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Complications: A Surgeon's Notes on an Imperfect Science    by Atul Gawande order for
by Atul Gawande
Order:  USA  Can
Picador, 2003 (2002)
Hardcover, Paperback, Audio, CD

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* * *   Reviewed by Hilary Williamson

If you've ever had surgery, you will find Complications totally fascinating ... and if you haven't, the odds are that you will require an operation at some point in your life. From the title, I expected this book to cover the material in its first part, that is factors that create 'Fallibility' in surgeons themselves. However, Dr. Gawande moves on to delve into complications in diagnosis, 'Mystery', and then in 'Uncertainty' he explains many other factors that challenge the decision process for any individual patient. He makes his points in terms of real patients and specific surgical procedures, which adds depth and interest to the book.

Part 1 on 'Fallibility' covers: the conflict between the desire to give the best care possible, and the need to provide novice surgeons with practice; the conflict between progress and experience in applied techniques; the assistance provided to human judgement by computer assessment; and the fact that mistakes are sadly commonplace. The author says '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.' Many of the topics addressed here apply equally to other professions. For example the 'behavioral sentinel events', that warn that something may be seriously wrong, apply equally well to an airline pilot as to a surgeon.

The second part, 'Mystery', covers topics ranging from fear of Friday the 13th to the application of new theories on the psychology of pain to debilitating chronic pain cases - with neuro-stabilizing compounds being developed from the venom of sea snails and Ecuadorian frogs, no less. The push by palliative specialists for pain to be considered the fifth vital sign, and for doctors to 'take suffering seriously, as a problem in itself', sounds encouraging. I learned about surgery for blushing, which apparently can be a severe social problem, and about gastric by-pass surgery to control extreme over-eating ... 'We are a species that has evolved to survive starvation, not to resist abundance.'

Finally, under 'Uncertainty', Dr. Gawande discusses: the need to make decisions in an environment of uncertainty; the importance of autopsies; the trade-off between the patient's right to decide and a doctor's concern that it be a good decision; the reluctance to say 'I do not know'; and finally the intuition factor in human judgement. There are many intriguing tidbits interspersed through the discussion, for example the derivation of the term 'graveyard shift' from people guarding their relatives' corpses from the performance of autopsies.

Overall, the author comes across as a rational physician in a field which is continually striving for perfection, but he also expresses a basic common sense and humanity in comments like 'the real task isn't to banish paternalism; the real task is to preserve kindness.' Indeed, many nowadays rail against the heavy-handed paternalism of physicians, and demand a more equal partnership in their own care. I recommend Complications highly both to potential patients and to the author's fellow practitioners. It's an honest an insightful treatise by someone who obviously cares a great deal about his subject ... but perhaps you shouldn't read it if you have elective surgery scheduled soon.

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