|Genre||Collection (Essays) (269 pp.)|
|Keywords||Anatomy, Anesthesia, Art of Medicine, Cancer, Catastrophe, Child Abuse, Children, Communication, Death and Dying, Disability, Disease and Health, Doctor-Patient Relationship, Eating Disorder, Empathy, Family Relationships, History of Medicine, Hospitalization, Human Worth, Impaired Physician, Infectious Disease, Medical Advances, Medical Education, Medical Ethics, Medical Mistakes, Medical Research, Obesity, Pain, Parenthood, Physical Examination, Physician Experience, Power Relations, Professionalism, Suffering, Surgery, Survival, Technology|
This masterful collection of essays was written by Gawande while he was a general surgery resident. The book consists of fourteen essays divided into three sections: Fallibility, Mystery, and Uncertainty. Although some of the essays fall clearly within the boundaries of the section title (such as "When Doctors Make Mistakes" and "When Good Doctors Go Bad" in the Fallibility section), others cross boundaries or don’t fall as squarely in these general themes ("Nine Thousand Surgeons," an anthropological essay on the cult and culture of a major surgical convention, is also located in the Fallibility section). Nevertheless, the many pleasures of the individual essays, the range of topics explored in depth, and the accuracy of the medicine portrayed are the true strengths of this work.
The book begins Dragnet-style with an Author’s Note: "The stories here are true." (p. 1) And it is this attention to fidelity that makes the essays so compelling. Because even when the truths are hard--the terrible acknowledgment by the medical neophyte about lack of skill and knowledge, the mistakes in judgment at all levels of doctoring, the nature of power relations and their effects on medical pedagogy and on the doctor-patient relationship, the gnawing uncertainties about so many medical decisions--the author confronts the issues head on with refreshing rigor, grace and honesty.
Many of the essays reference scientific and medical research (historical and current) as part of the exploration of the topic. This information is imbedded within the essay, hence avoiding a dry recitation of statistical evidence. Typically, the reader’s interest in an essay is immediately piqued by a story about a particular patient. For example, the story of an airway emergency in a trauma patient, her oxygen saturation decreasing by the second as Gawande and the emergency room attending struggle to secure an airway, surgical or otherwise, sets the scene for "When Doctors Make Mistakes."
This leads to a meditation on not only the culture of the Morbidity and Mortality Conference, with its strange mix of third-person case narrative and personal acceptance of responsibility by the attending physician (see Bosk, Charles, Forgive and Remember: Managing Medical Failure, U. Chicago Press, 1981 for an in depth analysis of this culture), but also a positive examination of the leadership role that anesthesiologists have played in improving patient safety via research, simulator training and systems improvement.
Gawande’s journalistic verve takes him beyond the confines of his own hospital and training to interview patients and physicians on topics as diverse as incapacitating blushing ("Crimson Tide"), chronic pain ("The Pain Perplex"), malpractice and incompetence ("When Good Doctors Go Bad") and herniorraphy ("The Computer and the Hernia Factory"). In addition, he visits his own post-operative patients at home ("The Man Who Couldn’t Stop Eating" and "The Case of the Red Leg") which gives a longer view of postoperative recovery and a broader exposure to patients’ perspectives.
Some of the most telling moments come with the introduction of his children’s medical problems into the text. These range from the relatively straightforward (a broken arm, but a chance to comment on detection of child abuse in the emergency room) to the downright parental nightmare scary (severe congenital cardiac defect in their oldest child and a life-threatening respiratory infection in their prematurely born youngest).
These last two experiences are introduced to provide an angle on issues of choice. Choice of a fully trained, attending physician rather than a fellow to provide follow-up cardiac care for their oldest, and the choice to opt out of the decision-making process for whether to intubate the trachea of the youngest and hence leave the medical decisions up to the care team.
Gawande is a welcome addition to the growing list of contemporary physician-writers such as surgeons Richard Selzer and Sherwin B. Nuland, autobiographical commentators on medical training such as Perri Klass and Melvin Konner, and essayists on social issues such as David Hilfiker. These thought-provoking essays could contribute to discussions in medical humanities or biomedical ethics courses (for example, see Whose Body is it Anyway? regarding informed consent issues, annotated in this database), and to consideration of the rough and tumble, uncertain world of medicine itself. However this book need not remain in the hands of the medically trained, as the informal, yet informational tone of the essays is well suited for a lay readership, which seems to grow ever more sophisticated in terms of medical knowledge.
I suppose it is this tone--humorous ("Hernias were SRO" quips the author on the filled to capacity audience in a huge lecture hall, p. 77), tender (his four-year-old son was "fairly zizzing with excitement" at seeing the huge tractor trucks owned by a patient, p. 176) and snapshot imagistic (describing a patient’s home as "a roomy, spic-and-span colonial with a galumphy dog," p. 250)--that makes his writing so appealing. This is the tone of an insider, for sure, but one with humility, intelligence and an infectious sense of curiosity.
|Publisher||Metropolitan Books/Henry Holt|
|Place Published||New York|
|Miscellaneous||A number of the essays have appeared, in somewhat different form, in The New Yorker and in Slate (http://slate.msn.com/). This collection was selected by the Book of the Month Club and was nominated for the National Book Award.|
|Annotated by||Shafer, Audrey|
|Date of Entry||05/08/02|