The Uncertain Art
Instinct and skill in surgical practice
Sometimes wrong; never in doubt." Atul Gawande quotes this saying about surgeons in the opening pages of Complications: A Surgeon's Notes on an Imperfect Science. The assessment is often intended derisively, but to Gawande, a medical student when he first heard it, "this seemed to me their strength. Every day, surgeons are faced with uncertainties.... [I]t cannot be taken for granted that a patient will come through better offor even alive....The moment made me want to be a surgeonnot to be an amateur handed the knife for a brief moment, but someone with the confidence to proceed as if it were routine."
Gawande did pursue a career in surgery, and as a senior surgical resident wrote Complications, which elegantly probes medicine at the edges of technology, medicine as an uncertain art. Through a series of loosely related essays, he explores how the surgeon is able to cut, excise, and suture despite the uncertainties that underlie each individual case. He tends to focus on surgical themes, but they highlight issues facing every branch of medicine. I first read many of his essays in the New Yorker. The issues they presented were so pertinent to those I faced in my own medical training that I am pleased to have the texts collected. I was only mildly disappointed that so little of the material was new.
Gawande unflinchingly confronts the deepest fears I nursed during my training. The strength and, indeed, the beauty of each essay is the rigorous academic approach he uses to illuminate medical behavior when scientific data are incompletethe point beyond which intuition and experience take over to achieve a final course of action. His approach enables him to distance himself from paralyzing anxiety and to dissect the modifiable risks. (Each chapter includes a summary, readily accessible to nonmedical readers, of the relevant medical material.) Bolstered by his analysis, he can approach his next patient with fresh insight and enthusiasm. And where most physicians hate to talk about medical errorseach of us recognizing how easily we could be at faultGawande demonstrates how physicians can combat error and use it to their advantage. By voicing our fears openly, he reins in the anxiety: "[I]t isn't reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it."
Gawande presents individuals to introduce specific issues. Vincent Caselli, for example, chose gastric bypass surgery in a last-ditch effort to treat the extreme obesity that prevented him from working, attending his daughter's wedding, or even walking upstairs at home. The vignettes vividly remind the reader of the patients who are, ultimately, the heart of medical care and the beneficiaries of Gawande's investigation. Gawande has kept in touch with many of them for months and even years. He is interested not in how their particular surgical procedure is holding up, but in how their experience with illness and operation has affected their lives. In the hospital, surgeons often carry a reputation for being superficial in their attention to their patients as individuals. "Sometimes wrong, never in doubt" can imply a cocky self-reliance that disregards the humanity of the patient in question. Gawande is not that kind of surgeon.
He divides his book into three broad sections: "Fallibility," "Mystery," and "Uncertainty." I found the opening section, "Fallibility," the most compelling. In the first chapter, Gawande lays bare the uncomfortable details of medical education that physicians-in-training encounter daily. To gain competence, doctors must practice their newfound skills under supervision and patients must let the novices provide their care. Gawande writes about learning to place central linesspecialized intravenous catheters inserted in the largest veins of the body to deliver more potent drugs for longer periods of time. Most commonly used in adults is the subclavian vein, deep in the chest. "There were 'slight risks' involved, I said, such as bleeding or lung collapse; in experienced hands, problems of this sort occur in fewer than one case in a hundred. But, of course, mine were not experienced hands." As Gawande had feared, he fumbled his first few attempts and ultimately let his supervising resident take over. He finally achieved proficiency after several months of frustration. "Practice is funny that way," he writes. "For days and days, you make out only the fragments of what to do. And then one day, you've got the thing whole. Conscious learning becomes unconscious knowledge, and you cannot say precisely how." Achieving that unconscious knowledge demands practice, and that practice requires patients.
The scariestbut also most stimulatingaspect of medicine is that medical training never ends. New techniques, new medications, new data accumulate at a dizzying pace. Gawande touches on this in an essay on medical conferences. Some say that in the three years after residency, young physicians learn as much as they did during residency. In medical school, I had complete faith in my residents, and blind reverence for the attending physicians. I trusted that they always knew "the right answer." I didn't feel like a doctor when I received my M.D., but I believed that someday, with enough training, I would.
Since graduating from residency a year ago, I have chosen to work for an isolated clinic in the Indian Health Service on the Navajo Reservation (see "Letter from Kayenta," September-October, page 18). Despite a few gray hairs at my temples, I still look young, and my patients are often suspicious that I am not a real doctor. "You sure you ain't no student?" they ask me warily. Reassured, they settle back in the gurney, ready to let me ask questions, probe their bodies, administer medications, and perform any necessary procedures. But I often rely on a consult with the bay of reference texts behind the nursing station, or on the experience of my colleagues, before making a final decision. As the attending physician, though, the final decision is still mine to make. I have certainly grown more comfortable in my role over the passing months, but I still enter the emergency department with a little trepidation, wondering what new situation will arise during that shift.
Our culture has difficulty accepting that each physician has a learning curve. "This is the uncomfortable truth about teaching," Gawande writes. "By traditional ethics and public insistence (not to mention court rulings), a patient's right to the best care possible must trump the objective of training novices. We want perfection without practice....So learning is hidden behind drapes and anesthesia and the elisions of language."
As a society infused with technology, we have come to demand a degree of consistency, accuracy, and efficiency from medicine that its human practitioners cannot hope to achieve: perfection. The second chapter of Complications deals with human error. Gawande puts himself on the examining table when he writes about a harrowing experience in which his own failure to anticipate a problem nearly cost a woman her life.
Shortly after Louise Williams, the drunken victim of a car accident, was brought to the emergency department unconscious, her oxygen level began to fall, requiring the physicians to insert a breathing tube into her trachea. Yet the intubation was complicated. The emergency physician had already suctioned more than a cup of blood from the back of her throat, which, Gawande notes, should have been his first clue that trouble was brewing. When he realized that he had to do an emergency tracheostomyan incision in the neck to gain direct access to the windpipehe fumbled. Louise survived, but Gawande "felt a sense of shame like a burning ulcer. This was not guilt: guilt is what you feel when you have done something wrong. What I felt was shame: I was what was wrong."
I felt sick to my stomach as the story unfolded, and when I put down the book, I vowed never to read it at bedtime again. As a physician, making the wrong decision oreven worsemaking the right decision but being unable to act on it, as happened to Gawande, is by far my most overwhelming fear. Gawande notes that fear, if unchecked, can be paralyzingbut neither can it be entirely laid aside. Despite consulting another physician before making a treatment decision, or taking a few moments to more carefully document why I opted for a particular therapy, I know I make many, mostly trivial, mistakes every day. Most are caught, some are avoidable, some are hard to anticipate. What makes Gawande's story so chilling for me and, I imagine, for many physicians, is that he appears to be a good doctor trying to do the right thing.
Gawande takes this wrenching story and transforms the terrifying, out-of-control feeling of the experience into a thoughtful exploration of how to improve the rate of preventable medical errors. He writes that "everything we've learned in the past two decades...has yielded the same insights: not only do all human beings err, but they err frequently and in predictable, patterned ways. And systems that do not adjust for these realities can end up exacerbating rather than eliminating error." He lauds the surgical tradition of the mandatory Morbidity and Mortality Conference, where the staff meet to review surgical complications, thereby enabling surgeons to admit to errorsand to learn from them.
In "Mystery," the book's middle section, Gawande presents problemspain, nausea, pathological blushingthat medicine doesn't understand very well. The essays enlighten, but lack the unflinching poignancy of the opening chapters. The last section, "Uncertainty," deals with how physicians cope with the unknowable and the uncontrollable in medicine. One essay describes watching patients make poor choices about treatment, often in spite of extensive counseling. Gawande wonders if physicians should be more forceful in guiding patients to the choice the doctors feel is most in the patients' interest: "[as] the field grows ever more complex and technological, the real task isn't to banish paternalism; the real task is to preserve kindness."
In the final chapter, Gawande regains the power of his opening essays. He writes about moments when that incalculable human factor responsible for the errors, misjudgments, and oversights dissected in the early chapters results in intuitive choices that save lives. Asked to evaluate Eleanor Bratton, a young woman with an infected leg, Gawande couldn't help considering as a possible diagnosis a devastating flesh-eating bacterial infection in its earliest stages. He fully expected to take her to the operating room, open the leg, and discover that the problem was a severe but straightforward case of skin infectionbut the small doubt in his mind was worth the surgical risks. Then the biopsy revealed the dead tissue indicating the presence of the flesh-eating bacteria. He and his supervising colleague together made a string of difficult decisions, choosing not to amputate the infected leg (knowing many colleagues might have chosen differently) and gambling on their instinct that her young, healthy body would be able to stave off an infection caught in its earliest stages. When they made the choices, Gawande was not entirely sure they had done the right thing. But Eleanor proved their instincts accurate, surviving an infection that carries a 40 percent mortality rate.
"For however many times our judgment may fail us," writes Gawande, "we each have our great improbable save." As physicians, we will all have our Louise Williamsesalmost suffocating under our handsbut we will also have our Eleanor Brattons. The dilemma is that we can't have one without the other. Somehow we must learn from the former, gaining the experience and the confidence to be swashbuckling rescuers in the face of uncertainty. As often as human nature thwarts us, sometimes it is our greatest strength. Gawande's redeeming conclusion allows me to lay the book down with a light heart. He has plumbed my deepest fears as a physician and left me with hope.
Ellen L. Rothman, M.D. '98, is the author of White Coat: Becoming a Doctor at Harvard Medical School.