Book Review: Complications

“No matter what measures are taken, doctors will sometimes falter, and it isn’t reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.”

Unlike other medical themed books I have recently reviewed, Complications, by Atul Gawande, is set in the USA with its insurance based system of healthcare. I can only assume that payment was not an issue for the patients treated as there is never any question, in any of the cases detailed, of the cost of the complex care provided. Indeed, when cost has already been taken care of, the tests and treatments offered are perhaps more complex than may actually be required.

Written when the author was a surgical resident, he explores in this book the myriad reasons why sometimes fatal mistakes can and are being made. These serve not to lessen the reader’s confidence in doctors but rather to remind us that they are human, and that they must learn a craft that is constantly changing due to welcome advances in surgical techniques, equipment and medication.

The first section of the book, Fallibility, explores the need to teach doctors for the future good of all. They must practice on patients if they are to adequately learn, and as they progress will not always be under close supervision. In the USA doctors become specialists in very particular areas leading to better statistical outcomes as the surgery and subsequent treatment is familiar to the clinical team. Nevertheless, individual patients will not always react in a uniform way. They bring their differing health issues, and sometimes doctors will diagnose incorrectly. With a growing culture of litigation, professional honesty may prove inadvisable. There is discussion of reliance on machines, rote learning and the improvements achieved through practice. One chapter looks at what happens when previously good doctors repeatedly fail to achieve satisfactory outcomes. It can be a challenge to kill the career of a once respected colleague, even when their actions are inadvertently killing patients.

The second section looks at the mysteries encountered in medicine, the diagnosis and results that remain inexplicable. One chapter touches on pain and the role of the brain, the reluctance to accept psychosomatic causes of physical issues. There is a chapter on prenatal nausea, another on blushing. The limited effectiveness of medical interventions alongside the lack of drugs for certain problems is acknowledged. The chapter on obesity suggests this problem is a particular challenge where there is no clear solution.

The third section looks at the uncertainty doctors face in diagnosing problems without opening patients up in surgery. There is a chapter on a patient’s right to decide on treatment, focusing on their lack of specialist knowledge and the pressure of being unwell and, perhaps, fearful. One case cited involved a young woman who the author treated, his recommended procedure invasive when there was a possibility it may simply have required antibiotics. Such choices are made on instinct, an imprecise use of science and learning. This is an ongoing issue – how much can be prescribed and made routine when dealing with the variations of people and their circumstances.

Although a fascinating account of actual cases, with a number of strong arguments and commentaries from the author, I found this book lacked the warmth, occasional humour, and undercurrent of emotion found in other medical themed books I have read. It is factual and interesting but perhaps less engaging to a casual reader. My medical student daughter was glowing in her praise.