Atul Gawande Complications Quotes

We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line. There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing. The gap between what we know and what we aim for persists. And this gap complicates everything we do.

No matter what measures are taken, doctors will sometimes falter, and it isn't reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.

Practice is funny that way. For days and days, you make out only the fragments of what to do. And then one day you've got the thing whole. Conscious learning becomes unconscious knowledge, and you cannot say precisely how.

We want perfection without practice. Yet everyone is harmed if no one is trained for the future.

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.

Pain is a symphony - a complex response that includes not just a distinct sensation but also motor activity, a change in emotion, a focusing of attention, a brand-new memory.

There have now been many studies of elite performers—international violinists, chess grand masters, professional ice-skaters, mathematicians, and so forth—and the biggest difference researchers find between them and lesser performers is the cumulative amount of deliberate practice they’ve had. Indeed, the most important talent may be the talent for practice itself.

In psychology, there's something called the broken-leg problem. A statistical formula may be highly successful in predicting whether or not a person will go to a movie in the next week. But someone who knows that this person is laid up with a broken leg will beat the formula. No formula can take into account the infinite range of such exceptional events.

we need practice to get good at what we do. There is one difference in medicine, though: it is people we practice upon.

Betterment is perpetual labor. The world is chaotic, disorganized, and vexing, and medicine is nowhere spared that reality. To complicate matters, we in medicine are also only human ourselves. We are distractible, weak, and given to our own concerns. Yet still, to live as a doctor is to live so that one's life is bound up in others' and in science and in the messy, complicated connection between the two It is to live a life of responsibility. The question then, is not whether one accepts the responsibility. Just by doing this work, one has. The question is, having accepted the responsibility, how one does such work well.

There is a saying about surgeons, meant as a reproof: "Sometimes wrong; never in doubt." But this seemed to me their strength. Each day surgeons are faced with uncertainties. Information is inadequate; the science is ambiguous; one's knowledge and abilities are never perfect. Even with the simplest operation, it cannot be taken for granted that a patient will come through better off - or even alive. Standing at the table my first time, I wondered how the surgeon knew that he would do this patient good, that all the steps would go as planned, that the bleeding would be controlled and infection would not take hold and organs would not be injured. He didn't, of course. But still he cut.

not only do all human beings err, but they err frequently and in predictable, patterned ways.

The core predicament of medicine - the thing that makes being a patient so wrenching, being a doctor so difficult, and being a part of society that pays the bills they run up so vexing - is uncertainty. With all that we know nowadays about people and diseases and how to diagnose and treat them, it can be hard to see this, hard to grasp how deeply uncertainty runs. As a doctor, you come to find, however, that the struggle in caring for people is more often with what you do not know than what you do. Medicine's ground state is uncertainty. And wisdom - for both the patients and doctors - is defined by how one copes with it.

The possibilities and probabilities are all we have to work with in medicine, though. What we are drawn to in this imperfect science, what we in fact covet in our way, is the alterable moment-the fragile but crystalline opportunity for one's know-how, ability, or just gut instinct to change the course of another's life for the better.

We are a species that evolved to survive starvation, not resist abundance

If there is a credo in practical medicine, it is that the important thing is to be sensible.

all human beings err, but they err frequently and in predictable, patterned ways.

We want progress in medicine to be clear and unequivocal, but of course it rarely is. Every new treatment has gaping unknowns - for both patients and society - and it can be hard to decide what do do about them.

The important question isn't how to keep bad physicians from harming patient; it's how to keep good physicians from harming patients. Medical malpractice suits are a remarkably ineffective remedy. (In reference to a Harvard Medical Practice Study)... fewer than 2 percent of the patients who had received substandard care ever filed suit. Conversely, only a small minority among patients who did sue had in fact been victims of negligent care. And a patient's likelihood of winning a suit depended primarily on how poor his or her outcome was, regardless of whether that outcome was caused by disease or unavoidable risks of care. The deeper problem with medical malpractice is that by demonizing errors they prevent doctors from acknowledging & discussing them publicly. The tort system makes adversaries of patient & physician, and pushes each other to offer a heavily slanted version of events.

Even worse than losing self-confidence, though, is reacting defensively. There are surgeons who will see faults everywhere except in themselves. They have no questions and no fears about their abilities. As a result, they learn nothing from their mistakes and know nothing of their limitations. As one surgeon told me, it is a rare but alarming thing to meet a surgeon without fear. “If you’re not a little afraid when you operate,” he said, “you’re bound to do a patient a grave disservice.

One wants to know whether, in the end, her troubles were physical or psychological. But it is a question as impossible to answer as whether a blush is physical or mental—or, for that matter, whether a person is. Everyone is both, inseparable even by a surgeon’s blade.

Western medicine is dominated by a single imperative—the quest for machinelike perfection in the delivery of care.

We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So

Medicine’s ground state is uncertainty. And wisdom—for both patients and doctors—is defined by how one copes with it. This

It is a reality of medicine that choosing to not do something—to not order a test, to not give an antibiotic, to not take a patient to the operating room—is far harder than choosing to do it.

A resident has a distinctive vantage on medicine. You are an insider, seeing everything and a part of everything; yet at the same time you see it anew.

Little more than a decade ago, doctors made the decisions; patients did what they were told.

They were regarded as children: too fragile and simpleminded to handle the truth, let alone make decisions.

And they missed out on treatments that they might have preferred.

So the night before the operation he did an unusual thing: he discussed the treatment options with her and let her choose.

decisions perhaps influenced by money, professional bias (for example, surgeons tend to favor surgery), and personal idiosyncrasy.

Most doctors, taking seriously the idea that patients should control their own fates, lay out the options and the risks involved.

Patients ask questions, look up information on the Internet, seek second opinions. And they decide.

and you will find that the larger, starker, and more painful difficulty is the still abundant uncertainty that exists over what should be done in many situations.

Errors are too common and widespread to be explained so simply.

Even good doctors can go bad, and when they do, colleagues tend to be almost entirely unequipped to do anything about them.

After a while, though, it seemed that the only thing he thought about was getting through all his patients as quickly as possible.

Doctors with high confidence in a judgment they made proved no more accurate than doctors with low confidence.

that many decisions made by physicians appear to be arbitrary—highly variable, with no obvious explanation.

The goal is to use explicit, logical, statistical thinking instead of just your gut.

what he has found is a stubborn, overwhelming, and embarrassing degree of inconsistency in what we do.

Some I am fortunate to still keep up with. Others I was never given the chance to know as well as I wish I could have. All of them have taught me more than any could know.

But once he put his recommendations down on paper it was hard for hospitals and medical groups not to follow through and hold doctors to the plan.

For the solution to chronic pain may lie more in what goes on around us than in what is going on inside us.

human beings commonly imagine patterns (whether good or bad) where really there are none.

But the truth of the matter is that it tends to raise as many questions as it answers.

we usually have only vague indicators to rely upon.

Human judgment, even expert human judgment, falls well short of certainty.

human beings are inconsistent: we are easily influenced by suggestion, the order in which we see things, recent experience, distractions, and the way information is framed.

We tend to give some variables too much weight and wrongly ignore others.

Yet compassion and technology aren’t necessarily incompatible; they can be mutually reinforcing.

The way that things go wrong in medicine is normally unseen and, consequently, often misunderstood.

When things go wrong, it’s almost impossible for a physician to talk to a patient honestly about mistakes.

At most, a doctor might say, “I’m sorry that things didn’t go as well as we had hoped.

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.

Even with the simplest operation, it cannot be taken for granted that a patient will come through better off—or even alive.

In surgery, as in anything else, skill and confidence are learned through experience

They believe in practice, not talent.

Skill, surgeons believe, can be taught; tenacity cannot.

Yet although the odds were against me, it wasn’t as if I had no chance of succeeding.

Medicine is, I have found, a strange and in many ways disturbing business.

but the best surgeons retain a deep recognition of the limitations of both science and human skill.

People may hate being embarrassed and strive not to show it when they are, but embarrassment serves an important good.

The side effects are not life-threatening, but they are not trivial. The

For all these reasons, the operation is at best a last resort,

Surgery itself is a kind of autopsy. “Autopsy” literally means “to see for oneself,” and, despite our knowledge and technology, when we look we’re often unprepared for what we find.

No matter what measures are taken, doctors will sometimes falter, and it isn’t reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.

fewer than 2 percent of the patients who had received substandard care ever filed suit. Conversely, only a small minority among the patients who did sue had in fact been the victims of negligent care.

Operations like that lap chole have taught me how easily error can occur, but they’ve also showed me something else: effort does matter; diligence and attention to the minutest details can save you.” .

They belong to the connected and the knowledgeable, to insiders over outsiders, to the doctor’s child but not the truck driver’s. If choice cannot go to everyone, maybe it is better when it is not allowed at all.

Medicine requires the fortitude to take what comes: your schedule may be packed, the hour late, your child waiting for you to pick him up after swimming practice; but if a problem arises you have to do what is necessary

A year on, Eleanor remained haunted by what happened to her. She still had no idea where the bacteria came from. Perhaps the foot soak and pedicure she had gotten at a small hair-and-nail shop the day before that wedding.

Human beings have an ability to simply recognize the right thing to do sometimes. Judgment, Klein points out, is rarely a calculated weighing of all options, which we are not good at anyway, but instead an unconscious form of pattern recognition.

It may seem harsh to say, but if it was a sixty-year-old man I would’ve taken the leg without question.” This was partly, I think, a purely emotional unwillingness to cut off the limb of a pretty twenty-three-year-old—the kind of sentimentalism that can get you in trouble.

With repetition, a lot of mental functioning becomes automatic and effortless, as when you drive a car to work. Novel situations, however, usually require conscious thought and “workaround” solutions, which are slower to develop, more difficult to execute, and more prone to error.

You have a cough that won’t go away—and then? It’s not science you call upon but a doctor. A doctor with good days and bad days. A doctor with a weird laugh and a bad haircut. A doctor with three other patients to see and, inevitably, gaps in what he knows and skills he’s still trying to learn.

Medical care is about our life and death, and we’ve always needed doctors to help us understand what is happening and why, and what is possible and what is not. In the increasingly tangled web of experts and expert systems, a doctor has an even greater obligation to serve as a knowledgeable guide and

In some way, it may be in the nature of surgery itself to want to come to grips with the uncertainties and dilemmas of practical medicine. Surgery has become as high tech as medicine gets, but the best surgeons retain a deep recognition of the limitations of both science and human skill. Yet still they must act decisively.

During the Second World War, for example, Lieutenant Colonel Henry K. Beecher conducted a classic study of men with serious battlefield injuries. In the Cartesian view, the degree of injury ought to determine the degree of pain, rather like a dial controlling volume. Yet 58 percent of the men—men with compound fractures, gunshot wounds, torn limbs—reported only slight pain or no pain at all. Just 27 percent of the men felt enough pain to request pain medication, although such wounds routinely require narcotics in civilians. Clearly, something that was going on in their minds—Beecher thought they were overjoyed to have escaped alive from the battlefield—counteracted the signals sent by their injuries. Pain was becoming recognized as far more complex than a one-way transmission from injury to “ouch.

Surgeons, as a group, adhere to a curious egalitarianism. They believe in practice, not talent. People often assume that you have to have great hands to become a surgeon, but it’s not true. When I interviewed to get into surgery programs, no one made me sew or take a dexterity test or checked if my hands were steady. You do not even need all ten fingers to be accepted. To be sure, talent helps. Professors say every two or three years they’ll see someone truly gifted come through a program—someone who picks up complex manual skills unusually quickly, sees the operative field as a whole, notices trouble before it happens. Nonetheless, attending surgeons say that what’s most important to them is finding people who are conscientious, industrious, and boneheaded enough to stick at practicing this one difficult thing day and night for years on end. As one professor of surgery put it to me, given a choice between a Ph.D. who had painstakingly cloned a gene and a talented sculptor, he’d pick the Ph.D. every time. Sure, he said, he’d bet on the sculptor being more physically talented; but he’d bet on the Ph.D. being less “flaky.” And in the end that matters more. Skill, surgeons believe, can be taught; tenacity cannot.

The anthropologist Lawrence Cohen describes conferences and conventions not so much as scholarly goings-on but as carnivals—“colossal events where academic proceedings are overshadowed by professional politics, ritual enactments of disciplinary boundaries, sexual liminality, tourism and trade, personal and national rivalries, the care and feeding of professional kinship, and the sheer enormity of discourse.

In medicine, we have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm for supervision and graduated responsibility. And there is reason to think patients actually benefit from teaching. Studies generally find teaching hospitals have better outcomes than non teaching hospitals. Residents may be amateurs, but having them around checking on patients, asking questions, and keeping faculty on their toes seems to help. But there is still no getting around those first few unsteady times a young physician tries to put in a central line, remove a breast cancer, or sew together two segments of colon. No matter how many protections we put in place, on average these cases go less well with a novice then with someone experienced.

Medicine is, I have found, a strange and in many ways disturbing business. The stakes are high, the liberties taken tremendous. We drug people, put needles and tubes into them, manipulate their chemistry, biology, and physics, lay them unconscious and open their bodies up to the world. We do so out of an abiding confidence in our know-how as a profession. What you find when you get in close, however—close enough to see the furrowed brows, the doubts and missteps, the failures as well as the successes—is how messy, uncertain, and also surprising medicine turns out to be

And it works. There have now been many studies of elite performers—international violinists, chess grand masters, professional ice-skaters, mathematicians, and so forth—and the biggest difference researchers find between them and lesser performers is the cumulative amount of deliberate practice they’ve had. Indeed, the most important talent may be the talent for practice itself. K. Anders Ericsson, a cognitive psychologist and expert on performance, notes that the most important way in which innate factors play a role may be in one’s willingness to engage in sustained training.

The M & M sees avoiding error as largely a matter of will—of staying sufficiently informed and alert to anticipate the myriad ways that things can go wrong and then trying to head off each potential problem before it happens. It isn't damnable that an error occurs, but there is some shame to it. In fact, the M & M's ethos can seem paradoxical. On the one hand, it reinforces the very American idea that error is intolerable. On the other hand, the very existence of the M & M, its place on the weekly schedule, amounts to an acknowledgement that mistakes are an inevitable part of medicine.

attending surgeons say that what’s most important to them is finding people who are conscientious, industrious, and boneheaded enough to stick at practicing this one difficult thing day and night for years on end. As one professor of surgery put it to me, given a choice between a Ph.D. who had painstakingly cloned a gene and a talented sculptor, he’d pick the Ph.D. every time. Sure, he said, he’d bet on the sculptor being more physically talented; but he’d bet on the Ph.D. being less “flaky.” And in the end that matters more. Skill, surgeons believe, can be taught; tenacity cannot. It’s an odd approach to recruitment, but it continues all the way up the ranks, even in top surgery departments. They take minions with no experience in surgery, spend years training them, and then take most of their faculty from these same homegrown ranks. And it works.

I was learning. In medicine, we have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm through supervision and graduated responsibility. And there is reason to think patients actually

But it’s not only the breadth and quantity of knowledge that has made medicine complicated. It is also the execution—the practical matter of what knowledge requires clinicians to do.

was once on trauma duty when a young man about twenty years old was rolled in, shot in the buttock.

Michael Jordan always had to wear University of North Carolina boxer shorts under his Chicago Bulls uniform.

I asked Byrnes Shouldice, a son of the clinic’s founder and a hernia surgeon himself, whether he ever got bored doing hernias all day long. “No,” he said in a Spock-like voice. “Perfection is the excitement.

what we aim for persists. And this gap complicates everything we do.

As one surgeon told me, it is a rare but alarming thing to meet a surgeon without fear. “If you’re not a little afraid when you operate,” he said, “you’re bound to do a patient a grave disservice.

no matter how careful we might be, no matter how much thought we might put in, a checklist has to be tested in the real world, which is inevitably more complicated than expected. First drafts always fall apart, he said, and one needs to study how, make changes, and keep testing until the checklist works consistently.

This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common that they are considered a routine complication. ICUs put five million lines into patients each year, and national statistics show that after ten days 4 percent of those lines become infected. Line infections occur in eighty thousand people a year in the United States and are fatal between 5 and 28 percent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care.

There’s one looming danger, though: the stalk of the gallbladder is a branch off the liver’s only conduit for sending bile to the intestines for the digestion of fats. And if you accidentally injure this main bile duct, the bile backs up and starts to destroy the liver. Between 10 and 20 percent of the patients to whom this happens will die. Those who survive often have permanent liver damage and can go on to require liver transplantation.

Drug and medical device companies offered invitations to free dinners around town nightly. And there were over five thousand three hundred salespeople from some twelve hundred companies registered in attendance here—more than one for every two surgeons. The

The companies’ most effective tactic, however, was simply to put out the goods and let surgeons play.

Two professors who study the science of complexity—Brenda Zimmerman of York University and Sholom Glouberman of the University of Toronto—have proposed a distinction among three different kinds of problems in the world: the simple, the complicated, and the complex.

Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist. Its mere existence indicated how far aeronautics had advanced. In the early years of flight, getting an aircraft into the air might have been nerve-racking but it was hardly complex. Using a checklist for takeoff would no more have occurred to a pilot than to a driver backing a car out of the garage. But flying this new plane was too complicated to be left to the memory of any one person, however expert. The test pilots made their list simple, brief, and to the point—short enough to fit on an index card, with step-by-step checks for takeoff, flight, landing, and taxiing. It had the kind of stuff that all pilots know to do. They check that the brakes are released, that the instruments are set, that the door and windows are closed, that the elevator controls are unlocked—dumb stuff. You wouldn’t think it would make that much difference. But with the checklist in hand, the pilots went on to fly the Model 299 a total of 1.8 million miles without one accident. The army ultimately ordered almost thirteen thousand of the aircraft, which it dubbed the B-17. And, because flying the behemoth was now possible, the army gained a decisive air advantage in the Second World War, enabling its devastating bombing