Bitter Medicine


A Surgeon's Notes on an Imperfect Science

By Atul Gawande

Metropolitan Books -- 269pp -- $24

Our society has long had a special regard for doctors. We place enormous trust in them and believe that even if one practitioner does not have the right answer, another surely will. Such complacency, though, is not justified. According to surgical resident Atul Gawande, physicians as often as not make decisions based on guesswork, instinct, or desperation. Their training is a long process of trial and error, with humans as their practice material. Diagnoses vary by doctor and even by time of day. As Gawande notes in his lucid Complications: A Surgeon's Notes On An Imperfect Science, studies of U.S. medicine have found "a stubborn, overwhelming, and embarrassing degree of inconsistency in what we do."

Anyone facing surgery would find this book an insightful read--and a disquieting one. Gawande's essays are divided into three sections with the dismaying titles Fallibility, Mystery, and Uncertainty. Each is meant to demonstrate how messy, tentative, and surprising medicine can be. A Harvard-trained doctor doing a surgical residency at a Boston teaching hospital, Gawande illustrates his themes with cases he has worked on or witnessed, giving readers the sense that they are in the operating room.

It is not a place for anyone looking for surety. His opening essay, about the way doctors are trained, gives a firsthand view of how novice docs are allowed to practice--on us. Granted, they have to get experience somewhere, but many patients are not aware that the person cutting open their chest may never have done it before. If they were, they would surely say "no, thanks"--as, writes Gawande, most doctors do when it comes to surgery performed on themselves or their families. But if everyone refused treatment by an intern or resident, how would doctors get the training they need?

Gawande does a good job of laying out many such conundrums inherent in the practice of medicine. Several of these essays appeared first in The New Yorker, where Gawande is a staff writer, and the polished presentation of that magazine shows. His writing is clear; his case histories fascinating.

They are also frightening. The final chapter explains how difficult it can be to make a foolproof diagnosis, using the example of a young woman who arrived at his emergency room with seemingly nothing more than an infected blister. By sheer "luck," Gawande had recently treated another patient who had died of necrotizing fasciitis, a rare, lethal infection that can be treated only by cutting out the infected tissue. He was worried about the new patient, and brought in a specialist willing to biopsy the leg, even though he thought the diagnosis unlikely. The patient did indeed have fasciitis, but the specialist decided to take a potentially huge risk and not amputate. Instead, the woman underwent four operations in four days. She was lucky enough to survive, with all her limbs. Still, Gawande writes that doctors can never be sure if their actions will prove wise. "That our efforts succeed at all is sometimes a shock to me. But they do. Not always, but often enough." Patients have little choice but to find comfort in that thought.

By Catherine Arnst

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