Thursday, July 05, 2007

'Complications' by Atul Gawande

Writing about books has two positive results and one negative. The positive results first. One -I never run out of subjects provided I keep on reading new books, and two - suppose I want to remind myself of this book, say a few years later, I can just read this review of mine. I have often felt the need for the latter. The negative result - I will be writing about things I have not experienced personally. Many of the ideas will not be my own. But I am willing to take that risk. Henceforth I plan to write about all the interesting books I read. I hope to intersperse the "book-review posts" with other subjects, but let that be for now.

The latest book I read, 'Complications' written by Atul Gawande, was very, very interesting, and it is an understatement. I have been interested in the medical field for as long as I remember. When I go to the doctor either as a patient or as the patient's relative, I am informed. I usually have a fair idea of the side effects of the medicines prescribed. However, after reading 'Complications', I realized how inadequate all that was. It was an epiphany. I trust a couple of doctors implicitly, and the fact that they too can be fallible, is scary, but true. The book talks about mistakes that even good doctors might make, and that wee bit of extra cautiousness that has often saved patients' lives.

Gawande writes with the clinical precision and detachment capable only of a surgeon. And yet there is humanity, there are the intense emotions that even doctors experience. There is not a dull chapter, or even a dull sentence in the book. It could be called delightful, if the subject were not so morbid and serious.

I remember freaking out when I went to the hospital at an unearthly hour and saw the young, inexperienced duty doctor instead of my usual gynecologist. One cannot deny that more experience makes better doctors. And age does matter. Most people I have met are more comfortable with old, experienced doctors than younger doctors with sophisticated degrees. Gawande states an instance where experience came in real handy. A patient came in with a reddened and swollen leg. All the indications were pointing toward cellulitis, a common but treatable infection. But just weeks ago, Gawande had lost one of his patients to necrotizing fasciitis, a rare and fatal bacterial infection that can be treated surgically, only in the very initial stage. (These bacteria, usually strains of streptococcus A, can enter the body through a "wound" as small as a pinprick.) His experience made him order a biopsy and his fears were indeed true. The patient had most of the tissue removed from her leg, but she survived. What would have happened to her if the doctor did not have this kind of an experience earlier? Would the warning bells have sounded even then? It is really hard to say!

There is also this matter of statistics. Cellulitis is a common infection. And about 5% of the cases, thought to be cellulitis at first, turn out to be necrotizing faciitis. Does this help the doctor make a decision on whether the patient in front of him right then has one or the other? Can a good doctor assume that exactly 5 out of a hundred cellulitis-patients that see him have the flesh-eating bacteria? No! Statistics are there to just comfort and/or caution, but they can never be used as a guideline.

From the days of Hippocrates and our own Sushruta, Medical Science has been improving. But newer technology has its own costs. I remember feeling elated when I read about "laparoscopic cholesystectomy" in my high school days. I thought of all the lives that would be saved because of the new technology. The thought that never came to me till I read "Complications" was the learning curve of the doctors. Gawande describes a laparoscopic cholesystectomy (the removal of the gall bladder) that he performed. Only after reading that did I realize how complicated it was, how difficult it was to learn new techniques. Doctors, like all others, take time to learn. But unlike us engineers, their experiments are with life; the stakes are high. One mistake, just half a second of haziness while wielding the scalpel can kill. Okay, I may be exaggerating, but the point is that doctors are responsible for the most precious things in this world.

And they deserve that responsibility. Risks have to be taken if lives are to be saved. Gawande talks about an unusual surgery, the gastric bypass surgery. (There was a report about this surgery in this week's 'Health' supplement of the Indian Express). In this surgery, the stomach is stapled, thereby reducing its size, and about a metre of the small intestine is bypassed, so that less food is absorbed. This is the best cure now available for morbid obesity. I mean, just think of the capability of one four-hour surgery! Many people are leading healthy and happy lives because of the surgery. So, at some point, a decision has to be made. For doctors, however, difficult decisions have to be made all the time.

In the Indian tradition, we say that one should trust the doctor completely. Indeed, it is said that the result is proportional to our trust. From a psychological perspective, this makes complete sense. Though *all* our illnesses are not rooted in the mind, many of them are. Therefore, trusting the doctor is important. But how far do we go? Ultimately it is our own body we are talking about. In Kannada they say 'ಹೊಸ ವೈದ್ಯರಿಗಿಂತ ಹಳೆ ರೋಗಿಯೇ ಮೇಲು', which is true to some extent (My grandma used to do this. She had diabetes, and whenever she ate an extra sweet, she would take a little more of her diabetes medication, without consulting the doctor!). There should be a sort of a compromise between the doctor and the patient as to who listens to whom, to what extent.

'Complications' got me started on thinking about a related thing. There are happy endings and sad endings. But, isn't 'Life' mysterious? A person who has four heart attacks may survive and thrive, whereas another may die of a pinprick. A pacemaker can help an ailing heart, a ventilator can substitute the lungs and a dialysis machine, the kidneys. What is the nature of that "one thing" that keeps all these and more working together in so much harmony that if one organ fails, all the others gradually fail, too. I am delving into Philosophy here, but isn't that a question worth considering?


Aram said...

Thanks for a long-awaited post.

" But unlike us engineers, their experiments are with life.." reminds me of an old joke.

A car mechanic complaining to the doctor about the latter's high bill says, "Doctor, you and I both are in the same business of repairing but I don't charge like you."

The doctor replies, "Try doing your repair work with the engine running."

Aram said...

One cannot deny that more experience makes better doctors. And age does matter."

This is generally speaking very true.

But, here are two exceptions.

Arthur Hailey's all-time classic, "Final Diagnosis" is about an ageing pathologist who was brilliant in his younger days but now due to personal tragedies and also ageing has not kept up with the latest in pathology and the result is that his incompetence affects the entire hospital.

The other instance is a personal experience. Once I went to a well-established German-returned oral maxillofacial surgeon ( he insisted upon being addressed as such if by ignorance we referred to him as a dentist)for a tooth extraction. He scared me saying that it was bound to be very painful as only small bits and pieces of the tooth remained. I opted to postpone the extraction and after some time went to my village to a newly qualified dentist who did the work without any fuss and with minimum pain for me.

Aram said...

"What is the nature of that "one thing" that keeps all these and more working together in so much harmony that if one organ fails, all the others gradually fail, too?
Answer: The Supreme Engineer - Niraakara, Nirguna whose divine design is what makes everything from a microbe to a mighty star working or stop working.

parijata said...

Thanks for waiting for my post :) Makes me want to write more and more.

Nice joke about the engineer and the doctor.

About age and experience, what you say is true. Younger doctors have a better idea of the new technology, and can often do a better job than the older ones. In fact, Gawande writes about doctors who just lose it and are forced to retire. (I wrote about that, too. But that paragraph did not turn out as good as I wanted it, so I removed it).

The nature of that "one thing"... As I think, I am lost for words.
"divine design is what makes everything from a microbe to a mighty star working or stop working"
Very nice way to put it!

Deepak said...

Good anlysis.Thats true"Life is a mystery".

Granthi said...

just happy to inform you that your review inspired me to ask my suppliers, Blossoms who ordered 2 copies of this book from their distributors.

I also read in your site about somebody ruing the fact that there were very few lady reviewers. Probably they were not aware of your outputs.

Keep up the good work.

parijata said...


Thanks for the encouraging words.
Blossoms is a very good store. I love the tall shelves stacked with books, old and new. The people who work there are very knowledgeable too. Shopping at that store is a very good experience.

Thanks for saying that my reviews count, too!

Granthi said...

was at gangarams
saw dr.gawande's second book 'better- a surgeon's notes on performance' and bought it though yet to start on the earlier one, 'complications'
your review does count

Aram said...

My very first introduction to blogs was when I googled to know why Hemu Ramaiah was selling her Landmark chain of bookstore to Tatas. The search took me to the "blahg" site of
Samanth Subramanian, a journo from Chennai.

He has interviewed Dr. Atul Gawande for The Hindu.

parijata said...

I read three-fourths of 'Better'. It is a very good book too. Doesn't he write well?

I read that interview. It's very interesting. I envy that blogger, really! But that's the advantage of being a journalist...