Many GPs have a dim view of the intellectual gifts of surgeons. But Atul Gawande, Harvard-trained cancer surgeon, is different. He has a degree in politics, philosophy and economics from Balliol College Oxford. He broke off his medical studies to work as health advisor to Bill Clinton. During his residency he started writing for the intellectual weekly, the New Yorker. His two books of essays are available in the UK: Complications: A Surgeon’s Notes on an Imperfect Science and Better: A Surgeon’s Notes on Performance.
Of the two, I prefer Complications. Written during his years as a resident, it has a freshness which Better doesn’t quite match. In Complications, a situation – learning to insert a central line, a case of necrotising fasciitis – triggers reflections on how we learn, how we make decisions, how we could do better. In Better, the established surgeon starts with a theme or a question – hospital-acquired infections, doctors and the death penalty – and subjects it to the same scrutiny. Complications may be more personal, but it may be Better with its broader scope, that can stimulate a widespread change of practice.
Managers and politicians often view medicine as an exact science and think that rigid guidelines will solve the problem of poor outcomes. “There should be no learning curve as far as patient safety is concerned” said a UK report. Gawande points out that at the front line, an imperfect science is practised by imperfect people with imperfect knowledge. We will never be right all the time, and we need to be honest with ourselves and our patients. But we can do better.