Complications: A Surgeon’s Notes on an Imperfect Science
The thing that still startles me is how fundamentally human an endeavor it is. Usually, when we think about medicine and its remarkable abilities, what comes to mind is the science and all it has given us to fight sickness and misery: the tests, the machines, the drugs, the procedures. And without question, these are at the center of virtually everything medicine achieves. But we rarely see how it all actually works. You have a cough that won’t go away— and then? It’s not science you call upon but a doctor. A doctor with good days and bad days. A doctor with a weird laugh and a bad haircut. A doctor with three other patients to see and, inevitably, gaps in what he knows and skills he’s still trying to learn.
We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line. There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing. The gap between what we know and what we aim for persists. And this gap complicates everything we do.
As pervasive as medicine has become in modern life, it remains mostly hidden and often misunderstood. We have taken it to be both more perfect than it is and less extraordinary than it can be.
There is a saying about surgeons, meant as a reproof: “Sometimes wrong; never in doubt.” But this seemed to me their strength. Every day, surgeons are faced with uncertainties. Information is inadequate; the science is ambiguous; one’s knowledge and abilities are never perfect. Even with the simplest operation, it cannot be taken for granted that a patient will come through better off— or even alive.
Surgeons, as a group, adhere to a curious egalitarianism. They believe in practice, not talent. People often assume that you have to have great hands to become a surgeon, but it’s not true.
And it works. There have now been many studies of elite performers— international violinists, chess grand masters, professional ice-skaters, mathematicians, and so forth— and the biggest difference researchers find between them and lesser performers is the cumulative amount of deliberate practice they’ve had. Indeed, the most important talent may be the talent for practice itself. K. Anders Ericsson, a cognitive psychologist and expert on performance, notes that the most important way in which innate factors play a role may be in one’s willingness to engage in sustained training. He’s found, for example, that top performers dislike practicing just as much as others do. (That’s why, for example, athletes and musicians usually quit practicing when they retire.) But more than others, they have the will to keep at it anyway.
Practice is funny that way. For days and days, you make out only the fragments of what to do. And then one day you’ve got the thing whole. Conscious learning becomes unconscious knowledge, and you cannot say precisely how.
In medicine, we have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. … But there is still no getting around those first few unsteady times a young physician tries to put in a central line, remove a breast cancer, or sew together two segments of colon. No matter how many protections we put in place, on average these cases go less well with the novice than with someone experienced.
The reality, however, turns out to be far messier. You do get good at certain things, my father tells me, but no sooner than you do, you find what you know is outmoded. New technologies and operations emerge to supplant the old, and the learning curve starts all over again.
Practice, it turned out, did not necessarily make perfect. Whether it did, the researchers found, depended on how the surgeons and their teams practiced.
The Harvard Business School study offered some hopeful news. We can do things that have a dramatic effect on the learning curve— like being more deliberate about how we train, and about tracking progress, whether with students and residents or senior surgeons and nurses. But the study’s other findings are less reassuring. No matter how accomplished, surgeons trying something new got worse before they got better, and the learning curve proved longer, and affected by a far more complicated range of factors, than anyone had realized. It’s all stark confirmation that you can’t train novices without compromising patient care.
With practice, it gets easier to manage all this information, just as putting a line in gets easier. The learning curve operates in matters of diagnosis no less than technique. An experienced cardiologist can sometimes make out a heart attack at a glance, the way a child can recognize his mother across a room. But at bottom the test remains stubbornly opaque. Studies have shown that between 2 and 8 percent of patients with heart attacks who are seen in emergency rooms are mistakenly discharged, and a quarter of these people die or suffer a complete cardiac arrest. Even if such patients aren’t mistakenly sent home, crucial treatment may be delayed when an EKG is misread. Human judgment, even expert human judgment, falls well short of certainty.
Western medicine is dominated by a single imperative— the quest for machinelike perfection in the delivery of care. … The keys to this kind of perfection are routinization and repetition: survival rates after heart surgery, vascular surgery, and other operations are directly related to the number of procedures the surgeon has performed. Twenty-five years ago, general surgeons performed hysterectomies, removed lung cancers, and bypassed hardened leg arteries. Today, each condition has its specialists, who perform one narrow set of procedures over and over again.
With repetition, a lot of mental functioning becomes automatic and effortless, as when you drive a car to work. Novel situations, however, usually require conscious thought and “workaround” solutions, which are slower to develop, more difficult to execute, and more prone to error. A surgeon for whom most situations have automatic solutions has a significant advantage.
Over the past four decades, cognitive psychologists have shown repeatedly that a blind algorithmic approach usually trumps human judgment in making predictions and diagnoses.
What accounts for the superiority of a well-developed computer algorithm? First, Dawes notes, human beings are inconsistent: we are easily influenced by suggestion, the order in which we see things, recent experience, distractions, and the way information is framed. Second, human beings are not good at considering multiple factors. We tend to give some variables too much weight and wrongly ignore others. A good computer program consistently and automatically gives each factor its appropriate weight. After all, Meehl asks, when we go to the store, do we let the clerk eyeball our groceries and say, “Well, it looks like seventeen dollars’ worth to me”? With lots of training, the clerk might get very good at guessing. But we recognize the fact that a computer that simply adds up the prices will be more consistent and more accurate.
It was estimated that, nationwide, upward of forty-four thousand patients die each year at least partly as a result of errors in care.
Studies of specific types of error, too, have found that repeat offenders are not the problem. The fact is that virtually everyone who cares for hospital patients will make serious mistakes, and even commit acts of negligence, every year. For this reason, doctors are seldom outraged when the press reports yet another medical horror story. They usually have a different reaction: That could be me. The important question isn’t how to keep bad physicians from harming patients; it’s how to keep good physicians from harming patients.
Medical malpractice suits are a remarkably ineffective remedy. Troyen Brennan, a Harvard professor of law and public health, points out that research has consistently failed to find evidence that litigation reduces medical error rates. In part, this may be because the weapon is so imprecise. Brennan led several studies following up on the patients in the Harvard Medical Practice Study. He found that fewer than 2 percent of the patients who had received substandard care ever filed suit. Conversely, only a small minority among the patients who did sue had in fact been the victims of negligent care. And a patient’s likelihood of winning a suit depended primarily on how poor his or her outcome was, regardless of whether that outcome was caused by disease or unavoidable risks of care. The deeper problem with medical malpractice suits is that by demonizing errors they prevent doctors from acknowledging and discussing them publicly.
Yet everything we’ve learned in the past two decades— from cognitive psychology, from “human factors” engineering, from studies of disasters like Three Mile Island and Bhopal— has yielded the same insights: not only do all human beings err, but they err frequently and in predictable, patterned ways. And systems that do not adjust for these realities can end up exacerbating rather than eliminating error.
James Reason makes another important observation: disasters do not simply occur; they evolve. In complex systems, a single failure rarely leads to harm.
Even in surgery there have been some encouraging developments. For instance, operating on the wrong knee or foot or other body part of a patient has been a recurrent, if rare, mistake. A typical response has been to fire the surgeon. Recently, however, hospitals and surgeons have begun to recognize that the body’s bilateral symmetry makes these errors predictable. In 1998, the American Academy of Orthopedic Surgeons endorsed a simple way of preventing them: make it standard practice for surgeons to initial, with a marker, the body part to be cut before the patient comes to surgery.
Sometimes it was just chintzy, free stuff. Booths were offering free golf balls, fountain pens, penlights, baseball caps, sticky pads, candy— all stenciled with company logos, of course, and handed over with a spiel and a brochure about some new technology a company was marketing. You might think six-figure surgeons would be oblivious to this kind of petty bribery. But you would be wrong.
The discussions were sparsely attended and mostly went over my head: it is impossible nowadays to have a working understanding of even the basic terminology in all of the fields under consideration.
On the one hand, strong evidence indicates that mistakes are not made primarily by this minority of doctors. Errors are too common and widespread to be explained so simply. On the other hand, problem doctors do exist.
This sort of burnout is surprisingly common. Doctors are supposed to be tougher, steadier, better able to handle pressure than most. (Don’t the rigors of medical training weed out the weak ones?) But the evidence suggests otherwise. Studies show, for example, that alcoholism is no less common among doctors than among other people.
Some 32 percent of the general working-age population develops at least one serious mental disorder— such as major depression, mania, panic disorder, psychosis, or addiction— and there is no evidence that such disorders are any less common among doctors. … There is no easy way to help, though. In private practice, there are no sabbaticals to offer, no leaves of absence, only disciplinary proceedings and public reports of misdeeds. As a consequence, when people try to help, they do it quietly, privately. Their intentions are good; the result usually isn’t.
We are all, whatever we do, in the hands of flawed human beings. The fact is hard to stare in the face. But it is inescapable. Every doctor has things he or she ought to know but has yet to learn, capacities of judgment that will fail, a strength of character that can break.
By contrast, one thing that has been shown is that human beings commonly imagine patterns (whether good or bad) where really there are none. It’s just how our brains work. Even totally random patterns will often appear non-random to us.
Other studies along these lines have shown that extroverts have greater pain tolerance than introverts, that drug abusers have low pain tolerance and thresholds, and that, with training, one can diminish one’s sensitivity to pain. There is also striking evidence that very simple kinds of mental suggestion can have powerful effects on pain. … Today, it is abundantly evident that the brain is actively involved in the experience of pain, and is no mere bell on a string.
Pregnancy sickness, Profet suggested, may have evolved to reduce an embryo’s exposure to natural toxins. She pointed out that women with pregnancy sickness strongly prefer bland foods that do not spoil easily (like breads and cereals) and are particularly averse to foods associated with high levels of natural toxins, such as bitter or pungent foods and animal products that are not extremely fresh. The theory also explains why sickness occurs mainly during the first trimester. That is when the embryo develops organs and is most sensitive to toxins; at the same time, it is small and its calorie needs are easily supplied by the mother’s fat stores.