Complications by Atul Gawande: Medicine as Imperfect Science

Introduction: Medicine as Art, Not 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 in science. In his book Complications: A Surgeon's Notes on an Imperfect Science — part memoir and part philosophical rumination on the state of modern medicine — Gawande examines various types of medical errors and misreadings drawn from his own career and others. Intentionally or not, the effect upon the reader is often unsettling. 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 among medical doctors, who usually instruct their patients in no uncertain terms what to do, and even among medical journalists, who often suggest that good health can be achieved through a specific regimen of diet, exercise, and preventative care. 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 harmful. From the patient's point of view, it is never heartening to hear that physicians inevitably make errors and that, despite the best efforts of the system to correct this through training, some mistakes may be impossible to prevent.

The efforts of medicine, in short, are not unwavering and fixed in their results, like balancing a chemical equation or applying 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 patients; it's how to keep good physicians from harming patients" — but rather in the imperfect nature of medicine itself, often frighteningly so from both the physician's and the patient's perspective (Gawande 57). The reliance upon habit means that questionable or even unsafe practices may be perpetuated from one generation to the next; intuition and guessing may mean that someone still in the early stages of their career lacks the necessary experiential reference points to make sound decisions, although even experienced physicians can grow lazy, sloppy, or burnt out.

Fallibility, Mystery, and Uncertainty in Modern Medicine

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 who may not present a complete or accurate picture of their symptoms; there is often an element of mystery as to what works with one patient and not with another; and physicians are eternally operating under conditions of uncertainty, thanks to the ever-changing nature of the human body and the human character, which elude even the most determined efforts at prediction. "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 patients and doctors — is defined by how one copes with it" (Gawande 229). For Gawande, good doctors know how to cope with uncertainty in productive ways without cracking under pressure; poor ones do not.

Medical Errors and the Physician-Patient Relationship

Some of the problems Gawande outlines are extremely disconcerting from a patient's perspective, such as the fact that physicians have amputated the wrong limb — though he does suggest that solutions are sometimes found in unexpected places, such as marking limbs with felt-tipped markers before surgery. The mistakes chronicled by the author are often uncomfortable to read: surgical instruments left in patients by accident, or biopsies taken from the wrong section of a woman's breast. Despite his assertion that physicians genuinely wish to uphold the core principles of the Hippocratic Oath and do no harm, he does include examples of physicians whose actions or inactions caused clear harm — such as an orthopedic surgeon who ignored a dangerous preoperative infection, resulting in permanent damage to the patient's knee (Gawande 90). The surgeon's dismissal of the woman's initial pain as mere complaining was not the result of imperfect medicine but of pure arrogance and a refusal to believe that an ordinary patient might be noticing something in her own body 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; they also have very human emotional frailties, such as unspoken resentment toward patients, which can eventually surface in incidents worthy of malpractice claims. 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 particularly sympathetic to the idea that doctors are being unfairly persecuted simply for being human.

Conclusion: Cautionary Lessons for Patients and Physicians

Gawande's book is an enlightening look into the mind of a surgeon and an important reminder of the limits of a field which is often accused of playing God. However, the average reader will likely be unsettled by some of Gawande's complaints about malpractice lawsuits. "Whatever the limits of the M&M [morbidity and mortality conference], its fierce ethic of personal responsibility for errors is a formidable virtue. No matter what measures are taken, doctors will sometimes falter, and it isn't reasonable to ask that we achieve perfection" (Gawande 74). Yet when there is a lack of perfection, that shortcoming often demands real and meaningful — at times financial — remedies. Complications remains an important cautionary tale for both patients and physicians about placing too much confidence in the reliability of medical objectivity.

Work Cited

Gawande, Atul. Complications: A Surgeon's Notes on an Imperfect Science. New York: Metropolitan Books, 2002.