Better and Complications

July 12, 2010 § 4 Comments

Atul Gawande scrubbing for surgery. Photo from gawande.com.

“How helpless human newborn babies are,” my wife commented as we were watching some TV programme about surrogate mothers. “I read something really interesting about that recently,” I said, and realized I’d just referenced something I’d read in “Better” or “Complications” by Atul Gawande for the umpteenth time that week.

I was a latecomer to the books of Atul Gawande. Having somehow formed the impression that the books were some sort of macho “surgical tales from the front”, I didn’t get them despite seeing a lot of other people doing so. How wrong I was. Better and Complications are two of the most thought-provoking books I’ve ever read.

Fallibility, mystery and uncertainty. Diligence, doing better and ingenuity. These are the subjects tackled by Gawande in Complications and Better respectively. Mixing patient stories, statistics and reflection, both books discuss medicine as an imperfect science, but from with different perspectives. In an interview on SAJAforum.org in 2007–when Better was published, Atul Gawande described the differences:

I found after I completed my surgery training that I was thinking about our imperfection in medicine from a new perspective. Complications was written by someone just out of medical school trying to understand why medicine is imperfect. Better is written from someone who has finally become competent but is wondering, given our imperfection and the complexity that medicine now requires, how does one actually become great at what one does. The answer has both mechanical and moral dimensions to it.

Both books are packed with fascinating and important insights. I recall a few:

  • Despite vast improvements in diagnostic technologies (CT, ultrasound etc.) there were found no improvement in the number of missed diagnoses picked up in autopsies, when researchers compared cases in 1960 and 1980 (Better, p. 197).
  • The groundbreaking antiemetic drug Zofran has reduced vomiting in chemotherapy patients, but has produced no improvement in the severity of their nausea. In fact, patients report having longer periods of nausea today than before the drug was introduced (Complications, pp. 140-141).
  • Satiety is induced by stretch receptors and protein receptors in the stomach and duodenum. Eating fat foods stimulates this reaction quickly. We also have receptors in the mouth, however, that trigger the hypothalamus to accelerate our intake of food. And again fat is the most potent stimulus. Scientists call this the “fat paradox”. Eating fat foods cause us to eat faster, getting more down before the gut receptors signals we’re full (Complications, pp. 170-171).
  • The fact that human babies are born relatively helpless compared to other mammals can be seen as a solution to an evolutionary problem. We have a large head because of our large brain, but we also have a small, fixed pelvis, so we can walk upright. To get that large head to fit through that small pelvis all human mothers, in a sense, give birth prematurely. The result is babies that can not walk or seek food for months (Better, p. 172).

First and foremost though, Gawande is a brilliant writer who tells both the stories of when medicine fail or fall short (Complications) and when it prevails against all odds (Better). Both books are highly recommended for anyone remotely interested in medicine, or just having their thoughts provoked.

For more on Atul Gawande’s writing, check out gawande.com.

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