Complications: A Surgeon’s Notes on an Imperfect Science

Gawande opens this essay with a story about a patient named Rowland Scott Quinlan, an architect who fell and hurt his shoulder in a workplace accident. Later, Quinlan began complaining of severe back pain that limited his ability to work and perform normal functions. Painkilling therapies largely lost their effect, and X rays revealed no source of the back pain. He saw a psychiatrist to address the possibility of the pain being mental. Even his own wife at times questioned if he was faking it while also observing the very real ways in which Quinlan’s quality of life had diminished.

Gawande admits that doctors find patients like Gawande, who complain about chronic pain and exhibit no traceable source of the pain, annoying. Pain like this defies logic, and doctors love logic. At Boston’s Brigham and Women’s Hospital, Gawande interviews Dr. Edgar Ross, who reveals statistics about the “virtual epidemic of back pain in this country today” that defies explanation in mechanical terms of strain or injury (118). Studies find that back pain predictors include “such ‘inorganic’ factors as loneliness, involvement in litigation, receipt of workers’ compensation, and job dissatisfaction” (119).

Gawande traces the dominant understanding of pain throughout the history of medicine, beginning over 300 years ago with Rene Descartes, who hypothesized that pain occurs when an injury to tissue stimulates nerves that then deliver a message to the brain, adding, “It is hard to overstate how ingrained this account has become” (120). However, a study of injured soldiers in WWII contradicted the Cartesian theory: Soldiers who felt happy to have survived battle reported feeling less pain.

Next came the Gate-Control Theory of Pain, developed by Patrick Wall and Ronald Melzack, which held that a “hypothetical gate could simply stop pain impulses from getting to the brain” (121). This theory made room for the idea that the brain not merely is a receiver of pain impulses but also contributes to the signal. Gawande cites a study of male and female ballet dancers versus non-dancers and their pain tolerance and thresholds. Gawande suggests the dancers’ discipline and athleticism caused them to feel less pain. Other evidence supports the idea that gender, belief system, and social factors might also contribute to pain.

Gawande describes operations and findings by Dr. Frederick Lenz that reveal how pain response can be “wildly out of proportion to the stimulus” (124). He says of two patients in particular, “Areas of the brain governing ordinary sensations appeared to have become abnormally sensitized—set to fire in response to perfectly harmless stimuli” (125).

The newest theory of pain, also proposed by Ronald Melzack, suggests that “it is the brain that generates the pain experience, and it can do so even in the absence of external stimuli” (125). This theory holds that an injury sends a signal that “still has to make it through the spinal-cord gate, but thereafter it joins a lot of other signals in the brain—from memories, anticipation, mood, distractions” (126).

New understanding about pain leads to innovations in medication, but “the fundamental problem for research is how to stop the pain system in such patients from going haywire in the first place” (127). As Gawande says, “some forms of chronic pain behave astonishingly like social epidemics” (127).

Gawande closes by saying that “the solution to chronic pain may lie more in what goes on around us than in what is going on inside us. Of all the implications of the new theory of pain, this one seems to be the oddest and the most far-reaching: it has made pain political” (129). 

Gawande explores the subject of nausea, or emesis, through the lens of a story of a single patient named Amy Fitzpatrick. Fitzpatrick became pregnant with twins and suffered from a condition called hyperemesis that caused her to experience extreme nausea and frequent vomiting throughout her entire pregnancy. She stopped being able to eat, lost weight, quit working, and saw her quality of life diminish.

Gawande segues into a technical discussion of nausea, which is caused by a variety of factors ranging from pregnancy to motion sickness, or which can be a side effect of poison and drugs, from anesthesia to chemotherapy. He underlines nausea’s extreme unpleasantness, citing Cicero’s fear of seasickness and mothers whose memories of nausea during pregnancy trump their memories of pain during childbirth.

Gawande examines the recognizable biological purposes of nausea—like expelling poison—while also calling attention to the more mysterious presentations of nausea. While pregnancy sickness may have evolved to protect embryos from even natural foods that would be harmful to their development, motion sickness seems to serve no purpose. Gawande says, “Researchers have now established that motion sickness occurs when there is a conflict between the motion we experience and the motion we expect to experience” (136).

Gawande revisits Amy Fitzpatrick’s story to survey the list of medications that didn’t work for her, saying “there is no universal antiemetic” (139). Fitzpatrick stumped doctors, and their inability to find a cause upset them and caused them to refer her to a psychiatrist, who suggested that she might be subconsciously resisting pregnancy. Fitzpatrick chose not to abort her pregnancy, despite the fact that many people who suffer with hyperemesis do choose abortion.

Gawande discusses the difference between nausea and vomiting, how they aren’t always connected, and how a drug or procedure to prevent vomiting may not ease nausea. Chemotherapy patients experience acute nausea immediately after drug therapy, “delayed emesis” that brings nausea and vomiting days later, and also “anticipatory nausea or vomiting” caused by sensory cues and reminders of chemotherapy (141).

Gawande explains palliative medicine, which centers around “dying patients—specifically in improving the quality of their lives rather than prolonging their lives” (142). Whereas most doctors are trained to alleviate suffering by looking for root causes, palliative medicine supports the idea that suffering alone—like nausea and pain, even when a patient is technically healthy—deserves treatment and care.

Gawande introduces an anchorwoman named Christine Drury who suffered from blushing. Growing up, she would blush from embarrassment in school and in public interactions. Though she was ambitious in her career and used to socializing, she would blush on camera. Her discomfort was easy to spot, causing her career to stall.

Blushing is complicated, “at once physiology and psychology. On the one hand, blushing is involuntary, uncontrollable, and external, like a rash. On the other hand, it requires thought and feeling at the highest order of cerebral function” (149). It’s often thought to be an expression of humiliation, but that doesn’t explain why people blush when they’re the center of positive attention. According to one theory, Gawande says, “the blush exists to show embarrassment, just as the smile exists to show happiness” (150). One updated theory holds that blushing may serve a social purpose: to identify for people when they’ve made a transgression and to communicate apology.

People with an extreme tendency to blush struggle to stop it, and many—like one neuroscientist Gawande profiles—organize their lives around avoiding attention to the detriment of their social and professional lives. Christine Drury elects to pay for an expensive operation in Sweden called endoscopic thoracic sympathectomy, wherein pieces of the two cords along the spine that control the sympathetic nervous system are removed. Gawande describes this procedure—which Drury undergoes successfully—in detail.

Drury, cured from her blushing, initially experienced joy and success. She improved her on-camera performance and got an on-air job. That initial reaction, however, didn’t last, and she felt like an imposter, saying, “I felt incredibly ashamed over needing to remove my difficulties by such artificial means” (159). As Gawande puts it, she felt “precisely the same embarrassment as before, only now it stemmed not from blushing but from its absence” (159). Gawande closes by asking whether Drury’s condition was psychological or physical and expands the discussion to a definition of people as both psychological and physical beings.

“The Man Who Couldn’t Stop Eating” begins with a scene of a gastric-bypass operation on a patient named Vincent Caselli, a construction contractor who weighed 428 pounds and who experienced severe deterioration in health, productivity, and quality of life as a result of his obesity. In 1999, at the time of the surgery, the gastric bypass was a relatively new operation gaining in popularity. Gawande participated in Caselli’s surgery and followed him through his post-operative phase to track his progress. He also interviewed Caselli to learn about his life and the circumstances that led to his obesity, gathering that Caselli’s reasons for eating and reasons for stopping eating weren’t unique, but that “the main difference seemed to be that it took an unusual quantity of food to make him full” (167).

Gawande segues into a more technical discussion of hunger, establishing through a list of diets that “the history of weight-loss treatment is one of nearly unremitting failure” (169). Most people who lose weight gain it back, with children being a noteworthy exception: “Apparently, children’s appetites are malleable. Those of adults are not” (170). Gawande also breaks down the biological processes by which humans eat and feel full, admitting “our knowledge of these mechanisms is still crude at best” (171). A study of patients with amnesia showed that a person’s memory of having eaten or not contributes to his appetite more than the fact of having eaten.

Gawande tells the story of a women in his office named Carla who also had gastric-bypass surgery and claimed to acquire “a profound and unfamiliar sense of willpower over food” (174). This change in attitude toward food, and in life in general, is common amongst gastric-bypass patients. Initially, Caselli didn’t experience this shift in a desire to eat. He wondered if things would ever really change, even after a drastic operation. As Gawande followed him in the months after the operation, however, eventually Caselli reported feeling satisfied with less food.

To Gawande, the popularity of gastric-bypass surgery and the speed at which new professionals, patients, and innovations flock to the field is a cause for concern. He also feels concerned by a culture that equates fatness with failure and that drives women to seek surgery seven times more than men despite being “only an eighth more likely to be obese” (182). Long-term effects of the surgery are relatively unknown.