Review of Complications: A Surgeons Notes on an Imperfect Science

 

After reading Paul Kalanithi's "When Breath Becomes Air" I had a craving for more physician authored books. Keep in mind however that technically these are very different books and read very different. However they share a very common theme. Gawande wrote this in his last year as residency. One of the central ideas of this book- that perfection and knowledge comes from practice and that practice has to essentially be stolen is fascinating. When do physicians lie? When they say that a pacemaker surgery for a patient above 80 has a 2.5% risk of death, does that equally portray a 10% risk of death in the first year following the surgery? But at the same time, this simple surgery still prolongs life, improves life, and genuinely carries a low risk- and a short recovery time compared to most surgeries. This simple argument and conversation can be had out in full with the patient and help them make a fully informed discussion. Except when it can't. Autonomy in medicine is a big interest of mine- history used to have it so that physicians had full control and decision making power with patients and with more modern times its been a complete 180. HIPAA makes sure patients have a right to their medical information and is extremely protective of it. I actually have become more and more of a believer that sometimes people don't know what they want. Or at the very least, environmental and more recent factors will play too large a role in the average person's decision making that can be extremely difficult to sway them away from. This is especially true in inpatient settings where the patient can have 1000 "little things" driving them crazy. They add up and it makes them not just poor decision makers but also anxious and depressed. Sometimes I explain to my patients that my most important job as a CNA is to make them feel a bit more human. A clean gown, a bath, a walk, fresh sheets. It all is still in the hospital but doing some good is better than doing none. Something as simple as McDonald's instead of hospital food could make that key difference in the patient seeing they can make  it through another hour, another day, another week. I bought a Carl Schneider book on autonomy in medicine that I'm looking forward to. The answer- as with most things, is not black and white, but various shades of grey. I think as a physician you need to decide what you think is best for the patient, then hear their wants- and why they're saying  that they want that. Then try your best to not convince or grab compliance- but to form a bridge of understanding between both and have a "story" of recovery for the patient rather than just your decision. This is all if everything goes perfect. Barriers such as bad past experiences, age difference, cultural difference, and more serve as lots of noise in trying to disturb this process. It's a lot easier to sit here and type out how things SHOULD go using perfect empathy 100% of the time than it is to do it. Systems should be implemented and general practice formed. The specifics of this though? Not sure. 

To get on  with the book it was very fun. The heavy theme of medicine being so imperfect despite our wishes otherwise is incredible. Gawande touches on so much in this book that it serves again as a great source of empathy, understanding common troubles in medicine, and just plain great story telling. Gawande is not afraid to make the reader uncomfortable, but it NEEDS to be discussed in medicine. We can't just keep ignoring the fact that we want perfection but perfection is attained through trial and error to learn. These errors? They can happen on you, they can happen on your children. Nothing is perfect, everyone understands that- yet we cannot help but be surprised at the lack of.... coherence or justice(?) when it is not so. As a CNA I have dealt with numerous confused and disoriented patients. Always, even if they don't know the year or where they are or even how to properly answer these questions, let alone the answer- there is an expectation of reality. "You can't do this to me." "What did I ever do to you." "Please leave me alone." These are commonly  heard as we perform either a bath, place an IV or a foley catheter. Even completely lacking any orientation there is still expectation in for a justice, for reason, for cause and effect. When reality is so often just. Chaos. Random. Too many factors to ever have a prediction in many cases. Medicine is not perfect. If I ever have a conversation with anyone about trying to convince them that I think I know what's best- I will make absolute clear- that doesn't mean I think I know what will happen. Life is full of unknowns and scary risks- yet we must decide anyways lacking the proper information. Later on we might have known what clues to look for but there is only the present, on the right now. We can either decide, prepare for future decisions, or die. Try our best- I hope mine will be good enough.