Strong Medicine

Doc Searls blogged yesterday about surgery involving general anesthesia and he continues today based on a lot of comments and emails he's received. Doc has pretty strong feelings on the subject, and the recent death of a friend following surgery probably fueled the following statement:

"Mistakes in medicine are worse than common. They're standard. We live and die by statistical rules for which success is the generally (but not entirely reliable) exception. We usually survive. But not always. Imagine if you knew that one out of every 100 drivers coming your way would hit you; but that you also have little choice but to drive if you want to live. That's how the bargain goes." - Doc Searls

I posted a comment on Doc's blog but I thought that I would post a similar note here as well. Now, my bias on the subject is that I am married to a doctor and have spent many years in the company of people practicing medicine. But I believe it is an informed bias because I have looked at the issue from both sides of the coin. I have been wheeled into the operating room before and I have come to know the people doing the operating.

Atul Gawande's Complications: A Surgeon's Notes on an Imperfect Science is perhaps the best book I have ever read on the subject of fallibility in medicine. (You can read an excerpt, an interview, and a speech with audio online.) Gawande, a former Rhodes Scholar who received his M.D. from Harvard Medical School and an M.P.H. from the Harvard School of Public Health, is now a practicing general surgeon in Boston and is a writer for The New Yorker. Despite Dr. Gawande's impressive credentials he candidly admits he, like everyone in the medical profession, makes mistakes. The book cuts through the thin layer of mystery to reveal that doctors are not immune to the fallibility that afflicts each of us.

"I think we're at a difficult juncture. On the one hand, medicine has become extraordinarily aggressive and bewildering and also powerful, in the sense that it is capable of truly extending people's lives, whether they have heart disease or kidney failure or even cancer. On the other hand, patients are being asked to make more choices and take on responsibilities of a greater magnitude than they ever have had to before. And that's because we have finally come to grips with the notion that, okay, doctors are not gods. But what comes after that? No one has really prepared anyone for this, and I think that's because we've never really shown people how medicine works: what decisions really matter, how they're made, how much uncertainty there is, how that uncertainty is dealt with. The thing that most startled me upon entering the medical profession is how human an endeavor it is. We have all the technology and studies and science and know-how and yet, in the end, it's still this tiny pair—the individual doctor and the individual patient—who are left to try to sort through it all. It's the decisions that are really critical. And those decisions are inherently imperfect because both doctor and patient are fallible, because there are still mysteries in medicine—things that we don't understand—and because there is always going to be uncertainty." - Atul Gawande, interview about Complications

To paraphrase Doc Searls, mistakes in [insert any occupation here] are worse than common. They're standard. I make mistakes at work every day. Just like everyone else I have ever known, I am fallible. Experience has taught me over the years not to make mistakes that doom projects or cost me my job. But I still make them and I try and learn from each of them. The same is true of doctors.

"In surgery, as in anything else, skill and confidence are learned through experience—haltingly and humiliatingly. Like the tennis player and the oboist and the guy who fixes hard drives, we need practice to get good at what we do. There is one difference in medicine, though: it is people we practice upon." - Atul Gawande, Complications

We want doctors to be perfect because life and death often hangs in the balance. But they are just as imperfect as the rest of us. As imperfect as the nurses, the hospital staff, the people who make the scalpels, retractors, clamps, gloves, scissors, sutures, stents, masks, gowns, retractors, clamps, aspirators, pumps, tubes, IVs, needles, syringes, respirators, beds, and lights, and the human body.