Complications: A Surgeon’s Notes on an Imperfect Science

A Swedish study in 1996 tested the expertise of a specialist physician against the accuracy of a computer in diagnosing a heart attack from an EKG. Gawande explains how medical students learn to decode often subtle variations in EKGs to assess whether a patient is having a heart attack, and he lays out the statistical frequency and consequences of misdiagnosis to introduce the motivation for finding the most accurate way to diagnose a condition like a heart attack. The computer, he reveals, outperformed the doctor by 20%.

Gawande expresses the guiding principle of this essay: “Western medicine is dominated by a single imperative—the quest for machinelike perfection in the delivery of care” (37). He then offers multiple examples to support the fact that this quest exists and, in many cases, returns favorable results. The Shouldice Hospital in Toronto boasts statistics-defying speed and success rates for hernia operations because it’s the only procedure the hospital offers. Gawande visits Shouldice to observe surgeries and interviews doctors. His experience there challenges the traditional approach to becoming a surgical specialist, and he asks: “Depending on the area of specialization, do you—and this is the question posed by the Swedish EKG study—even have to be human?” (41).

In wondering about the human element to diagnosis, Gawande presents two of his personal experiences side-by-side. In both stories, he relies on his intuition rather than the obvious signs to diagnose a patient with appendicitis. In one case, he was right; in the other, he was wrong. He cites a study in Paul Meehl’s 1954 book Clinical Versus Statistical Prediction, which determined that an algorithmic formula was more accurate in predicting a prisoner’s likelihood to violate parole than were psychiatrists’ predictive evaluations. Of the studies reviewed by Meehl, Gawande says that the statistical approach came out equal to or better than human judgment in “virtually all” cases. Gawande lists the reasons for human inferiority, which include humans being “easily influenced by suggestion” and bad at “considering multiple factors” (44).

Despite acceptance in the medical community that treatment improves with specialization and routinization, there’s still resistance to turning diagnosis over to computers. Gawande surmises that technology may not be antithetical to the doctor-patient relationship because, “On the simplest level, nothing comes between patient and doctor like a mistake” (45).

Gawande recounts a detailed story of a time he made a mistake that almost cost a patient her life. The patient arrived in the emergency room, unconscious, after surviving an automobile accident. When another doctor had trouble inserting a breathing tube in her throat, causing her to rapidly lose oxygen, Gawande attempted to perform an emergency tracheotomy—an incision in the neck to pierce the trachea and allow for the insertion of a breathing apparatus. Gawande pauses the storytelling to reflect on the challenges he faced and the mistakes he made: “If I had actually thought this far along, I would have recognized how ill-prepared I was to do an emergency ‘trache’” (51). Ultimately, another doctor successfully took over the operation, and the patient lived.

Gawande segues into a broader discussion about medical error. He offers statistical and anecdotal evidence to support that “dangerous doctors” are not the only perpetrators of mistakes: “The fact is that virtually everyone who cares for hospital patients will make serious mistakes, and even commit acts of negligence, every year” (56). He argues that medical malpractice lawsuits are ineffective tools to correct the problem of error: “The deeper problem with medical malpractice suits is that by demonizing errors they prevent doctors from acknowledging and discussing them publicly” (57).

Doctors do, however, speak openly at morbidity and mortality (M&M) conferences. M&Ms are institutions at teaching hospitals that protect discussions of error from legal discovery and offer a formalized, weekly process to address errors in patient care. He evaluates its virtues: “the M & M is an impressively sophisticated and human institution. Unlike the courts or the media, it recognizes that human error is generally not something that can be deterred by punishment” (62). He also acknowledges that it’s full of contradiction: “On the one hand, it reinforces the very American idea that error is intolerable. On the other hand, the very existence of the M & M, its place in the weekly schedule, amounts to an acknowledgement that mistakes are an inevitable part of medicine” (62).

Gawande moves to a discussion of human error, propped up by research that suggests “disasters do not simply occur; they evolve. In complex systems, a single failure rarely leads to harm” (63). This idea leads Gawande to critique the M&M for viewing error as the result of individuals and not process.

Gawande presents the field of anesthesiology as a successful example of a system that reduced error as a result of critical analysis and systemic improvement from an unbiased researcher: a non-physician: “In a decade, the overall death rate dropped to just one in more than two hundred thousand cases—less than a twentieth of what it had been” (68). Surgery, Gawande suggests, would benefit from a similar approach.

Gawande closes with a story of a time when he nearly made a life-threatening error in a routine gallbladder procedure but caught himself just in time, saying, “I may have averted disaster this time, but a statistician would say that no matter how hard I tried, I was almost certain to make this error at least once in the course of my career” (72). Gawande reflects that, while data shows that many errors in medicine are indeed systems errors, individuals must still strive for human perfection: “The statistics may say that someday I will sever someone’s main bile duct, but each time I go into a gallbladder operation I believe that with enough will and effort I can beat the odds” (73).

In this essay, Gawande recounts how, in his sixth year of residency, he was surprised and delighted to be finally invited to the annual Congress of Surgeons. The convention took place in Chicago and was attended by over 9,000 surgeons from around the world. In Gawande’s telling of the story, he arrives at the convention wide-eyed and eager to learn. He has trouble choosing among the abundant attractive events in his program, eventually attending a lecture about hernias in which doctors hotly debate best practices and a movie theater screening of filmed operations that leave Gawande awestruck.

Gawande pokes fun at the components of the convention, namely the large “technical exhibit,” which features performative salespeople hawking high-tech wares. Though slightly wary of the salesmanship, Gawande finds himself genuinely interested in investigating a new kind of artificial skin, testing out “electronic scalpels that cut through tissue with ultrasonic waves” (80), and watching a live feed of an off-site surgery featuring a cutting-edge device. He also stumbles upon an unassuming exhibit of old documents written by surgeons throughout history. Gawande is amazed when he attends a presentation on tissue engineering, whereby organ tissue is grown in laboratories.

Gawande admits that the surgeons’ convention is characterized not just by high-minded individuals seeking knowledge but also by the same commercial and social motivations that drive people of all professions to attend conventions. However, he walks away heartened by the bonding conversations he has with other surgeons on the convention buses. Surgeons, he says, largely experience isolation as a result of their profession and enjoy the opportunity to experience community.

Gawande profiles a doctor whom he calls Dr. Hank Goodman and whose story is emblematic of bad doctors, most of whom aren’t violent “monsters” but rather regular doctors who exhibit drastic changes in their professional behavior. Gawande introduces Goodman plainly:

Hank Goodman is a former orthopedic surgeon. He is fifty-six years old and stands six feet one, with […] outsize hands that you can easily imagine snapping a knee back into place. He is calm and confident, a man used to fixing bone (88).

Gawande traces Goodman’s upbringing, his overnight decision to go into medicine, his military career, and his experience in a top orthopedics-residency program. He immediately became a star at the clinic, won an award, and seemed to enjoy the job. Eventually, however, Goodman changed: “the only thing he thought about was getting through all his patients as quickly as possible” (93).

Gawande presumes to understand one possible cause of Gawande’s shift: The more popular he became, the more surgeries he took on, the more money he made, and the higher he set his standard for professional worth. His reputation as “the guy who never said no” made it difficult for him to turn away work (93). Eventually he started cutting corners and refusing to fix mistakes. He became a danger to his patients.

Gawande offers statistics about doctors who experience burnout, suffer mental disorders and addiction, or merely become “ill, old, and disaffected, or distracted by their own difficulties” (95). He then addresses the challenges in the structure of medical workplaces and in medical culture that make it difficult to spot, confront, and remove problematic doctors. Gawande suggests that some doctors do nothing out of laziness; other times, the reason “is that no one really has the heart for it” (93). He says, “when people try to help, they usually do it quietly, privately. Their intentions are good; the result usually isn’t” (95). Nurses and support staff often work around bad doctors, fixing mistakes quietly or referring patients elsewhere.

Gawande then profiles a physician, Dr. Kent Neff, and his Professional Assessment Program, through which hospitals were invited to send problematic doctors to Neff for assessment and a prescriptive for rehabilitation. Neff would give doctors drug and alcohol tests and psychiatric evaluations to determine if they could safely practice medicine, and, if not, he would provide a therapeutic recommendation. Still, Gawande wonders generally about a system wherein doctors turn in other doctors, asking: “would you ever be ready to see Hank Goodman operate again?” (103).