Complications: A Surgeon’s Notes On An Imperfect Science
Are doctors perfect? Does the population perceive them as incapable of mistakes? Isn’t medicine a perfected web of technology disallowing mistakes to be made? Atu Gawande (2002) states, “It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line” (pg. 7). How can medicine be imperfect? These are questions requiring answers.
The fallibility of medicine has been well kept secret among doctors the world over (Atu Gawande, 2002). Gorovitz and MacIntyre (1976) believe the knowledge of medicine is not all inclusive. Furthermore, health care professionals make mistakes due to lack of progress in the medical arena pertaining to that particular patient’s ailments (Gorovitz and MacIntyre, 1976). Within the first part of the Atu Gawande’s book, fallibility is discussed at length. The art of medicine is not the knowledge of what to do it is the willingness to try no matter what the odds are (Charles, 1989). A doctor is just as susceptible to second guessing themselves as any lay person (Ghosh, 2004). This potential for greatness comes living with uncertainty and proceeding forward without hesitation. Gawande (2002) states “Every day surgeons are faced with uncertainties” (pg. 15). The trick is to continue with the objective in mind and do not become dissuaded from the task at hand due to naysayers (Ghosh, 2004).
The factors contributing to the fallibility of medicine is the prior emotional influences of the patient and the physician, differing values, and errors of modern technology (Ghosh, 2004). Furthermore, physician fallibility cannot be completely eliminated (Ghosh, 2004). However, it can be reduced to a comfortable level producing a minimum amount of angst for both the patient and the physician (Ghosh, 2004). This is done by applying strategies are used by many and denounced by none.
These strategies include relying on the most basic of clinical principles (Ghosh, 2004). History taking and involving the patient with the decision making process are two strategies used to reduce the level of fallibility (Ghosh, 2004).
The second topic of discussion found in the book is Medical Mysteries. Who would ever think medical mysteries exist in this modern age of technology? Gawande (2002) presents several mysterious occurrences that defy the laws of medicine. One is the fallacy of the of the full moon phenomenon. Gawande (2002) states “…one thing that has been shown is that human beings commonly imagine patterns (whether good or bad) where really there are none” (pg. 111). Although several research studies have taken place with a full moon at the apex of the study, there has not been any links made between increased lunacy and the full moon (Gawande, 2002).
Martin, Kelly, and Saklofske (1992) believe many different vehicles are responsible for the myth of the lunar influence. The first of these is the increased television and movie exposure regarding lunar changes and the supposed effects of it (Martin, Kelly, and Saklofske, 1992). Martin, Kelly, Saklofske (1992), state “Anecdotal evidence about lunar effects is not hard to find and reporters know that one good anecdote trumps ten scientific studies when it comes to reader interest even though such evidence is unreliable for establishing significant correlations” (pg.71).
The second reason provided is the ever present folklore and traditional aspect. According to Kelly and Martens (1994), topics such as fertility, birthdates, and birth control have all been based on the phases of the moon. However, after multiple research studies, “…no relationship between moon phase and number of spontaneous deliveries” were found (Kelly & Martens, 1994).
The third reason given is misconceptions about the moon’s effects on earthly objects and beings (Kelly, Rotton, & Culver, 1996). Many people believe the moon has a far reaching power over humans due to the proven fact of the moon’s affect on the ocean’s tides. This is a reasonable assumption considering the size of the ocean compared to the size of one human being. Furthermore, it is has been stated both the earth and the human body is made up of 80% water (Kelly, Rotton, & Culver, 1996). This is a known fallacy. The surface of the earth is 80 percent water (Kelly, Rotton, Culver, 1996), not the entire earth itself. This is in effect a play on words not the exact truth, which is how many misconceptions begin.
All of these were investigated by Gawande (2002) and found to be lacking in substance. He chose to work a Friday that fell on the 13th day of the month; and it was a full moon with a possible eclipse. He chose to ignore all of his peer’s dire warnings. Beyond all medical investigations, scientific discoveries, and scholarly papers negating the evidence of lunar influences, his night was akin to a horror movie. He received an emergency room full of patients, multiple trauma victims, and a police chase to add to the foray.
The second mystery discussed in this book is that of pain. Pain sometimes cannot be eradicated by providing medicine (Gawande, 2002). Delving into why the pain exists is imperative prior to treating the pain (Gawande, 2002). Gawande (2002) states, “For the solution to chronic pain may lie more in what goes on around us than in what is going on inside us” (pg.129). This is a pretty profound statement in itself. What does cause the pain we all experience from time to time? Does the pain derive from mental stress or is it strictly physical in nature? These are all questions that come to mind while reading this book. Gorovitz and MacIntyre believe medicine is about treating the whole person not just the problem at hand (1976). “The core of the activity is not merely to apply a general rule to a particular case, but also to understand the particular case as a person” (Gorovitz and MacIntyre, 1976, pg. 71).
The third mystery identified by Gawande (2002) is that of hyperemesis related to pregnancy. The patient in question experienced nausea and vomiting her whole pregnancy without relief. Gawande (2002) admits to the treatment of hyperemesis as being “…fairly primitive”(Gawande, 2002, pg. 141). He also goes on to state the most newly innovative drugs still could not reduce the vomiting in a large number of cancer patients (Gawande, 2002).
Along with all of the other aspects with practicing medicine, uncertainties regarding how to proceed follow the course. These uncertainties range from how to request an autopsy to how to tell when someone is lying.
These uncertainties have in effect handicapped the medical field. This has been done by not allowing knowledge of why someone died prevent another death from occurring. At the top of this handicap is the avoidance of doctors in requesting autopsies (Gawande, 2002). The doctors would rather avoid this unseemly topic than to place themselves in a position of ridicule by grieving family and the ever present need to be viewed as omnipotent (Gawande, 2002). Autopsies have been used to provide knowledge for centuries with the first known autopsy performed in 1533(Gawande, 2002).
Until the twentieth century autopsies had acquired a bad name. At that time a group of well known physicians spoke out for the renewal of autopsies. Gawande (2002) states “They defended it as a tool of discovery, one that had already been used to identify the cause of tuberculosis, reveal how to treat appendicitis, and establish the existence of Alzheimer’s disease” (pg. 193).
Throughout the book Gawande lays open the inner workings of medicine and the practice of it. He portrays physicians as humans and not Gods. He also insists as humans they make mistakes and are not one hundred percent correct all of the time. Finally, the statement “For what seems most vital and interesting is not how much we in medicine know but how much we don’t-and how we might grapple with that ignorance more wisely” (Gawande, 2002, pg. 8) is the most honest account of how the practice of medicine should be conducted.
Charles, B. (1989). Hazards of modern medicine. Journal of American medical association, 261, pg. 1610-1617
Gawande, A. (2002). Complications: A surgeon’s notes on an imperfect science. New York: Henry Holt and Company
Ghosh, A.K. (2004). Dealing with medical uncertainty: A physician’s perspective. Minnesota Medical College, 87(10), pg. 48-51
Gorovitz, S. and McIntyre, A. (1976). Toward a theory of medical fallibility. Journal of Medical Philosophy, 1, pg. 51-71
Kelly, I.W., Laverty, W.H., Saklofske, D.H. (1990). Geophysical behavior: LXIV. An empirical investigation of the relationship between worldwide automobile traffic disasters and lunar cycles: No relationship. Psychological reports, 67, pgs. 987-994
Kelly, I. and Martens, R. (1994). Lunar phase and birthrate: An update. Psychological reports, 75, pgs. 507-511
Kelly, I.W., Rotton, J., Culver, R. (1996). The moon was full and nothing happened: A review of studies on the moon and human behavior and human belief. The Over Edge. Amherst, New York: CSICOP
Martin, S.J., I.W. Kelly, and Saklofske, D.H.(1992). Suicide and lunar cycles: A critical review over 28 years. Psychological Reports, 71, pgs.787-795.