Sunday, September 22, 2002		Books

Medicine, anything but black and white
Kuljit Bains

Complications
by Atul Gawande. Penguin.
Pages XX + 251. Rs 250.

MEDICINE is about life and death; a patient is at once a body and a mind; afflictions are physical and mental; and the doctors, the protagonists of the whole show, can be saviours, next only to God, as well as the Devil, at least for those who have suffered a wrong cut from their knife. All this adds up to just the right setting for a non-fiction thriller based on a real phenomenon that touches our life itself—doctors and the treatment they give us.

Complications is written in a style that makes it like a "commercial" movie that has an "art" movie theme and characters. It delves deep into the science of medicine, though dealing more with the human side of it than technology. And this is the side that has all the grey areas—the patient’s hopes and fears, the doctor’s doubts and confusions.

Gawande is a surgeon by training, but is evidently as good with the pen as with the scalpel. He has been writing for mainstream publications as a medical correspondent, and has worked hard on the skill of writing. In this book he puts to use both the skills, bringing out his personal experiences as a surgeon and investigating various aspects of the perplexing field as a journalist to examine the agonies of both the doctor as well as the patient.

What we read is a learning experience, maybe even for most doctors. Take for instance one conclusion that is drawn from a statistical study that if a machine analysis report says one thing about your condition and the doctor says another, go by the machine! Now this is a conclusion any patient would need guts to accept, but then Gawande gives statistical proof. In one study they made a very reputed cardiologist analyse 2240 ECG reports under comfortable conditions and gave the same reports also to an artificial intelligence machine. The machine gave 20 per cent more correct answers than the doctor! "Western medicine is dominated by a single imperative—the quest for machine-like perfection…." "A surgeon for whom most situations have automatic solutions has a significant advantage."

This leads us to the next example he quotes of a hospital that performed only hernia operations. Such operations in the USA generally cost $4000 and take 90 minutes to perform. The failure rate is about 10 to 15 per cent. At this particular hospital, the time taken is 30 to 40 minutes, the failure rate about 1 per cent, and all this at almost half the cost. How come? Focused practice and procedures is the answer. The more the doctor is like a machine, the better he is.

The radical (and scandalous for doctors) conclusion is that "the individualised, intuitive approach that lies at the centre of modern medicine is flawed—it causes more mistakes than it prevents." There are hundreds of studies within as well as without medicine that have compared computers with human judgement. The machines almost always win.

Then comes the hot topic of suing doctors when they are thought to have made mistakes. It is found that suing consistently fails to improve the service of a hospital. Most doctors will make a certain number of mistakes and suing can’t help that. Also, most cases are not against "rogue" doctors. But these cases do cause damage: they prevent doctors from coming out openly about their mistakes and discussing them for future correction.

In explaining all these phenomena, the writer takes us through his personal experiences in emergency rooms and operation theatres and all the tension and suspense of the cases. Reading the book actually, at times, raises your pulse; such is the skill of writing employed, all with mid-plot twists and surprise endings. To know that it’s real case he’s describing, only adds to the thrill.

The Pain Perplex is probably the most involved and revealing chapter in the book. Explaining all the physiological and mental issues involved in chronic pain cases, the conclusion drawn is: never think a patient is faking pain. All pain is finally felt in the brain. Even if no physiological reasons are found for a particular patient, his pain in the brain is no less. The solution may be found outside the patient rather than inside.

Also taken up are doctor issues like handling a colleague who may go bad, medical conventions and their use and abuse. Less-seriously taken subjects like nausea, blushing, and weight problem are explained in rather new perspectives. One chapter, Whose Body is it Anyway? touches the very delicate subject of who takes the decision on the course of treatment, the patient or the doctor? All this is brought to us through real-life cases.

If nothing else, after reading the book you’ll see your doctor more as a human than a god or devil, and hope he will perform like a machine!