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by Atul Gawande
Picador USA, 2002
Review by Sue Bond on Apr 30th 2004

Complications

This book is divided into three parts: fallibility, mystery and uncertainty, aspects of life we are unused to hearing discussed in the medical world. Atul Gawande illustrates, explores and makes come alive this world, in language which is clear and engaging.

He takes the reader on a journey through some common and not-so-common conditions and situations. The chapters in the first part range over the need for humility, the recognition that mistakes are made in medicine and what to do about them, and the handling of doctors who should no longer practise.

For example, the Shouldice Hospital outside Toronto does nothing but hernia operations and their recurrence rate is one percent, but the doctors do not get bored because '[p]erfection is the excitement'. Gawande presents to the reader the disturbing idea that maybe certain surgical procedures don't need to be performed by human beings, but could very successfully be done by machines. He then ends the chapter thus: 'Maybe machines can decide, but we still need doctors to heal.'

The second part contains chapters on pain, nausea, blushing and overeating. The author ponders the difficulty of treating chronic pain adequately, stating that 'the solution to chronic pain may lie more in what goes on around us than in what is going on inside us', and stresses the reality of the pain to the sufferer, whatever the cause.

In all of these stories, Gawande shows himself to be mindful of the patient as a whole person. The chapter about the woman who has uncontrollable, severe blushing that threatens her career as a television newsreader reveals the complexity of a seemingly simple problem. It is one friend's cruel comment that almost undoes her after she has had successful surgery to correct the problem. There is no surgical remedy that can prevent such unkindness.

The difficulties of obesity and its treatment in the morbid cases is sensitively and imaginatively presented.

The third part takes the reader into the world of the autopsy, particularly when and how and why it is requested, and how difficult it can be to approach grieving relatives with such a request. He touches upon sudden infant death syndrome, and this is probably the only weak chapter in the book. It is much too short to deal adequately with this subject, and as such only gives the reader the story of a sensational and rare case where a woman killed eight of her ten babies.

The chapter 'Whose Body Is It Anyway?' is as profound and thorough as the previous is not. Gawande takes the reader through case histories which demonstrate the points he wants to make, and the difficulties there are in negotiating good practice with patient autonomy and informed decision-making.

He ends with a rare condition, but a fascinating one. It illustrates the concept of intuition and how it can work spectacularly well, but how it can also be problematic. He shows the reader how going only by a logical reasoned approach such as 'decision analysis' would have led to a totally different outcome for the young female patient.

This is a readable, well-written, compassionate, thoughtful book, written clearly and without jargon, and of interest and importance to both the medical and non-medical reader.

2004 Sue Bond

 

Sue Bond has degrees in medicine and literature and a Master of Arts in Creative Writing. Reviews for online and print publications. She lives in QueenslandAustralia.