Atul Gawande

¶ … Surgeon's Notes on an Imperfect Science According to author and surgeon Atul Gawande, the practice of medicine, despite its veneer of scientific objectivity, is often based more in art and subjective impressions than science. In his book A Surgeon's Notes on an Imperfect Science (which is part memoir and part philosophical rumination on the state of modern medicine), Gawande examines various types of medical errors and misreadings in his own career and others.

Intentionally or not, the effect upon the reader is often unsettling, and although Gawande makes suggestions for how to improve the practice of medicine, he implies that mistakes are unavoidable because patients and doctors are human. Even statistics elude the unpredictability of medicine. "In psychology, there's something called the broken-leg problem. A statistical formula may be highly successful in predicting whether or not a person will go to a movie in the next week.

But someone who knows that this person is laid up with a broken leg will beat the formula. No formula can take into account the infinite range of such exceptional events" (Gawande 42). Gawande admits that human beings on an individual level can be remarkably difficult to treat and diagnose: "We look for medicine to be an orderly field of knowledge and procedure. But it is not.

It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line" (Gawande 7). There is a bracing honesty to Gawande's tone that is rarely found amongst medical doctors who usually instruct their patients in no uncertain terms to do x, y, and z and to even medical journalism which often suggests that good health can be followed through a specific regime of eating, exercise, and regular preventative medicine.

Gawande admits that sometimes even when physicians do all the right things much goes wrong and even when wrong things are done the outcomes are not entirely for ill. From the hapless patient's point-of-view, it is never heartening to hear that physicians inevitably make errors and despite the best efforts of the system to correct this through training, because of human frailties, some of these mistakes may be impossible to prevent.

The efforts of medicine, in short, are not unwavering and fixed in their predictable results, like balancing an equation in chemistry or the laws of gravity in physics. Gawande admits that physicians are imperfect human beings, just like their patients. "There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing. The gap between what we know and what we aim for persists. And this gap complicates everything we do" (Gawande 7).

Gawande states that usually the fault lies not in the physicians themselves, who are often trying to do the right thing -- "the important question isn't how to keep bad physicians from harming patient; it's how to keep good physicians from harming patients" -- but rather in the imperfect nature of medicine, often frighteningly imperfect from both the physician's and the patient's point-of-view (Gawande 57).

The reliance upon habit means that questionable or even unsafe practices may be adhered to generation after generation; intuition and guessing may mean that someone still in the beginning stages of their practice may lack the necessary experiential reference points to make good decisions (although even experienced physicians can get lazy, sloppy, and burnt out) Gawande structures his book according to three sections, appropriately titled fallibility, mystery, and uncertainty, which he considers the three cornerstones of what is problematic in modern medicine: humans are fallible (including patients that may not present a perfect picture of their symptoms); there is often an element of mystery as to what works with one patient and not with another; and the fact that physicians are eternally operating under conditions of uncertainty, thanks to the ever-changing nature of the human body and character that eludes even the most stalwart efforts to predict the future.

"The core predicament of medicine - the thing that makes being a patient so wrenching, being a doctor so difficult, and being a part of society that pays the bills they run up so vexing - is uncertainty…Medicine's ground state is uncertainty. And wisdom - for both the patients and doctors - is defined by how one copes with it" (Gawande 229). For Gawande, good doctors know how to cope with uncertainty in positive ways without cracking under pressure; bad ones do not.

Some of the problems which Gawande outlines are extremely disconcerting from a patient's perspective, such as the fact that physicians have cut off the wrong limb although he does suggest that solutions are possible in ways that are often unexpected, such as labeling such limbs with felt-tipped markers before surgery. The mistakes chronicled by the author are often uncomfortable to read, such as surgical instruments left in patients by accident or biopsies of the wrong sections of a woman's breast.

And, despite his protestations that physicians genuinely wish to observe the core principles of the Hippocratic Oath to do no harm, he does include examples of physicians whose actions or inactions very much did harm, like an orthopedic surgeon who ignored a dangerous preoperative infection which resulted in permanent damage to the patient's knee (Gawande 90).

The surgeon's dismissal of the woman's initial pain as whining was not the result of imperfect medicine but pure arrogance and a refusal to believe that an ordinary patient might be spotting something in her own body that required care that the physician had overlooked. These examples seem to belie Gawande's stated insistence that most errors on the part of the medical profession occur despite the well-meaning intentions of physicians.

It is not simply that physicians sometimes make bad decisions but they have very human emotional frailties such as unstated resentment to their patients that eventually boil forth and bubble over into malpractice-worthy incidents. Gawande understandably believes that the threat of malpractice has been detrimental to the physician-patient relationship but many of the accounts of careless and uncaring physicians he describes do not make the reader overly sympathetic to the idea that doctors are being unfairly persecuted for being human.

Gawande notes that the physician-patient relationship has become so broken that many doctors are now relying upon computers rather than their own good sense for diagnostic advice. "What accounts for the superiority of a well-developed computer algorithm? & #8230;human beings are inconsistent: we are easily influenced by suggestion, the order in which we see things, recent experience, distractions, the way information is framed" (Gawande 45). Doctors are not automatons and are not immune from this, despite their medical and scientific training. Ideally, computers should take guesswork out of the process.

A computer will not be influenced by the fact that the last EKG of a patient was good, versus others which indicated disease. Additionally, because of the concerns regarding malpractice, using computers also gives a wary physician an additional line of defense against allegations he or she did not do all that was possible to mitigate any potential harms, given that the doctor relied upon a proven system created by a software program vs. his or her own instincts.

However, there is a certain paradox to this: on one hand, we want patients to be more attentive to individual patient needs; on the other hand we want them to be less human in their objectivity and less prone to making mistakes. And, of course, because computers are created by humans, they are not entirely perfect either. One of the reasons patients may be so uncomfortable with this aspect of medicine is that so much of medicine is quite harsh and invasive, and would be considered 'wrong' were not.