share information and figure out when there are certain patterns that suggest what things can be done to improve safety. We really haven’t been able to do that. (link)
Instead of simply turning it over to the legal system, Gawande is interested in expanding the processes that doctors themselves have evolved for analyzing their mistakes and fostering a sense of accountability via feedback networks and candid self-criticism (he’s big on surgical “M&M” meetings, for instance).
While the first half of Complications deals more with surgery, the second half is more general — case studies and interesting problems that have cropped up in recent years. One involves a patient suffering from chronic pain, and explores some of the recent advances in pain-psychiatry that have been made; another tells the story of a pregnant woman who had extremely severe nausea (hyper-emesis); and a third deals with a television newscaster who had a severe case of uncontrollable blushing. These case studies generally go beyond the mere “human interest” angle; in each case, Gawande uses the example to discuss some recent advances in the science.
Medical malpractice reform is a complex issue, and as an outsider I’m far from well-equipped to say “here is what should be done.” So here are some starter links.
1) One recent study has questioned the claim (common among those who favor caps) that frivolous malpractice litigation has reached crisis proportions.
2) Another study has questioned whether introducing “pain and suffering” liability caps would actually significantly reduce costs.
3) And another study I came across suggests that the current system encourages doctors to be so defensive that they order lots of unnecessary tests, which increases insurance costs and makes the whole system more expensive.
4) Finally, a bill has been introduced in the U.S. Senate (S.22) that would put caps on Pain and Suffering (non-economic) damages; Senator Ted Kennedy has given his detailed response, which makes a number of good points. [UPDATE: The bill was defeated]
Great post. I read his book as an M1 and am always happy to see his articles in NEJM. His most recent one discussed the ethics of involving doctors in executions.
As a side note, I think S22 and its counterpart S23 were both defeated in the Senate on Monday? I was at the American College of Obstetricians and Gynecologists annual meeting in DC and they actually sent over busloads of doctors to rally on capitol hill, then sit in for the vote. S23 was the bill specifically to limit awards against obs, who have been the most hard hit by medmal lawsuits. As a future ob/gyn this is obviously something I can’t be objective about, but I will say this: in IL where I’m from the malpractice premiums are so high there are only 2 practicing obstetricians in the county where I grew up. To discount these bills as saying they’re simply protecting negligent doctors and greedy insurance companies trivializes the patient access issue that’s at stake here.
It’s so sad. I’m going into ob/gyn and although I love obstetrics, I’m planning a future in a gyn specialty because I’m too leery of the liability in ob. My friends and I sort of half-joke about how there will be no more obstetricians around to deliver the babies when we all get around to having kids.
(That was rambly and way off topic, I have to disengage now, but thanks for the post!)
Rupa, Thanks for the update — I hadn’t seen anything about the result of the vote, which surprisingly received no mainstream media coverage whatsoever. Here are some more details for the politically-minded.
Pennsylvania (where I live) is having similar problems with doctors leaving the state and many medical students choosing to not to specialize in high-liability areas.
I know, all I saw was a quick blurb buried in NYT, and a quick online search didn’t yield anything. It is the 3rd time in the last 4 years such a bill has been shot down, so it’s probably not even that newsworthy anymore.
It’s funny, because Republicans have been talking about this for years; it was one of Bush’s main campaign planks in 2004, and since they control the Congress and the Executive, you’d think they would have made this happen by now if they really wanted to. But I suspect they are worried about giving the Dems a populist campaign issue this year — which is why several prominent Republican senators actually voted against the bills, while others didn’t bother to show up to vote.
Perhaps the plan is to continue taking campaign contributions from doctors, and milk this for as long as they can without paying the political price… (The Dems of course do this too on their own issues.)
yeah! one of my fave medico-authors being on SM 🙂 thanks amardeep… his writing style is excellent and really insightful into the surgery world (more than ER/Grey’s Anatomy combined)… similar to intern blues written by (can’t recall at the present moment… one of those books like ‘house of god’ which is somewhat of a rites of passage read for those entering the medical field…
as for defensive medicine… i think we do order more than we need to cover our bums…and with malpractice insurance rates sky high, several docs (esp ob/gyn, one of the most expensive along with neurosurgery) have had to quit practicing since it is pretty damn impractical….
in my field there is luckily a lower rate of malpractice, and the tests we order are for treatment purposes…you know it was one of the things that went through my head when i decided which field of medicine to pursue…which one had lower incidences vs. high incidences…although not the final deciding factor.. it did play a role…
You know when Kaavya V was on here, all the wannabe brown writer types went insane with jealousy?
This is my equivalent moment. I would like to be alone now, I don’t feel talking to anyone.
I wonder what the docs/residents/med students on SM think of this so called movement
I think Gawande is generally in favor of a policy of more disclosure of error and less secrecy, though he balks a little at the word “apology.” He has this to say in the same interview in the New Yorker online that I linked to before:
Instead of simply turning it over to the legal system, Gawande is interested in expanding the processes that doctors themselves have evolved for analyzing their mistakes and fostering a sense of accountability via feedback networks and candid self-criticism (he’s big on surgical “M&M” meetings, for instance).
I haven’t read the book and don’t know the guy, but internal accountability measures rarely work as strongly in the interests of outsiders affected, in my opinion. For example, New York has no truly independent agency to monitor the police (it has the Civilian Complaint Review Board, which is a sham). I would imagine doctors would be a bit better, but not all that much.
I think the litigiousness of it all has to do more with the fact that people are constantly screwed over by insurance companies and the byzantine health care administrative procedures in the U.S. in general–and that includes doctors, patients, and everyone in between. Ultimately, the only way to solve this is probably to reduce paperwork, put medical decisions in the hands of medical professionals and their patients, and eliminate annoying middlement controls in favor of financial accountability measures that are not predicated on making sure insurance companies don’t lose any power.
Also, as a child of two doctors, I can tell you that it’s perfectly possible to be a caring and decent doctor even with the threat of malpractice hanging over your head. Neither of them were surgeons though.
I haven’t read the book and don’t know the guy, but internal accountability measures rarely work as strongly in the interests of outsiders affected, in my opinion. For example, New York has no truly independent agency to monitor the police (it has the Civilian Complaint Review Board, which is a sham). I would imagine doctors would be a bit better, but not all that much.
Yes, I see what you mean. He favors them because they are technical and dispassionate, but one can imagine cases where it would be in their best interest not to be as rigorous as possible. Gawande, for his part, never says that he thinks that the threat of litigation should be taken out of the system, but rather that it should be coupled to a feedback mechanism that considers doctors as essentially ‘good,’ (committed ethical professionals), and aims to make them better than they were before rather than knock them out of practice. Information openness might also provide data at that could be used to improve the system as a whole (as has happened case of the cerebral palsy treatment centers Gawande talks about in one of the New Yorker articles).
BB, once you’re done moping about not being as big a rockstar as Atul Gawande, it would be interesting to hear your perspective on some of these issues 😉
since we’re talking about medical literature..here is a review in the NYT for a new book written by a female brainsurgeon, dr. katrina firlik... pretty cool beans.. now neurosurgery is an old boys network if i ever did see one… kudos to her…
Since there are so many medical doctors on this site, I read that a baby born today will have a life expectancy of 140 years old. So thank you in advance Doctors of the world for making the new retirement age of 110 years old. Cheers to all of you for that, I really mean it. One hell of a job you guys are doing. Seriously
Gawande, for his part, never says that he thinks that the threat of litigation should be taken out of the system, but rather that it should be coupled to a feedback mechanism that considers doctors as essentially ‘good,’ (committed ethical professionals), and aims to make them better than they were before rather than knock them out of practice. Information openness might also provide data at that could be used to improve the system as a whole (as has happened case of the cerebral palsy treatment centers Gawande talks about in one of the New Yorker articles).
This isn’t unreasonable. However, don’t doctors already have their own processes for decertifying people? I really don’t know.
If they were to take an aggressive stance towards malpractice that included patients and others in the process, they might be able to reduce the anger that people have over the long run (kind of like alternative incarceration). The jury awards might go down by themselves then (and at that point the doctors could bitch out the malpractice insurance companies b/c the premiums would be out of whack with the jury awards).
i’ve been meaning to read gawande’s “complications” for awhile now, this entry made me wanna finally take the plunge.
didn’t realize there were mutineers in philly…since everyone else always suggests it, i’m gonna say it this time–philly meetup!
Sparky, I’m down. I know one desi blogger in Philly — Salas from Philadelphia Metroblogs.
But I don’t know anyone else… A meetup of three may be small but it’s a start.
a few things–I am almost always a silent observer, but I feel compelled to comment…
1) “sorry works” is a really important concept in medicine now, i think–so much so that at my hospital, we are actively encouraged by our attendings (when there is a major medical error–I’ve seen one so far) to be honest, ‘fess up, and let the *&it fly where it may. Why? Because studies have shown that accountability and honesty go quite far in reducing malpractice cases–aside from being the morally appropriate, decent human thing to do.
2) “Complications” is a great read–I read it about two years ago and loved it. All med students should be required to read it so they know what they’re getting into, whether they’re going into surgery or not (I’m in Peds)…the world out there is raw. Don’t forget it.
3) Doctors do have methods of self-policing…if a really flagrant error (or even not-so-flgrant, to be honest), these things spread like wildfire through the hospital. When the “powers that be” are made aware (normally sooner rather than later), there are normally meetings and meetings–and if it’s bad enough, or has happened at a suspicious frequency, stuff starts happening: from warnings to suspension to being fired to having your license revoked. However, sometimes the system isn’t reactive enough–sometimes a LOT of “little things” need to happen before it’s brought up.
4) A random thought: how many times do physicians order tests not because they think something is really clinically needed, but more “just in case”? (Answer: VERY, VERY OFTEN) Think about how much money the system would save if we could just go with our gut instincts and eliminate the “cover your a___” tests?
there are a few SM philly bloggers that i know… i’m sure you can gather up a handful… :)..
amardeep, yay! i’m gonna be away this summer, but will be back in august…so in the meantime, more philly SM’ers can come out of the closet. 🙂