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Journal of the Academy of Hospital Administration

Book Review

Author(s): Rajiv Kumar Jain

Vol. 14, No. 1 (2002-01 - 2002-06)

"Complications: Notes from the Life of a Young Surgeon".

Reviewed by: Rajiv Kumar Jain*

Atul Gawande, having done his MD from Harvard Medical School (equivalent to MBBS in India), MPH from Harvard School of Public Health, doing residency training in /general Surgery for last eight years and writing for the internet magazine "Slate" and for the "New Yorker" has now created a masterpiece in a best seller format. "Complications" is a collection of true stories in the area of medical ethics, medical errors, uncertainty in medical science, medical negligence, medical jurisprudence and much more. The style of writing is gripping, sensitive and lucid. One starts wondering why more of such writings/experiences don"t come to surface. The author"s background as a laboratory scientist, a public health researcher, a student of philosophy and ethics, and a public health policy adviser in government, son of two doctors; father a successful urologist, mother a part time paediatrician, a husband and apparent, has helped him in making him look at issues in truly non-partisan ways, yet not loose his sensitively of characters involved.

The book evolves through its three parts viz., Fallibility, Mystery and Uncertainty, each having five chapters. Any hospital administrator would share the dilemmas, contradictions and uncertainty involved in medical science as well as the deficiencies and imbalances in the system of medical regulation of ethics. The author rightly points out in the introduction itself "We look for medicine to be an orderly field of knowledge and procedure.... It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals and at the same time lives on the line". That"s how the book is beyond all textbooks of medicine and hospital administration. Yet every physician or practitioner of the science and art of medicine as also every health and hospital administrator must read this book.

"When Doctors Makes Mistakes" and "When Good Doctors Go Bad" are eye openers. Any senior surgeon would testify that similar stories have been experienced some time or the other in his/her lifetime. Yet, what have we done to protect patients? What have we done to protect our profession? The relationship between repetition and perfection has been brought out in "The Computer and the Hernia Factory". The reference to "Market Driven Health care: Who Wins, Who Loses in the Transformation of America"s of Harvard Industry by Professor Regina Herzlinger of Harvard Business School and the concept of "health-care focused factory" to start to debate on automation and specialized centres for cardiac surgery, bone-marrow transplant, breast cancer etc., is timely for consideration of Indian health planners also.

Medicine has not yet reached a stage where we could explain or cure all human symptoms of ill-health or concerns of human being for being not normal. The section "Mystery" brings into focus this very issue. Recently, I saw an extract of the chapter "Full Moon Friday the Thirteenth" in the "Outlook" magazine. Here, Atul becomes George Orwell. His prose, lucidity, organisation, simplicity and accuracy is at its zenith in this section. The judges and lawyers should read this section to enlighten themselves on the uncharted sea that the practitioners of medicine venture every day all over the world.

The section "Uncertainty" has been opened with "Final Cut" so appropriately. The autopsies that are done, and more importantly not done, to enable better diagnosis and appropriate treatment for future patients as well as record and analyze medical errors, is worth consideration. To ask questions from the dead is a wise strategy to make uncertainties in medicine into certainties. The well known Sudden Infant Death Syndrome (SIDS) has been re-looked at with a breath of fresh air in "The Dead Baby Mystery". The last chapter in the book "The Case of the Red Leg" is soothing and softening, yet thought provoking. The crucial and central issue of uncertainty has been brought to the fore when the author writes "the thing that makes a patient so wrenching, being a doctor so difficult and being a part of a society that pays the bills they run up so vexing - is uncertainty". The basis of medicine is concrete observations and hard evidence. Yet, at times decisions based on the contrary are more appropriate and effective, for patient"s life. The dilemma of not executing an intervention in medicine being more difficult than executing perplexes many surgeons and physicians alike.

After going through the book, I have to give credit to Henry Finder, Malcolm Gladwell and Jacob Wiesberg, the editor, writer (The New Yorker) and Chief political Correspondent (Slate) respectively to find, encourage, guide and nurture this new age medical journalist - Atul Gawande. It"s no surprise that "The Best American Science and Nature Writing 2000" and "The New Yorker" essay collection "In Sickness and In Health" have included Atul"s writing. I am sure Atul has a greater future in medical writing than practice of medicine. Meanwhile, all health administrators should read this book for their entertainment and enlightenment.

Author: Atul Gawande

ISBN 0-14-302845-6


Penguin Books India Ltd.

11 Community Centre, Panchsheel Park,

New Delhi - 110 017, India

Year of Publication, Pages; Price: 2002, 251,

Rs. 250 (Paperback)


* Deputy Chief Medical Director,
Indian Railways Medical Service,
New Delhi, India.
For correspondence:
480, Sector 37,
Faridabad 121003, Haryana, India.
E-mail: [email protected] and
[email protected].

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