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Complications: A Surgeon's Notes on an Imperfect Science
By Atul Gawande
Hardback 288 pp Metropolitan Books $24
Paperback 288 pp Picador $13

Over the years, a lot of attention has been paid to the inner workings of hospitals and the medical profession, from the 1960s television series "Marcus Welby, MD" and today's "Scrubs" and "ER," to the eloquent writings of physician-writer Richard Seltzer, who has described the moment-to-moment tension as human beings hover between life and death.

There's a reason why all this makes such riveting material. It allows us to have a front-row seat at the core human drama -- the battle for survival, when people whose lives hang in the balance may or may not be plucked from the brink by the heroics of those whose job it is to try to save them.

I've found myself just as fascinated as the next person with the various popular explorations into medical science, human nature, fate, and the blurry edges of life and death. Yet, in my experience, none of the attempts so far has come as close to parting the curtain on the inner workings of medicine as Atul Gawande's best-seller Complications: A Surgeon's Notes on an Imperfect Science.

Born into a family of doctors, Gawande grew up hearing medical tales and hanging around hospitals. While still a resident, he began writing for The New Yorker, and a number of the articles published there made it into this book.

There's good reason this work was a National Book Award finalist: Gawande's writing is close to the bone, sometimes excruciating in its candor. A brilliant and thoughtful writer, he probes a realm in which there are often no easy answers, no sitcom wrap-ups. The central predicament of medicine, the author points out, is uncertainty, and things do not always turn out well. "In recent years," writes Gawande, "we in medicine have discovered how discouragingly often we turn out to do wrong by patients."

To use the word "notes" rather than, say, "observations" in the otherwise perfect title of this book is to diminish its polished and eloquent quality. It is typical, perhaps, of the humble attitude Gawande brings to his subject. With rare insight and an even rarer willingness to admit his own failures as a surgeon, while acknowledging his successes, the author has an incisive ability to bring medical drama to life.

When Gawande, then still a resident surgeon, must face the criticism of an attending physician after bungling an emergency tracheostomy, his unflinchingly detailed recounting of what went wrong gives the reader a clear view of the difficult choices doctors have to make. Gawande also shares the shame he feels when he makes a wrong choice while treating the patient, an 34-year-old woman who has been brought in, unconscious and unable to breathe. Already turning blue, with blood flowing into an incision in her throat, the woman is in danger of going into cardiac arrest. As seconds tick by, Gawande realizes he is in trouble. Did I make the correct incision? Should I call the staff physician in charge to supervise? Gawande worries. He makes the wrong decision and must face the burning glare of a Morbidity and Mortality committee.

That kind of second-guessing might raise the hackles of any doctor. But what Gawande feels is quite different: "I felt a sense of shame like a burning ulcer. This was not guilt: guilt is what you feel when you have done something wrong. What I felt was shame: I was what was wrong."

Complications is full of these wrong turns, but also right ones. In chronicling his own failures, Gawande offers a chilling truth: "All doctors make terrible mistakes." But he also writes of the heroic saves, those exhilarating moments when everything goes right. His account of diagnosing and treating a young woman's case of flesh-eating bacteria is an awesome and humbling excursion into medicine at its life-saving best.

Part of the fascination with this journey is that Gawande lets us see the surgeons up close, steers us through the complexities of decision making, and illuminates the breakthroughs and breakdowns. Seldom have I learned so much while turning pages with such pure enjoyment. Even when writing about the statistical analysis of medical errors or exploring the practical uses of an autopsy, Gawande pulls the reader in. If a few of the chapters are less compelling than others -- nausea makes for less interesting reading than does flesh-eating bacteria, for instance -- Gawande still shines as a storyteller. It's not all easy reading, though, especially if a hospital stay is in your future.

Gawande's book is by turns horrifying and hopeful. Above all, he shows the reader -- in deep, mesmerizing detail -- how iffy and complex it all is. "We are all, whatever we do, in the hands of flawed human beings," he writes. "The fact is hard to stare in the face. But it is inescapable."

"We find it hard in medicine to talk about this with patients," he admits. Yet in these pages he has done just that. His book is a memorable, spellbinding exploration of human suffering and the search for relief.

Just when the author has scared the hell out of you about ever getting close to a hospital, he presents a scenario that makes you incredibly grateful that hospitals and doctors exist -- illustrating how, in this imperfect science, it's possible to save people. "That our efforts succeed at all is still sometimes a shock to me," he writes. "But they do. Not always, but often enough."

-- Karin Evans is a former deputy editor of Hippocrates magazine and senior editor for Health magazine. She's currently at work on a book about exercise and aging, titled "Running with Sister Madonna."

First published July 18, 2003
Last updated March 6, 2008
Copyright © 2003 Consumer Health Interactive

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