Mistakes made in operating theatres are matters of life and death, but the writings of one American surgeon reveal just how often it's a case of trial and error. Kathryn Holmquist reports.
Atul Gawande was a "surgical resident" in Boston - our term for a "junior doctor" - when he went against advice to write a series of exposés about the mistakes surgeons make. His shocking but beautifully written essays, originally published in the New Yorker, are now released as a book: Complications: A Surgeon's Notes on an Imperfect Science. The book is on the shortlist for the National Book Award (the US version of the Booker Prize). Whether or not Complications wins the prize, Gawande's brilliant essays have torn away the veil that has so long protected surgeons from scrutiny. Being a patient has suddenly become more complicated.
Gawande broke the rules to reveal the surgical learning curve that inevitably increases the risks of patients dying. Yet practice is the only way surgeons can learn.
Gawande's first essay focused on his virgin attempt to insert a "central line". This involves threading a two-foot-long, 20-gauge wire that looks like the steel D string of an electric guitar through the subclavian vein in the chest. You cannot see what you are doing, but if you puncture the lung, damage the heart or lose direction altogether and penetrate the brain, you have killed your patient.
But there's a first time for everything. If the patient is lucky, somebody has let the resident try on a goat or a cadaver first. However, usually the resident's first endeavours are on a living person whose family are praying in the waiting room.
The patient, conscious during the procedure, doesn't know it's the first time for the resident. To increase the patient's confidence, residents throw shapes and use secret language with their attending surgeons to give the impression that they are experienced in the procedure.
"Ow," the patient shouts. The resident has missed. So he tries a second time. "Ow!" the patient shouts again. The attending surgeon takes over and gets it in one go. The next day, the resident will try again. Learning has to be fast. Gawande confides that by the time the surgeon has overcome his first mistake to insert a central line successfully in patients number two and three, he is already teaching other people how to do it.
Shortly after Gawande's book was published in the US, he found himself inserting a central line into a keen reader of the New Yorker. The patient knew too well of the risks. To make matters worse, Gawande was a senior resident supervising a more junior resident, who was herself inserting a central line for the first time.
"I subscribe to the New Yorker," is not a line that most patients would consider essential when consulting their surgeon, but in this case it was all too relevant. Gawande says he explained the risks to the patient who consented, but not before giving the cautionary words: "I'm willing to give her one go. After that, you do it." The resident got it in one go.
"I think the patient was more relaxed knowing the risks," says Gawande. "We talked about it honestly, which is what patients and surgeons need to do."
Gawande tells me this story from his hotel room in London, where he is spending one week's holiday away from his work at Brigham and Women's Hospital in Boston to promote his book while celebrating his 10th wedding anniversary with his wife, Kathleen Hobson.
A Stanford graduate, Kathleen has given up her career to be full-time mother to the couple's three children, Walker (7), Hattie (6) and Hunter (4), an uneasy decision for her. When Gawande returns to Boston, he will be starting as a lecturer in the Department of Public Health at Harvard University, while also practising at Brigham and Women's as both a surgeon and a teacher.
Obviously, his decision to spill the guts of the surgical profession hasn't done him harm. "For too long, surgeons have been seen as gods. Surgeons are human beings, yet we spent so long convincing patients that we were more or less infallible. Now the veneer has broken down. The media picks up every sensational error. So how do we go forward, now that we understand that doctors are not gods?" he asks.
PRACTICE makes perfect and most surgeons don't get enough practice before they start operating on real patients, Gawande asserts. Surgeons may try a new procedure after a three-day workshop where they get no experience on a patient. Inevitably, death rates rise when they try the procedure on their first patient.
One example of this occurred at Great Ormond Street children's hospital in London in the 1980s. Surgeons on a "learning curve" for a new heart procedure called "switch" inadvertently killed many children before they perfected the operation and began to save lives. By the time they had perfected the operation, many more children were surviving to live far longer lives. The early patients literally gave their lives for the benefit of those who came later. And this experimentation, Gawande tells us, happens all the time. Patients unknowingly sacrifice their own lives to improve the chances for those who follow.
Gawande, the son of two Indian doctors - a paediatrician and a urologist - grew up in Athens, Ohio. He went to Stanford, then began medical school at Harvard. At the age of 25, he campaigned for Al Gore and by the age of 26 he found himself on Bill Clinton's advisory team in Little Rock, during Clinton's first presidential campaign.
Once they got to the White House, Gawande worked 21-hour days. "Clinton slept only four hours a night, which meant that we advisers slept for three hours. We had briefings at 11 p.m. and again at 6 a.m. Clinton projected two different personalities - one to his team and another to his friends. To his team, he was a stern and demanding taskmaster," says Gawande.
Distancing himself from Hillary Clinton's failed health programme, Gawande prefers to stress his influence on Clinton's welfare programme, which improved the lives of low-income families through a system of tax credits. If he were given carte blanche over the US medical system, Gawande would introduce universal health insurance - a scheme based on equality in which the son of a doctor would get the same treatment as the son of a trucker.
Living the courage of these ideals is a different matter, Gawande admits. When Gawande's first child, Walker, was six weeks old, the infant went into cardiac arrest with a potentially fatal heart defect. The cardiology resident, who was learning - as Gawande knew too well - saved Walker's life with emergency surgery. Further surgery would be required as Walker grew up. As Gawande was leaving the hospital, the resident handed him his card, hoping that Gawande would choose him as Walker's surgeon.
Gawande, who has written passionately about residents' needs to practise on patients if medicine is to move forward, refused the invitation. He explained, as kindly as he could, that he had already chosen a senior paediatric cardiologist, experienced in the surgery, to take Walker's case.
Was this decision hypocritical or pragmatic? Gawande reasons that the resident had already benefited from the experience of practising on Walker.
Gawande was acting as a parent, not as a doctor, when he chose the best possible doctor for his child.
But how does this square with Gawande's ideals that the son of a doctor and the son of a trucker should be treated equally? Gawande says he would like to see changes in the system so that parents, and patients, don't have such choices to make. "The well-connected and the well-informed get a different kind of care. It was OK for me making the decision to use information and connections because that's the way the system works," he reasons.