Complications

November's book: Complications, A Surgeon's Notes on an Imperfect Science

The first time I read this book I was pretty early in my medical training. It was fun to read it again after a few years, this time with a much different perspective. I have been there for many of the scenarios that Gawande describes, being as he was a resident. Anyway, I have my own medical opinion of what he has produced. I am interested to know how the rest of you felt about the points he made. Here are some topics of discussion, with my thoughts:

1)"The core predicament of medicine -- the thing that makes being a patient so wrenching, being a doctor so difficult, and being a part of a society that pays the bills they run up so vexing -- is uncertainty." (pg 229)

---This seems to be the theme of the entire book. Other than the "mystery" chapters where he details some rare and bizarre conditions, Gawande mostly seems to be explaining just how human modern medicine really is. In spite of all the advances of science, medicine comes down to a fallible doctor in a room with a patient -- and several unknowns.

Personally, I tend to agree. I of course have been working rather diligently (happy birthday, Alvin) for the past several years to learn things most people don't know. I think it's safe to say that I'm better than the rest of you at being a doctor. But in the end, I'm not really perfect at this -- nor will I ever be. I'm basicaly the guy with a competetive advantage for this field.

I remember prior to my mission, I thought there were people who spoke French and people who didn't. It was incredibly naive, but there it is. I remember listening to my MTC instructors use the language so freely, and I did my best to copy them. Even after I got to the country, I thought the more experienced elders were using perfect French. Only with time and experience (and actually a lot of dedicated study) could I recognize that probably 2/3 of the missionaries were finishing their mission with sub-standard French, and markedly American accents.

I think much of America has the naive thinking I used to have about language ability: "A board-certified physician is qualified to be my doctor." In reality, there are widely disparate levels of ability, care, and dedication - to say nothing of the unknowns we encounter no matter our ability. Back when I got into medical school, there were several people who advised me to work hard but not too hard -- "What do they call the guy who gets last place in his medical school class? . . . Doctor." That may be true, but the title only means so much. This goes to the malpractice comment later, but people expect doctors and medicine to behave like a robot and a factory. It's not that easy. "We look for medicine to be an orderly field of knowledge and procedure. But it is not." (page 7)

2) Autonomy, consent, and the role of the patient.

"The decision was Lazaroff's." (pg 210)
"Could it have been a mistake, then, even to have told him about the surgical option?" (pg 216)
"patients frequently don't want the freedom that we've given them." (pg 219)

---I'm curious how you feel about today's world of patient autonomy and informed consent. This idea, that the patient should approve all medical decisions, is strictly taught in our medical schools. It's one of the basic tenets of ethical medical practice -- as much as beneficence and nonmalfeasance. I personally met with about 30 patients yesterday to have them sign "informed consent" paperwork for interventional radiology procedures. The basic principle is that the patient must be of sound mind and aware of the risks, benefits, and alternatives of a procedure before allowing the doctors to proceed.

This all sounds great on paper, or in a courtroom. But personally I don't really like it. I essentially walk into room after room and say (not really here, folks; I'm using hyperbole to make a point...) "Mrs So-and-so, your doctor has asked us to place a stent in your liver. I'm going to ask you to sign a sheet that says we might kill you, but that you want us to proceed anyway. Of course we never try to kill people in our department, but there's always that one you didn't see coming..." That way, when the patient does die, we can point to our document as protection.

But only in extremely rare cases does the patient grasp what may or may not happen on our table today. And almost nobody can objectively detach themselves from the numbers. I can tell patients the odds that we'll cause internal bleeding, infection, and even death. Still, it almost never means they understand the best course of action. In the end, I get two types of people. 1- the patients who look at me with a carefree smile and say "where do I sign?" and 2- the patients who are shocked by all the complications I am forced to mention and sign with "if you really think this is the best thing for me." Interestingly, I have never personally encountered a patient who refused consent for a medical procedure that was recommended by their physician.

OK so there are some patients who are crazy and who refuse consent, but I mean normal people.

So I'm not saying that we should hide facts and decisions from patients. I do believe our current "autonomy" and "informed consent" framework is built around lawsuit protection rather than patient care. I think a more reasonable approach is to discuss the procedure with the patient, in as much detail as they desire, leaving the words "cardiac arrest," "brain injury," "loss of life," and others out of the discussion.

One other (very real today) problem with the "Patient Autonomy" movement is cost. We let patients dictate how much care they do or do not receive.

Wait... pause... My personal code of ethics and even religion are going to come out in this paragraph. Just bear that in mind; I would not and cannot force my feelings on someone else.

Where was I? We are all going to die. All of us. And experienced doctors can tell when you are on your way out. Almost universally, though, we don't recommend stopping care. We sugar coat things and give patients (or families) the sense that there is a better chance of recovery than there really is. So we talk to patients or their families about these expensive and likely futile options, again having the informed consent discussion. We basically leave it up to them if we continue "agressive" care or not. My experience is that almost no one can choose to give up. Either the patient doesn't want to give up(naturally), or the family doesn't want to live with the burden of "not having done everything we could." So the medical costs in the last year of life skyrocket.

Enough about that...

3) "Top performers dislike practicing just as much as others do. But more than others, they have the will to keep at it anyway."

---just like that quote.

4) "We find it hard, in medicine, to talk about this with patients." (page 23)
"No matter how accomplished, surgeons trying something new got worse before they got better." (page 30)

---Basically, I just like how he describes the learning process within medicine. Would you accept a "trainee" performing your procedure? Are you brave enough to ask your doctor how many of the procedures he or she has done, and would the answer change your willingness to let them proceed?

So for me personally, I take it as my professional responsibility not to touch a patient unless I know what I'm doing. So if I tell you I'm going to cut you open, you can rest assured I know how to do it right. It is true, though, that I don't have the experience that others may have. And when a rare complication occurs, my first move will be to find someone more experienced. This is also not fundamentally a problem of students/residents vs. certified physicians. I listened this morning to a discussion between a junior and senior faculty member in my department. A patient was scheduled with the younger doctor for a procedure he has not done often. The discussion dealt with whether to tell the patient of the doctor's inexperience or recommend the senior faculty member perform the procedure, among other options.

5) "To the public - and certainly to lawyers and the media - medical error is fundamentally a problem of bad doctors." (page 47)
"And a patient's liklihood of winning a suit depended primarily on how poor his or her outcome was, regardless of whether that outcome was caused by disease or unavoidable risks of care." (page 57)
"We are all, whatever we do, in the hands of flawed human beings. That fact is hard to stare in the face." (page 105)

---My wife is already wondering when I'm going to emerge from this entry, and you probably are too. Let me be brief:

When our oldest was born, my wife was given 10 times the correct dose of a medication. Her heart was overloaded, she went into "flash pulmonary edema," and spent the next day and a half on a ventilator. It was a blatant, clear-cut, medical error. My aunt, a hospital administrator, summed up several people's comments when she said that we should get our hospitalization for free, and could get a whole lot more.

We did nothing. Not because we were not harmed, but because I believed that everyone makes mistakes. The doctor, who was indeed responsible, was legitimately contrite. That was enough for me. In the moment, we were concerned about the long term implications -- not just for my wife but also for our family size due to the emergency C-section that was required. But even with all those emotions, I was more prepared to forgive than to litigate.

But, as the book does point out, people love to sue when the outcome is poor. And (some, not all) lawyers love to help them along.

6) The Man Who Couldn't Stop Eating

OK; we could do a whole discussion on obesity and appetite, but let me just say this much. I agree that some people have a pathologic compulsion to eat. That being said, I am not a fan of gastric bypass surgery. The bottom line is that you make it so painful to eat that the patient retrains themselve. Or rather, some patients. Far too many gastric bypass patients learn to accomodate the change and end up worse than before. In the meantime, you are taking some of the worse possible candidates to the OR and undergoing a surgery with a very real risk of death or disability.

If a person is so desparate to change, can they not dig deeply and find the motivation to change themselves? Gawande gives anecdotal reports of patients who could not possibly have improved without the surgery. I would counter his anecdotes with many others who (in the absence of a successful obesity pill) believe that surgery is easier than fixing their broken lifestyle.

We were not nearly as fat as a country 20 years ago, and again less so 40 years ago. I do not believe that appetite is new to our generation. We have just become too indolent to take care of it ourselves.

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Anyway, I enjoyed this book. Share what you thought; feel free to use my discussion points or not.