43 pages • 1 hour read
Atul GawandeComplications: A Surgeon’s Notes on an Imperfect Science
Nonfiction | Essay Collection | Adult | Published in 2002A modern alternative to SparkNotes and CliffsNotes, SuperSummary offers high-quality Study Guides with detailed chapter summaries and analysis of major themes, characters, and more.
Themes
Fallibility and the Quest for Perfection
The co-existence of fallibility amidst the quest for perfection is a defining trait of medicine and, consequently, of the book Complications. As Gawande weaves together disparate essays about individual mistakes, systemic flaws, and even bad behavior, he constantly keeps in view the ways doctors, researchers, and other medical professionals make these mistakes while striving for perfection. The life-and-death stakes of medicine turn a theme of fallibility amidst the quest for perfection into a suspenseful narrative tool.
In “When Good Doctors Go Bad,” Gawande zeroes in on the case of Dr. Hank Goodman to discuss one doctor’s egregious error but also to discuss surgeons’ relationships with their own fallibility, and with each other’s. Doctors are supposed to band together to confront and remove a troublesome doctor, but as Gawande says, this process rarely happens smoothly, if at all: “no tight-knit community can function that way” (94). In Goodman’s case, it took a third party, a facility dedicated to rehabilitating “bad doctors,” to step in and face his fallibility head-on.
Gawande includes several stories of patient care that involve errors or wrong calls by doctors, the sheer number of examples serving to normalize the fallibility of physicians who might be generally thought of as near-perfect. This fallibility is especially on display in stories of doctors who become patients or the loved ones of patients. A doctor with a blushing problem, despite his understanding of medicine, has trouble coping when he is the one afflicted: “This is someone who makes his living studying disorders of the brain and the nerves. Yet he could not make sense of his own condition” (151).
Alongside his efforts to candidly discuss error and flaw, Gawande also includes examples of when medicine achieves something close to perfection. The Shouldice Hospital in “The Computer and the Hernia Factory” is one such example with its stunning success rate based on robot-like perfection in human performance. Humans are not computers, but they can act like them. Gawande quotes Harvard pediatric surgeon Lucian Leape in saying, “a defining trait of experts is that they move more and more problem-solving into an automatic mode” (39).
Gawande doesn’t shy away from pointing out where medicine fails. He identifies numerous instances of human error, bad judgment, ego, disorganization, and failure to embrace progress—all of which undermine medicine’s veneer of perfection. He also acknowledges repeatedly that humans are crucial to patient care, and his outlook is ultimately optimistic:
What we are drawn to in this imperfect science, what we in fact covet in our way, is the alterable moment—the fragile but crystalline opportunity for one’s know-how, ability, or just gut instinct to change the course of another’s life for the better (251).
Mystery and the Pursuit of Scientific Truth
In Complications, Gawande makes it clear that doctors are scientists—they’re individuals who rely on data and logic: “If there is a credo in practical medicine, it is that the important thing is to be sensible” (110). Indeed, the successes of medicine are owed in large, demonstrable part to science. This profession built on unequivocal truth and evidence is the backdrop against which instances of mystery stand in such noteworthy (and, to doctors, frustrating) contrast. The fact that these two contrasting forces stand side-by-side in medicine is an important theme in Complications.
Physicians operate in a realm of mystery and data in which both questions and answers abound. As Gawande says about the gastric bypass, an operation growing in popularity more quickly than he feels comfortable with: “every new treatment has gaping unknowns—for both patients and society—and it can be hard to decide what to do about them […] And so we forge ahead” (183).
The subject of nausea, as discussed in “A Queasy Feeling,” is a prime example of mystery amidst understanding. Nausea is utterly commonplace, and yet its biological purpose, its myriad disparate causes, and its inconsistent treatability confound doctors. The medical community that performs such innovative operations as the removal of a segment of the sympathetic nerve system (in “Crimson Tide”) is the same medical community that doesn’t “have a convincing explanation of why anxiety or the sight of blood or of vomit itself should make people sick” (136).
There are also the stories of treating a patient with a mysterious or incurable ailment, in which the co-existence of knowing and unknowing is ever-present. Doctors may know something about the condition, and many things about the human body, and still not be able to identify the one thing that could make a difference for a patient. In “A Queasy Feeling,” Gawande suggests that the pinnacle of patient care might be in embracing the incompleteness of knowledge—“simply receiving a measure of understanding—of knowing what the source of the misery is, seeing its meaning in a different way, or just coming to accept that we cannot always tame nature” (144).
Gawande expresses the theme of mystery in stylistic ways, too. He structures stories of real-life surgery in standard storytelling structure, with exposition, rising action, climax, and resolution. He establishes himself as a man of science, certainly, but one who’s capable of wonder and awe at that very science and at the mysteries that abound within it. He structures essays in such a way that the reader meets a question and then goes on a journey of discovery, fraught with tension, dread, and awe. Gawande enables mystery to be felt, not just talked about.
In discussing a patient who suffered with blushing, Gawande extends an example of medical mystery to reflect on the mystery of human existence, in general: “One wants to know whether, in the end, her troubles were physical or psychological. But it is a question as impossible to answer as whether a blush is physical or mental—or, for that matter, whether a person is” (160). Connections between medicine and the outside world raise the idea of mystery to universal importance.
Gawande expresses wonder at doctors’ ability to work within mystery: “That our efforts succeed at all is still sometimes a shock to me. But they do. Not always, but often enough” (252).
Uncertainty and Confidence
Gawande develops the theme of uncertainty most significantly in Part 3, titled “Uncertainty,” but doubt and uncertainty are present in each of the essays, as are their counterparts of action and confidence. As Gawande says, doctors are called on to make decisions every day in the face of rampant mystery, lack of knowledge, and doubt. As with the other themes in this book, it’s the pairing of opposites—action amidst uncertainty— that gives this theme significance.
In “Final Cut,” Gawande discusses doubt in two distinct, but related, ways. The first is the doubt physicians feel when asking families for permission to perform autopsies on loved ones: “Still, when it is time to ask for a family’s permission to do such a thing, the images weigh on everyone’s mind—not least the doctor’s. You strive to achieve a cool, dispassionate attitude toward these matters. But doubts nevertheless creep in” (190). This disclosure of how doctors feel is noteworthy given that doctors are expected to be decisive and authoritative.
This essay also explores doubt in more scientific terms, as autopsies are used to answer questions about what happened to patients in order to find things doctors missed. Gawande suggests that “what discourages autopsies is medicine’s twenty-first-century, tall-in-the-saddle confidence” (193). With technology, innovation, and expertise, the cause of death of a patient is frequently not up for debate. Gawande, however, also offers an example of a patient, Mr. Jolly, whose death he completely misdiagnosed, whose X rays failed to make sense even after the cause of death was known. Doubt and decisiveness are strange bedfellows in the field of diagnosis and treatment, and autopsies often reveal surprising truths.
Throughout Complications, Gawande relentlessly cites studies about human error, and physician error specifically. In “The Case of the Red Leg,” however, he cites a specific study that discusses human error in the context of confidence: “Doctors with high confidence in a judgment they made proved no more accurate than doctors with low confidence” (238). In other words, confidence may counteract uncertainty in emotional terms, but not in terms of results. He even includes himself in this unpleasant reality: “It disturbed me, however, to have felt so confident about what had happened that day and to have been so wrong” (197).
Gawande offers examples of situations in which his own decisiveness amidst uncertainty, based on a gut instinct or intuition, was pivotal in patient care. His judgment call in “The Case of the Red Leg” to test a patient for a far more severe disease than she was being treated for was not based on fact or certainty, and yet it saved her life.
Gawande addresses the idea that medicine is supposed to have answers: “We want progress in medicine to be clear and unequivocal, but of course it rarely is. Every new treatment has gaping unknowns—for both patients and society—and it can be hard to decide what to do about them” (183). This statement challenges the idea that progress and innovation come as a result of answers, suggesting that progress and innovation sometimes speed out ahead of answers. Certainty, therefore, is not a precondition for action and decisiveness.
Gawande closes the essay “Final Cut” with a spotlight on certainty: “There is still room enough to get better, to ask questions of even the dead, to learn from knowing when our simple certainties are wrong” (201). Uncertainty may be worrisome, but even certainty is often untrustworthy.
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