Atul Gawande, the US based surgeon, Harvard academic and writer, will be delivering the BBC Reith lectures this year, starting on 25th November (BBC Radio 4). You can view an outline of the lectures here: http://www.bbc.co.uk/programmes/articles/6F2X8TpsxrJpnsq82hggHW/dr-atul-gawande-2014-reith-lectures
Gawande has recently published a book called Being Mortal, on the subject of medical care in old age and for those suffering from terminal illness. I have not yet read that, but I did recently read one of his earlier books: Complications – a Surgeon’s Notes on an Imperfect Science. Complications was published in 2004 and is essentially a series of short chapters on different aspects of surgery, many based on Gawande’s own experiences during the period he was training to be a surgeon. The book is well worth reading, because it challenges many of our stereotypical views of surgeons and surgery.
Practice rules, not talent
We tend to assume for example that surgeons must have a “natural talent”, allied with skilled hands and manual dexterity. However, Gawande points out that surgeons themselves believe in practice, not talent. He says that talent helps, but that experienced surgeons value most “people who are conscientious, industrious, and boneheaded enough to stick at practising this one difficult thing day and night for years on end”. That is not to say that anyone can be a surgeon, of course, but it is not what we lay people would expect.
Specialisation in surgery is key
Gawande also underlines the importance of specialisation in surgery. We tend to assume that a skilled surgeon can switch effortlessly from doing a heart bypass to removing a brain tumour. Gawande’s view is that avoiding errors is the most critical aspect of surgery, both in conducting operations and in the related areas of understanding a patient’s history and allergies, diagnosis and correctly calculating drug does. He says we need “machinelike perfection in the delivery of care”, and the best way to achieve this is through “routinisation and repetition”. He features the Shouldice Hospital near Toronto that specialises in hernia operations, with surgeons carrying out 600 to 800 procedures a year (basically doing nothing else), but which has a much lower rate of hernia recurrence than other centres – at least as of 2004. He quotes a Harvard surgeon, Lucian Leape, who has said that “a defining trait of experts is that they move more and more problem solving into an automatic mode”.
Gawande also tackles the problem of patient choice. A typical patient (at least in the UK) will have little knowledge of the personal qualities or experience of the surgeon who operates on them. We may be given a list of possible surgeons by our GP, but most of us would have little or no basis for choosing one over another, apart from the convenience of their location. Gawande, however, points out that a doctor who works in the same hospital with a group of surgeons, or who otherwise has personal knowledge of surgeons in particular specialities, may insist on one rather than another operating on him or on a member of his family.
The question of experience is related to this. Most of us would be reluctant to submit to the hands of a surgeon who is carrying out his first (or even fifth) procedure, but how would we know? Gawande is admirably honest about his own early attempts at inserting a “central line” in the chest, to permit intravenous nutrition. He describes in a most dramatic way how this is done, and how things could go badly wrong in inexperienced hands. I suspect that as patients we are philosophical about this, understanding that all professionals must acquire their experience in some way. But it does raise the question of how surgeons could train more through simulation techniques, in the same way that pilots learn to fly using flight simulators before they are let loose on the flying public (how many of us wonder when we are flying whether this is a pilot’s first true flight?).
There are also fascinating chapters on patients with unusual conditions who can treated through surgery, but often at the risk of serious complications. For example, a young woman suffering from a “blushing complex”, who was treated through a delicate operation on the sympathetic nerves in the chest – and who did not suffer from a frequent complication that can affect the eyes. Another woman developed a mysterious leg infection, which could easily have been mis-diagnosed as a simple infection, but which Gawande correctly identified as a case of “flesh-eating disease” (or necrotizing fasciitis), which can be quickly fatal, but which he and colleagues were able to treat in time partly because Gawande had recent experience of another patient with the same condition.
There are also excellent chapters on bariatric surgery, operations to deal with intractable pain, surgical mistakes and autopsies (the one rather grisly chapter in the book).
I do not know how Atul Gawande finds the time to be a practising surgeon, academic and writer/commentator, but it is to be hoped he will find it possible to combine all of these activities. The value of Complications lies very much in the practical experience on which it is based.