Sunday, June 8, 2008

Book Review (7/34) Complications: A Surgeon's Notes on an Imperfect Science by Atul Gawande

The old joke goes something like this:

A tourist is wandering around New York city and he is clearly lost. He walks up to a local and asks, “How do you get to Carnegie Hall?”. “Practice, Man, Practice” responds the local.

Despite the groans this joke elicits, there is sure to be a few wry smiles because of how true the statement is. If you want to be good at something you have to practice. Sure it helps if you have some natural talent, but the desire to be good at something and the will to keep practicing is just as important. Chris Ballard writes of Kobe Bryant in a recent article in SI:

There’s a difference between loving basketball and liking basketball. There are only about 30 guys in the league who love it, who play year round. Allen Iverson loves to play when the lights come on. Kobe loves doing the shit before the lights comes on. This thing, this freakish compulsion, may be the hardest element of the game to quantify. There are no plus-minus stats to measure a player’s ruthlessness, his desire to beat his opponent so badly he’ll need therapy to recover. One thing’s for sure: You can’t teach it. Is so Eddie Curry would be All-NBA and Derrick Coleman would be getting ready for his induction ceremony in Springfield, Mass. But people know it when they see it

Despite similar levels of athletic ability, his ability to practice more and harder than anyone else is the reason that Kobe Bryant is the best player in the NBA. The importance of practice isn’t limited to sports. Atul Gawande, in his book entitled Complications: A Surgeon’s Notes on Performance states that studies have shown that the difference between the ability of elite performers (from violinists to chess players to athletes) and lesser performers is the amount of deliberate practice. In fact, Gawande cites a study by Ericsson who claims that the most important talent is the willingness to practice! Incredibly, elite performers hate practice just as much as their less able peers. However, they are somehow able to push through and will themselves to practice anyways.

Thus, if a person is to become exceptional at their profession, the best thing to do is to practice practice practice. This is obviously easy for Kobe Bryant; it just means more time in the gym. However, Gawande raises an important question: How do we teach surgeons? Obviously, to become an expert surgeon, one must have lots of hands on practice. However, how ethical is it to allow a surgical intern to practice on someone whose life is at stake? Study after study has shown that a patient is more likely to have a successful operation the more experienced a surgeon is. Yet the fact remains that as a society we need to train new surgeons. Additionally studies have shown that when new operating procedures are introduced, patient mortality increases in the short term (but decreases in the long term). How can we train surgeons on new procedures without putting patients at risk?

Gawande does a great job describing these problems and speaks of how he understands the need to train surgeons but he himself has refused to let an intern operate on one of his family members. I can see how much of an internal struggle this would be. I understand that we need to train new surgeons, but I sure as hell don’t want to be the first person a surgeon has ever operated on.

And all that thought was brought on by the first chapter! As usual Gawande’s writing stimulates the mind and the rest of the book is a quick read. Gawande discusses the problem of bad doctors, what should happen when a doctor makes a mistake (and every doctor will eventually make a mistake), the purpose of medical conferences, and a series of interesting case studies. I found the final chapter (about a young girl who may or may not have contracted the flesh eating bacteria) especially interesting. Gawande compared his successful diagnosis to the situations described inGary Klein’s work on firefighters in the field.

But the dilemma that stayed with me was how can we train surgeons without putting patients at risk? It is clear from studies of elite performers that the only way to become proficient in a profession is to practice practice practice. Yet who would want to be on the other end of the knife when a mere novice is holding the scalpel?

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