Complications: A Surgeon’s Notes on an Imperfect Science

Gawande tells the story of Marie Noe of Philadelphia and her 10 children, all of whom died between 1949 and 1968. While one was stillborn and another died at the hospital, eight died at home, mysteriously. The deaths were once officially attributed to SIDS, or sudden infant death syndrome. Gawande explains that SIDS is not the name of a specific disease but rather an umbrella term given to the medical mystery of infant death. After some years, Marie Noe was arrested and charged with homicide. Though no new evidence was uncovered in the autopsies, doctors decided the number of deaths created a pattern, and that was evidence enough of foul play.

Gawande discusses the difficulty of achieving certainty in determining whether abuse is behind a child’s injuries. He says, “doctors look for the parents to tell us much more than any physical evidence can” (205), and he explains how social factors like poverty increase the likelihood of abuse. He exposes his own concern as a parent of a daughter who once broke her arm—he worried he would be suspected of having harmed his child, knowing what he knew from being a doctor.

As it turned out in the case of Marie Noe, the infants’ deaths were in fact homicide. Noe, in her seventies by the time of her trial, pled guilty to all eight counts. As Gawande says: “it is sometimes not science but what people tell us that is the most convincing proof we have” (207).

Gawande explores the subject of patient autonomy in this essay, initiating the discussion with a story of a terminal patient, Mr. Lazaroff, who opted to have surgery on his spine despite doctors’ warning him that the possible side effects of surgery might be life-threatening. They told him the best-case scenario of the operation was not that it would save his life but that it might restore some movement to his lower body. Gawande describes the surgical scene in detail, explaining how the operation itself went well but that the aftermath of the surgery hastened Mr. Lazaroff’s death and meant that the last days of his life were spent hooked up to machinery—an outcome Mr. Lazaroff had expressly not wanted. Gawande sees this case as an example of a patient making a decision against his own best interests.

Gawande tracks the evolution of decision-making in medicine, which, up until a decade before the writing of this book, was largely left to physicians. Doctors were expected to make the decisions in patient care and weren’t expected to be transparent in their decision-making. In 1984, a doctor and ethicist named Jay Katz published The Silent World of Doctor and Patient and incited a shift in the medical community toward placing the burden of decision-making entirely in the patient’s hands. Gawande was trained according to this doctrine, but he raises the question: When a patient is making a bad decision, should a doctor intervene?

Gawande puts forth a hypothetical situation to expose the process by which a doctor might persuade an unwilling patient to undergo specific treatment. He describes certain tactics a doctor may employ, like speaking with him or her outside of the context of an examination room, sitting on the same side of a table, and repeating back the patient’s concerns. Gawande claims: “Before a thoughtful, concerned, and, yes, sometimes crafty doctor, few patients will not eventually ‘choose’ what the doctor recommends” (219).

Gawande develops this idea into an argument that patients ultimately don’t want to make their own medical decisions: “they’re glad to have their autonomy respected, but the exercise of that autonomy means being able to relinquish it” (220). Gawande tells the story of his own experience with his infant daughter’s illness: He preferred to leave big decisions up to the doctors in charge, feeling that they could more easily deal with the emotional burden of critical decisions surrounding his daughter than he could. For many reasons, including their ability to decide “without the distortions of fear and detachment” (222), Gawande argues that doctors are often better equipped than patients to make difficult calls.

Gawande closes by arguing, “where many ethicists go wrong is in promoting patient autonomy as a kind of ultimate value in medicine rather than recognizing it as one value among others” (224). He closes with a story of working with a surgeon who violated a patient’s wish not to be intubated, only to save the patient and receive the patient’s gratitude when he recovered.

Gawande tells the suspenseful tale of a 23-year-old patient, Eleanor Bratton, who came into the emergency room with a red leg, having been previously diagnosed with cellulitis—a bacterial infection of the skin that is rarely serious. Gawande had a bad feeling about Bratton, perhaps influenced by a patient he’d seen a few weeks before. That other patient had contracted necrotizing fasciitis, a condition caused by flesh-eating bacteria that most of the time results in amputation and/or death. Gawande felt that the possibility of arriving at the same diagnosis in Bratton’s case would be ridiculous since the disease is so rare: “if you hear hoofbeats in Texas, think horses not zebras” (233). Still, he followed this hunch, and, with two more opinions from other physicians, a frightened Bratton consented to a biopsy of the tissue.

Gawande explores the uncertainty in treating patients on a larger scale, identifying statistics that prove how even when knowledge of the right thing to do exists somewhere, that knowledge doesn’t necessarily travel everywhere: “much of medicine still lacks the basic organization and commitment to make sure we do what we know to do” (236).

Gawande says that “three decades of neuropsychology research have shown us numerous ways in which human judgment, like memory and hearing, is prone to systematic mistakes” (238). Physicians are no exception. Some experts suggest doctors should use “decision analysis,” which involves penciling out all possible outcomes and their likelihoods and making a decision based on logic. Gawande finds this a flawed approach, and when he tried it after the fact on Bratton’s leg case, his decision tree suggested he should not operate.

Still, the doctors did operate on Bratton, and they found that she did indeed have the rare flesh-eating bacteria. Gawande details her treatment, which involved time in a hyperbaric chamber and multiple operations. He identifies the moments even in the diagnosis and surgery when physicians met with uncertainty and made seemingly arbitrary or emotional calls, like the one to save her leg.

Gawande meditates on the role of intuition in medicine. He quotes cognitive psychologist Gary Klein in saying “judgment […] is rarely a calculated weighing of all options, which we are not good at anyway, but instead an unconscious form of pattern recognition” (248). He cites an anecdote about a firefighter saving the lives of his team on a split-second hunch as an example.

Though some experts put forth ideas to streamline decision-making in moments of uncertainty, Gawande maintains some faith in the role of the individual doctor to get it right in those critical moments. It’s the “improbable save,” as in the case of Eleanor Bratton, that gives him this confidence.