Review: Complications: A Surgeon’s Notes on an Imperfect Science by Atul Gawande

This book is fantastic, but I’ve had a hard time convincing friends to read it. The full title is Complications: A Surgeon’s Notes on an Imperfect Science, and they’re wary of this subject for the potential gross-out factor, the fear of learning that doctors aren’t perfect, and the suspicion that it’ll be technical and boring. I’ll address these, but the main thrust of this review is to say Atul Gawande has written an engaging work with sincerity and compassion. He contrasts stories of failed attempts with wondrous success cases, tackles the difficult subject of how a good doctor can become dangerous, and speaks for patient education. His observations are presented as a series of essays that can be picked up for a quick read, but will likely pull you from one to the next.

To the first concern: Is this book stomach-churning? When House comes on, I change the channel before I get drawn in by the story. I know there will be at least two moments per episode that will force me to turn from the screen. However, I’ve watched ovarian cysts being surgically removed on YouTube, because those videos are in the context of a medical procedure performed by professionals; unlike on House, there’s a low chance something will go wrong for the sake of drama. If, like me, you draw a line between the gratuitous and the educational, you can stomach this book. There are graphic scenes, but they’re written to explain a situation, not to impress or frighten a layman.

The second concern: Will this book disillusion me as to the competency of my doctors? Probably. Medical mistakes can be painful, life-changing, or life-destroying. No one wants to think too hard about the worst-case scenario of procedures they’re about to endure. Gawande discusses potentially dangerous doctors in two forms: the doctor who is still learning, and the doctor who has become sloppy. To the former, there’s an element of hope because people can always learn, right?

. . . the angle looks all wrong. I motion for her to reposition. This only makes her more uncertain. She pushes in deeper and I know she does not have it. She draws back on the syringe: no blood. She takes out the needle and tries again. And again, the angle looks wrong. This time Mr. G feels the jab and jerks up in pain. I hold his arm. She gives him more numbing medication. It is all I can do not to take over. But she cannot learn without doing, I tell myself. I decide to let her have one more try. (34)

This slice of horror is tempered by an explanation that Gawande also learned this procedure through trial and error. He describes the doubt and fear that can set in and how this must be laid aside. It’s a human look into a surgeon’s mind when many people would prefer their doctors to be unambiguous heroes. “When Good Doctors Go Bad” was more unnerving:

In one case, he put the wrong-size screw into a patient’s broken ankle, and didn’t notice that the screw had gone in too deep. When the patient complained of pain, Goodman refused to admit that anything needed to be done. In a similar case, he put a wrong-size screw into a broken elbow. The patient came back when the screw head had eroded through the skin. (91)

Doctors like this are the worst-case scenario and Gawande recounts the difficult process of having this man suspended: the mounting suspicion, the increased lawsuits, and the doctors and hospital staff who steered patients from Goodman’s office. He doesn’t stoop to casting Goodman as a straight-up villain, he’s more interested on commenting on burnouts within the medical community as a whole.

And lastly: Is it boring? Gawande uses medical details and technical jargon when necessary and skips them when they’re not the point of an anecdote. In “Nine Thousand Surgeons,” he recounts his time at the American College of Surgeons convention. He recounts three films that particularly impressed him with a sense of wonder and describes them for the reader; rather than yakking about technical difficulties that only his fellow surgeons might appreciate, he dips into metaphors that anyone can understand (though he risks over-simplifying):

. . . removed a colon cancer from deep in a patient’s pelvis and then reconnected her bowel entirely laparoscopically—through tiny incisions that required only Band-Aids afterward. It was a startling, Houdini-like feat—something akin to removing a model ship from a bottle and constructing a working car in its place using just chopsticks. . . . The most elegant clip, however, was . . . repairing a defect of the esophagus known as Zenker’s diverticulum. This is an abnormality that normally requires an hour or more to repair and an incision in the side of the neck, but in the film the surgeon managed to do it through a patient’s mouth in fifteen minutes with no incision at all. (78)

These types of anecdotes are my favorites. It’s encouraging to hear stories of medical advances, cleaner procedures, and improved mortality rates in amongst the other anecdotes that might make a hypochondriac skittish around the ER. So much of what makes this book great is its sensitivity and balance. Though Gawande is a surgeon himself, he writes of the fear of bringing his sick daughter to the ER, of handing her off to other doctors and trusting their decisions over his own. Doctors, surgeons in particular, have a reputation for being walled off from patients’ concerns, but he writes as though this wall is non-existent. It is neither an exposé to out incompetent doctors or practices, or an attempt to placate patients, it is simply his account of being a surgeon who is constantly striving to be better.

Overall: 4.5 (out of 5.0) This book is everything it needs to be, plus some. I’d like if he simplified things a little less (it felt I was being talked down to at times), but it’s nice that this book is accessible to non-medical folk. If you’re squeamish, skip pages 48-55 because they detail a failed tracheostomy.