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Good Book Review

April 7, 2002 NY Times

'Complications': An Uncompromising Look at Medical Fallibility By F. GONZALEZ-CRUSSI

Let no one suppose,'' Bernard Shaw once declared, ''that the words doctor and patient can disguise from the parties the fact that they are employer and employee.'' Indeed, until recently, metaphors for the doctor-patient relationship evoked intercommunicating vessels between which no liquid passes unless one is set higher than the other. The fluid was, of course, the healing influence or vis curativa. And the physician had to be the upraised vessel. Only thus would the beneficial contents flow, from all-knowing doctor to appropriately lowered, humble and unquestioning patient.

That this peculiar physics is going out of style is only too apparent. Today's ideal reflects the enlightened notion that both doctor and patient are reasonable people whose combined efforts are required to combat disease effectively. But in that harmonious relationship, the physician's candor is essential. This is one reason why ''Complications,'' a book written by a surgeon, Atul Gawande, is a breath of fresh air. Tellingly, its three main sections are titled ''Fallibility,'' ''Mystery'' and ''Uncertainty.''

Each part consists of a group of narratives, couched in an engaging, agile style and somehow adverting to the shortcoming of the medical profession suggested by the heading. Thus, in ''Fallibility,'' the reader confronts the sobering fact that physicians must learn, and that learning, even in the best organized, most expertly supervised environment, involves mistakes. Alas, some patients will be harmed. Worse yet, the poor, the uninsured, the most disadvantaged populations suffer the most, since it is for these that physicians in training bear the greatest amount of unsupervised responsibility. All this we may find revolting, but in the current system no viable alternative is in sight. ''We want perfection without practice,'' Gawande writes. ''Yet everyone is harmed if no one is trained for the future.''

At a time when more and more American medicine is regarded as an industry, the uses and customs of industrial corporations are being deployed in the clinic. I once heard the impressive slogan ''zero mistakes'' ardently propagandized by a highly paid consultant at the hospital where I worked. On the one hand, the slogan reflected the commendable ethos of unflagging intolerance to mistakes; on the other, it undermined its own effectiveness by running counter to the categorical truth, vouched for by the experience of milleniums and confirmed by the foremost thinkers of every age, that human beings are fallible.

Gawande's chapter on medical mistakes I consider a model of its kind. It includes a well-informed review (notes on sources are provided for each chapter) of ways in which operational measures taken from industry have directly benefited, and might continue to improve, medical practice. At the same time, it underscores the fact that the parallel can go only so far. For the goal in the clinic, unlike the assembly line, is not the delivery of a fixed product or even a whole catalog of defined products. The goal is health and well-being, and these are in no small measure constructs of the perplexing, intricate, idiosyncratic human mind.

''From what I've learned looking inside people,'' Gawande writes, ''I've decided human beings are somewhere between a hurricane and an ice cube: in some respects, permanently mysterious, but in others -- with enough science and careful probing -- entirely scrutable. It would be as foolish to think we have reached the limits of human knowledge as it is to think we could ever know everything.'' The truth is, he says with a justifiable flourish, that medical practice ''may well be more complex than just about any other field of human endeavor.''

Under ''Mystery,'' Gawande takes us to the boundless realm of the medically unexplained. Diseases come and go, often without apparent cause. Or a causal role is rashly attributed to factors that are purely coincidental. The same demonstrable abnormality shows up in some patients with excruciating symptoms while in other patients it courses unperceived. An epidemic of backache among physicians who formerly withstood endless hours stooping in the operating room may be related, Gawande suggests, to growing dissatisfaction with their profession. Without lecturing to us, by the sole expedient of telling us fascinating stories, Gawande, who is also a staff writer on medicine and science for The New Yorker, leads us to ponder the knotty philosophical riddles enmeshed in the very texture of disease: what is the meaning of pain; how can it be that intangible, abstract phenomena, like memories and desires, dovetail seamlessly with concrete, organic manifestations; why would bodily reactions, presumably of evolutionary usefulness, suddenly go awry (as in the engrossing story, called ''Crimson Tide,'' of a girl who blushed uncontrollably); or how easily the mind-body ties turn to shackles that are disabling (as in the appalling case histories of patients with morbid obesity).

The last section, ''Uncertainty,'' ushers us farther into the twin domains of fascination and bewilderment. ''The core predicament of medicine -- the thing that makes being a patient so wrenching, being a doctor so difficult and being a part of a society that pays the bills they run up so vexing -- is uncertainty,'' Gawande writes. ''Medicine's ground state is uncertainty. And wisdom -- for both patients and doctors -- is defined by how one copes with it.''

We are given a glimpse of that mysterious, tragic condition, the sudden, unexplained death of infants (SIDS, or sudden infant death syndrome), for which in my own lifetime at least a dozen hypothetical explanations have been seriously entertained. As a pathologist, I thoroughly enjoyed the chapter named ''Final Cut,'' in which Gawande, with admirable forthrightness, tells us that one important cause for the decline of the autopsy is hubris. Physicians today believe that with modern high-tech medical instrumentation no diagnosis can escape them, a stance that defies recent studies showing that 40 percent of the time an autopsy uncovers abnormalities not diagnosed during the patient's life, and one-third of these are of such magnitude that they would have modified the course of treatment, had they been known opportunely.

Again, the writer who tells us all this is not lecturing. He is practicing with uncommon dexterity that arcane alchemy for which I can summon no better name than ''verbal magic,'' and which consists in making the concepts emerge by themselves, merely by parading before us men and women who live their lives and die their deaths in front of us, the readers.

By his own admission, Gawande purported to tell us unambiguously what is right with medicine and what is wrong with it. This he has done admirably well. At a time when a hospital advertises with the phrase ''where miracles happen''; when physicians claim, without blushing, to perform ''cardiac resuscitation,'' letting people believe that they bring back Lazarus every day, candor like Gawande's deserves unreserved praise.

Contrary to what public relations officers seem to think, honesty and frankness do more for the public's confidence in the medical profession than extravagant boasting or supercilious gasconade. ''Complications'' ought to earn Gawande a place of distinction among physicians who try their hand at the belles-lettres. Others are perhaps more lyrical; some more poetical; still others more philosophical, or better able to depict what Aldous Huxley called ''the multiple amphibiousness'' of man, the multifaceted richness of human experience. But none surpass Gawande in the ability to create a sense of immediacy, in his power to conjure the reality of the ward, the thrill of the moment-by-moment medical or surgical drama. ''Complications'' impresses for its truth and authenticity, virtues that it owes to its author being as much forceful writer as uncompromising chronicler.

F. -Crussi, emeritus professor of pathology and a writer, lives in Chicago.