If doctors are our high priests, then surgeons are something like deities, but one US specialist isn't afraid to admit they sometimes make mistakes. Atul Gawande tells Anna Mundowwhy it's important to understand the fallibility in medicine
On a perfect spring day - with apple blossom overhead and underfoot - I am in Boston to interview the writer and physician Atul Gawande. My friend Julie has come to the city for a weightier medical appointment, to see a surgeon who hopes to perform a series of operations that might enable her to eat again, or at least to swallow. Julie's throat is scarred shut from treatment she received for advanced neck cancer. If a new passageway cannot be created, she will remain on a feeding tube for the rest of her life. She is 61. Never smoked. Never previously sick. Today she hopes to meet a doctor who is practically a miracle worker.
Gawande knows what every doctor knows: that there are no miracle workers in his profession. There are incompetent physicians, superb physicians and everything in between. And even the best make mistakes. Gawande is a rarity (some say a traitor) because he doesn't just acknowledge the existence - and the extent - of medical failure; he writes about it.
"When I wrote Complications, it felt to some people that I was breaking a code," he says. "One said to me: 'This may be good for patients, but is it good for doctors?' And that question alone bothered me. In a world where we seem to think we can get trust only by pretending to be gods, we aren't sure how to acknowledge our own ordinariness and fallibility. I started writing as a trainee who was supposed to know it all but didn't know it all. I've subsequently learned that you can't possibly know it all."
Complications: A Surgeon's Notes on an Imperfect Sciencefurther enhanced the reputation that Gawande had earned with articles for the New Yorker and Slate as a writer-philosopher, not just a physician-writer. His second book, Better: A Surgeon's Notes on Performance, takes the reader from the wards and operating rooms at home to the battlefield hospitals of Iraq, from the death chambers of US prisons to an Indian province fighting a polio outbreak.
"This is a book about how success is achieved in medicine," Gawande writes in his introduction. "And it's the particulars that are significant.At bottom, success comes out of a constant struggle between the details of how the world works and the character and ability of the people in it - out of the human struggle to do better."
He goes on to identify diligence, the commitment to do right and ingenuity as three essential qualities in a profession where "we cannot settle for average".
Tall, lean and cool in a white shirt, dark designer suit and loafers, this modest 41-year-old, who looks Indian (his parents are Indian doctors) and speaks with an Ohio accent, describes his typical week. "Mondays and Wednesdays I have clinic. Thursdays and Fridays are full days in the operating room. In a week I will see maybe 30 patients, which is not a ton. I do primarily cancer surgery, so maybe 80 per cent of my consults end up needing the operation. Then I have my share of general surgery patients; everything from lumps and bumps to why is my belly hurting me?"
Gawande is a leading specialist in endocrine surgery at Brigham and Women's Hospital, in Boston, and he also teaches at Harvard Medical School. "I will perform about 350 operations in the next year," he writes. "For six, maybe eight patients - roughly 2 per cent - things will not go well. They will develop life-threatening bleeding. Or I will damage a critical nerve. Or I will make a wrong diagnosis. Whatever Hippocrates may have said, sometimes we do harm."
In half of those cases, he admits, "I will simply have done something wrong, and my mistake may change someone's life forever." Gawande writes affectingly about physicians' guilt and sorrow; he examines malpractice lawsuits insightfully and makes recommendations for improving the process.
His point, however, is not how bad medical performance is but how much better it can be if its results are carefully monitored. "There are places that have figured out how to get better results than elsewhere, and we don't know what they know. Patients are aware of this. They're wondering what hospital they should go to, which surgeon they should see. They're hungry for that information. And people in medicine are hungry to pick up lessons from the people who are doing better than they are."
Comparing death rates is not enough, Gawande insists. In Better, he cites, among other examples, former US treasury secretary Paul O'Neill's admittedly short-lived success in reducing hospital infection rates in a Pittsburgh hospital; the continuous data-gathering and performance analysis carried out by the Cystic Fibrosis Foundation; and the US military's reduction of death rates for wounded soldiers from 25 per cent in the Gulf War of 1991 to less than 10 per cent today. (In a recent New York Times article, Gawande examined how this willingness to expose medical failure itself failed when it came to caring for wounded soldiers at Walter Reed Army Medical Center.)
Gawande understands avoidance. "I spent a lot of time trying to avoid becoming a physician," he says, laughing, "which is what every good Indian child is supposed to become." He rebelled by studying philosophy at Oxford ("where everyone was asking questions I didn't understand") and then becoming involved in politics (he was an adviser to President Clinton on health policy). "But I kept coming back to medicine. It was predictable for my kind of personality and something I knew I could do."
Surgery attracted Gawande, in part, because "surgeons are allowed to be characters and to think things through in their own idiosyncratic way". They also keep failure uppermost in their minds: "That's just how surgeons think." It is also, Gawande stresses, how patients should think. He advises his patients to bring all their medications to each appointment, "because people often get things wrong, can't remember, or the doctor prescribes something in conflict".
In the hospital, to the irritation of some staff, he advises: "If you have a sick family member, don't leave them alone. With so many nurses and doctors coming and going, there are very few who see how things change over time. You can be the glue for that. You're also the person who can say 'Did you wash your hands?' or 'I think he already had that.' It's not just a negative role. As a physician I can tap them, ask the family 'How do you think he's doing today?' These small things make a huge difference."
Our time is almost up, although Gawande looks as if he could sit happily for hours. It is an impression I suspect he gives in every situation, no matter how dire. I tentatively mention my friend Julie and ask what it is like, as a surgeon, to be the object of a patient's hope. "Oh no," Gawande says softly when I mention Julie's appointment. "Can I ask what her problem is?" He nods as I describe it. Familiar ground. "She's going to her surgeon with the same emotion my patients typically have, a combination of fear and hope," he says. "You easily become the vessel for that. What you try to manage is hope that's too high, pessimism that's too low and what they're ready to hear."
Gawande recently travelled to his father's birthplace in India, for scientific rather than sentimental reasons, and the experience further humbled him. "I'm this Harvard-trained surgeon who had nothing to teach them," he says, smiling. "They would ask me: 'What's your technique for bladder surgery or for treating a brain tumour?' And I would say: 'Call a urologist and a neurosurgeon.' But they have to be all of those things, develop the ingenuity to operate and see 200 patients in a morning. I couldn't handle 20 in a four-hour clinic." He pauses for a moment.
"The thing to remember is that medicine is about taking responsibility for other people, no matter how much we try to turn it into shift work. If you don't feel that responsibility, you're not doing your job."
Better: A Surgeon's Notes on Performance by Atul Gawande is published by Profile Books, £12.99 in UK