Complications: A Surgeon’s Notes on an Imperfect Science

“The moral burden of practicing on people is always with us, but for the most part unspoken.”

In “Education of a Knife,” Gawande exposes an uncomfortable truth, that doctors must practice to become experts, and that practice must be performed on real people. This “unspoken” truth is just one of the taboos Gawande gives voice to in this book, imbuing it with intrigue and import. This “moral burden” doctors feel, according to Gawande, speaks to their essential humanity—a quality Gawande reinforces repeatedly.

“By traditional ethics and public insistence (not to mention court rulings), a patient’s right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden.”

This quotation contains an admission of a contradiction at the heart of medicine, which is that patient care and doctors’ practice are occasionally at odds. This contradiction is part of a larger motif of contradictions. It’s an example of the kind of taboo topic, a “hidden” truth, that Gawande tackles openly and with vigor.

“When I’m in the operating room, the highest praise I can receive from my fellow surgeons is ‘You’re a machine, Gawande.’ And the use of ‘machine’ is more than casual: human beings, under some circumstances, really can act like machines.”

Gawande exposes the mentality of surgeons as a way for the reader to begin to understand the building blocks of the medical profession. The data-driven culture and perfectionist personality type of doctors is important in many of the essays in the collection, giving context to themes of fallibility and uncertainty. This machine-like ability of human doctors is also a source of wonder and mystery.

“I asked Byrnes Shouldice, a son of the clinic’s founder and a hernia surgeon himself, whether he ever got bored doing hernias all day long. ‘No,’ he said in a Spock-like voice. ‘Perfection is the excitement.’”

Gawande interviews physicians and includes details about their appearance, behavior, and speaking style to elucidate their philosophies or approaches to medicine. The reference to Spock, a character from Star Trek who’s half-human and half-Vulcan, is a colorful and humorous nod to Dr. Shouldice’s unemotional demeanor. The fact that Dr. Shouldice finds fun in repetition is a surprising contradiction.

“There is, however, a central truth in medicine that complicates this tidy vision of misdeeds and misdoers: all doctors make terrible mistakes.”

Here, Gawande boldly implicates all doctors, and by extension, himself, in the category of doctors who “make terrible mistakes.” The sentence is constructed in a way that builds tension and suspense before landing on its unpleasant conclusion. It’s an example of Gawande aiming for truth over comfort and, in telling that uncomfortable truth, demystifying it.

“As one surgeon told me, it is a rare but warming thing to meet a surgeon without fear. ‘If you’re not a little afraid when you operate,’ he said, ‘you’re bound to do a patient a grave disservice.’”

In discussing this fear that the speaker and, likely other doctors, feel, Gawande upends the social stereotype of a doctor who’s calm and confident. It’s part of his strategy to humanize doctors, even if it means disclosing an unsettling truth. This doctor’s statement also contains a counterintuitive idea—that fear might contribute positively, rather than negatively, to performance—adding it to the list of surprising contradictions.

“It would be deadly for us, the individual actors, to give up our belief in human perfectibility.” 

This conclusion comes at the end of “When Doctors Make Mistakes,” an essay about the natural and even necessary fallibility of doctors. Still, knowing what he knows about error, Gawande strongly advocates for faith in humans’ ability to achieve perfection. It’s emblematic of Gawande’s style, which involves taking a hard look at an assumption or a status quo, evaluating the realities of a conundrum, and concluding with a renewal of faith in the ideal.

“This may explain why many doctors take exception to talk of ‘systems problems,’ ‘continuous quality improvement,’ and ‘process re-engineering.’ It is the dry language of structures, not people. I’m no exception: something in me, too, demands an acknowledgment of my autonomy, which is to say my ultimate culpability.”

In the first section of his book, Gawande presents important evidence about the systemic nature of error in medicine, as well as evidence that supports technical innovation in diagnosis and the machine-like streamlining of surgery. However, he pauses to acknowledge his own resistance to some of these findings, thus calling attention to his own humanity. He both understands his function in a larger system and asserts his autonomy within that system, accepting the contradiction.

“I debated going to a lecture on the proper way to dissect a neck or a session on new advances in managing gunshot wounds to the head, but finally decided on a panel debate about the best way to repair hernias of the groin. I arrived early, and already the auditorium’s fifteen hundred seats were filled. Hernias were SRO.”

Gawande’s sense of humor is present here and throughout the essay “Nine Thousand Surgeons.” His description of the lecture on hernias as “SRO,” or “standing room only,” speaks to his wit. It underscores the theme of fallibility n this essay, which involves taking a less serious look at doctors on their off hours.

“In the course of the afternoon, I cauterized cold cuts, used advanced laparoscopic equipment to remove ‘gallstones’—actually, peanut M&Ms—from inside a mannequin’s abdomen, and used an automated suturing device to sew closed a wound in a weirdly human-looking piece of flesh. (The salesman was coy and would not tell me what it actually was.)”

This passage, with its quirky specifics and deadpan tone, is exemplary of the playful approach Gawande adopts in “Nine Thousand Surgeons.” In this essay, he endeavors to expose the non-serious side of doctors. The images of M&Ms-as-gallstones and lunchmeat-as-tissue are humorous, whimsical details that evoke Gawande’s more lighthearted, even absurd experiences at the convention.

“Doctors […] are for the moment the healthy few who live among the sick. And it is easy to become alien to the experiences and sometimes the values of the rest of civilization.”

Gawande characterizes doctors as being simultaneously human and superhuman. The choice of the word “alien” emphasizes this. This boundary between doctors and patients is fleeting, however, as all doctors, and many doctors in this book, also eventually become patients.

“Physicians will turn in problematic colleagues—the ordinary, everyday bad doctors—only as long as the consequence is closer to diagnosis and treatment than to arrest and prosecution […] Just ask yourself, could you abide by a system that rehabilitated drug-addicted anesthesiologists, cardiac surgeons with manic psychosis, or pediatricians with a thing for little girls if it meant catching more of them? Or, to put it another way, would you ever be ready to see Hank Goodman operate again?”

Gawande wrestles with the idea of “bad doctors” in “When Good Doctors Go Bad.” In this passage, Gawande departs from his usual style and uses the second-person “you,” which has the effect of drawing special attention to the stakes and difficulty of this dilemma. He also implicates the reader in his doubt, unloading the burden of answering the unanswerable question all on his own.

“Pain is a symphony—a complex response that includes not just a distinct sensation but also motor activity, a change in emotion, a focusing of attention, a brand-new memory.”

This employment of metaphor is an example of what gives Gawande’s science-based essays a literary quality. The comparison of pain to a “symphony” expresses how, if pain is noise, it’s created by a multitude of instruments. The use of figurative language to describe pain also indicates that pain itself is both tangible and abstract, both real and surreal.

“To her doctors, she was now a spectral, ever-present reminder of failure—the kind of patient whose very existence is a reproach to them and their expertise.”

The “her” in this quote is Amy Fitzpatrick, a pregnant woman who suffered from hyperemesis and for whom doctors could not find a successful therapy. Gawande suggests here that cases like Fitzpatrick’s are frustrating, even demoralizing to doctors, who are used to a measure of consistency and perfection. This connects to the theme of fallibility versus perfection, as doctors rationally understand but also sometimes don’t accept their imperfections and impotence.

“For some patients, simply receiving a measure of understanding—of knowing what the source of the misery is, seeing its meaning in a different way, or just coming to accept that we cannot always tame nature—can be enough to control their suffering. A doctor can still help, even when medications have failed.”

Here, Gawande meditates on the role of a physician that exists alongside technical ability. For all the advances in science and technology that Gawande explores in his essays, he often uncovers the power of some incalculable human element in patient care. This contradiction between a doctor’s impotence and her/his essential helpfulness is another piece of the book’s paradox motif.

“What’s more, the encounters felt easy and ordinary, without a glimmer of her old self-consciousness. At the airport, she recalls, she and her father were waiting in a long check-in line and she couldn’t find her passport. ‘So I just dumped my purse out onto the floor and started looking for it, and it occurred to me that I was doing this—and I wasn’t mortified,’ she says. ‘I looked up at my dad and just started crying.”

This quotation comes from Christine Drury, a patient who suffered from blushing her whole life and underwent an operation to rid herself of the disorder. It distills the effect of the cure to a single, scenic moment of epiphany. The particular scene that Drury depicts, paired with insight into how she felt, grounds the patient’s experience amidst more theoretical and clinical discussions of the blushing mystery.

“But it is a question as impossible to answer as whether a blush is physical or mental—or, for that matter, whether a person is. Everyone is both, inseparable even by a surgeon’s blade.”

This quotation is emblematic of Gawande’s poetic flourish, an example of how he elevates the more grounded discussions of science and medicine to a literary plane. Here, he takes a question about medicine and extends it to humanity in general. The phrase “inseparable even by surgeon’s blade” is a nod to both the incredible power and the ultimate futility of science when it comes to understanding humans.

“It is hard to contemplate the human appetite without wondering if we have any say over our lives at all.”

This statement betrays Gawande’s willingness to stare into the unknown. Even as a writer skilled in articulating logical arguments based on precise evidence and philosophy, he’s also able and willing to contemplate what he can’t explain. This pairing of knowledge with wide-eyed mystery is fundamental to Gawande’s style and to operating in the world of medicine.

“‘I used to be real reluctant to push food away,’ he told me. ‘Now it’s just—it’s different.’ But when did this happen? And how? He shook his head. ‘I wish I could pinpoint it for you,’ he said. He paused to consider. ‘As a human, you adjust to conditions. You don’t think you are. But you are.’”

This quotation comes from Vincent Caselli in “The Man Who Couldn’t Stop Eating.” It’s an example of how Gawande accumulates wisdom not just from experts but from patients, too. The uncertainty Caselli expresses touches on the theme, as he seems to be at peace with the unknown.

“‘Autopsy’ literally means ‘to see for oneself,’ and despite our knowledge and technology, when we look we’re often unprepared for what we find.”

This reference to etymology nods to Gawande’s interest in the history, as well as the cultural understanding, of medicine. In “Final Cut,” Gawande takes a hard look at an uncomfortable topic—the autopsy—and presents it to the reader, warts and all. In this way, the essay itself, and the collection as a whole, are autopsies of the medical profession. Gawande invites the readers to see for themselves.

“From what I’ve learned looking inside people, I’ve decided human beings are somewhere between a hurricane and an ice cube: in some respects, permanently mysterious, but in others—with enough science and careful probing—entirely scrutable.”

Gawande uses two models to describe predictability: hurricanes, which are sometimes similar but ultimately unpredictable, and ice cubes in a fire, which predictably always all melt. These analogies give readers a visual, relatable way to understand probability. When Gawande places humans somewhere on the spectrum, it’s a humorous but useful way to explain the simple complexity of humans.

“I wanted them to decide—doctors I had never met before. The ethicist Jay Katz and others have disparaged this kind of desire as ‘childlike regression.’ But that judgment seems heartless to me. The uncertainties were savage, and I could not bear the possibility of making the wrong call.”

Gawande includes a handful of personal stories in his essays that place him and his child on the opposite end of the doctor-patient relationship than the one he usually occupies. This method of switching perspectives—from doctor to interviewer to researcher to subject—gives all Gawande’s essays depth, authority, and variety. His language here, too, builds a striking sense of ethos that gives personal context to the debate about autonomy in patient care.

“In all the confusion of different approaches that different doctors take to a given problem, somebody must get it right. And each of us—used to making decisions under uncertainty every day—remains convinced that that somebody is me.”

Gawande articulates his incalculable belief in human autonomy and capability. His categorizing of doctors as individuals who believe in their own power builds on the book’s theme of confidence in the face of uncertainty. It’s also characteristic of Gawande’s worldview and the message he tries to relate in his writing: that good outcomes do happen, and idealism can coexist with all manner of unpleasant or challenging realities.