Friday, May 12, 2006

Atul Gawande's ‘Complications’

[X-Posted at SM]

I recently picked up Atul Gawande's Complications: A Surgeon's Notes on an Imperfect Science in a bookstore in Philly. While I thought I already had a favorite Indian doctor-writer in Abraham Verghese, Gawande gives him a run for his money here.

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 improve and 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 closely 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 published a number of times in 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. 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 law, 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.]


Prathibimba (ಪ್ರತಿಬಿಂಬ) said...

This book is really good. But I think he got away without incurring the wrath of his fellow doctors because of his Harvard degrees. If it was any lesser mortals, they would have crucified him.

9:51 AM  
Amardeep said...

I'm not sure -- I think he is trying to make some constructive criticisms. And he is pretty insistent that doctors themselves should be focused on their problems, rather than lawyers (that is a message most doctors want to hear).

Incidentally, the paragraph you quoted in your blog post is a good one.

It's true that it's a lot easier to be heard from the point of view of someone at the top of the professional ladder. But if you look at his background -- Rhodes Scholar, studied philosophy in Europe, took creative writing classes in college -- it's clear that he's always been interested in writing and literature as well. He's one of those rare people who is very good technically at what he does and has the ability to step outside of his job to look at it as an outsider might.

10:45 AM  
Neale said...

I usually mildly enjoy Gawande's one off essays in the NYer but found a slew of them difficult to read.

Vergehese's God's Own Country, on the other hand, is one of my favorite non-fiction reads.


1:29 PM  
Amardeep said...

I actually think Gawande is a very good writer. But his style is more technical, journalistic, and wonky than Verghese's.

Verghese is a novelist at heart, while Gawande, I think, is a journalist at heart.

3:21 PM  
Anna said...

"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."

This sentence is a bit of a nonsequitur, insofar as the intrinsic purpose of tort law (with the exception of punitive damages) is not improving how well doctors do, but rather compensating an injury. Compensation is a retrospective task, while improvement is prospective. An equivalent statement would be "while Lawyer X doesn't come out strongly on the question of improving medical care through surgical M&M meetings, he doesn't think a strictly medical response to failures is likely to improve the ability of those who are injured to cope with the serious financial burdens imposed by those injuries."

Gawande himself does not make this mistake. When he does discuss tort reform, at the end of the New Yorker interview you quoted, the response he suggests is a legal one, well-considered and debated by law professors, lawmakers, and others in the legal community: a no-fault compensation system similar to those which Gawande notes have been implemented in other countries to deal with medical injuries, and in the US (a somewhat imperfect analogy)under the DOJ Vaccine Compensation Program. One of the purposes of the no-fault system, where it exists, is to limit costs in places with universal health care. Conversely and unfortunately (as Gawande again points out), lack of universal healthcare and the insufficiency of other government benefits is one of the reasons for the high costs of medical injuries-- whether compensated by an insurance company, jury award, or left entirely to the injured to pay-- in the United States. Compensation, which is tort law's purpose, is a complicated issue, but not one that doctors have any particular aptitude for, or prerogative to, solve on their own.

7:48 PM  
mahesh said...

i think that doctors in western countries are generally practicing defensive medicine- that is, they order lots of unnecessary tests and subject their patients to unnecessary examinations and procedures because of the fear of getting sued. that way, when they do get sued, they have something to fall back on- "hey look, i did everything i possible could!!". even experienced doctors who know exactly what they are doing will do all these unnecessary things "because their lawyer told them to".

i went to india recently where things are completely different (i'm not talking about private hospitals, they're simply too unethical for me). there is no fear of lawsuits so the doctors just tell the patients- "this is what u have, these are the tests u need" and afterwards "this is the treatment i'm going to recommend". now there will be mistakes because its impossible to be right all the time. but i am not sure that the huge cost of "defensive medicine" is worth the meagre benefits that can be gained by putting patients thru all sorts of tests most of which will be irrelevant.....

4:27 AM  
Amardeep said...


This sentence is a bit of a nonsequitur, insofar as the intrinsic purpose of tort law (with the exception of punitive damages) is not improving how well doctors do, but rather compensating an injury. Compensation is a retrospective task, while improvement is prospective.

Perhaps I should have been clearer that I don't think these things should be collapsed into each other (Gawande certainly doesn't).

But I guess the implicit point I'm after here is that prospective and improvement-oriented thinking ought to be part of the public debate about medicine. If the focus is exclusively on a short sighted concept of the "patients' bill of rights," it's possible that the greater common good will suffer.

I'm interested in no-fault arrangements especially for extremely risky or experimental procedures, but I don't know much about how it works in places with nationalized health care.

11:26 AM  
Anna said...

American doctors wouldn't put patients through an enormous number of unnecessary tests and procedures if either doctor or patient, rather than a third party insurance company, was paying for the procedures. While it's true that American culture is both more litigious and more risk averse than others, I think these incentives would have similarly perverse affects in other countries. Think of the kind of medicine (and expense) that might have resulted had Dr. Kulkarni's patients in the Mukherjee film Anand had access to MRIs, etc. and a good PPO plan.

I agree that a prospective and improvement-oriented thinking ought to be part of a public debate about medicine (though, you've thrown me by interjecting yet another concept, the "Patients' Bill of Rights," which doesn't have much to do either with tort claims or with self-monitoring, but rather with patient involvement in treatment decisions through things like understandable information, etc.), but perhaps cynically, I worry that it doesn't get us very far. I think a focus on medicine itself is a narrow and doctor-centric approach to the more pressing question of improving public health. Clearly, the best way to avoid the risk of medical complications is to stay away from doctors by staying well. America has some of the best and most expensive doctors in the world-- especially among specialists like Dr. Gawande-- and some of the unhealthiest and unhappiest patients. And, as Dr. Gawande points out, even the best people make mistakes under the best circumstances. It seems to me, then, that the proactive, "greater good" approach would be to put effort into improving primary care and general health, while finding cost/time efficient and fair ways to compensate those who suffer medical injuries.

Maybe I'm just being a prickly lawyer (full-disclosure: med-mal isn't my area, though I do represent low-income patients in the Medicare/Medicaid, constitutional, and disability rights contexts), but it does seem to me that we already expect too much omniscience of doctors-- and they expect it of themselves-- without adding the ability to self-monitor to their plate.

1:15 PM  
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9:07 PM  

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