It’s complicated

by | Thursday | January 7, 2010 | 5 comments

I haven’t even made it all of the way through the book yet, but I’m riveted by Atul Gawande’s Complications: A Surgeon’s Note on an Imperfect Science. Though the author is a human physician, I think anyone here in the veterinary field would find much in the book that would have you nodding as I was, so engrossed during my after-work pedicure splurge that I failed to notice the tech painting my toenails a distinct fluorescent orange instead of the demure pink I had put aside. It was worth it.

Those of you not in the field at all would like it too, I think. It’s one of the more honest assessments I have read on the practice of medicine in a long time. Among the assertions:

1. Good doctors are not the most talented, but the most tenacious. Talent only gets you so far, but practice- overandoverandover- is what makes you excel.

2. Yep, having newbies work on you stinks and they do mess up quite a bit more. Therefore it sometimes behooves doctors to tap dance around the reality of who, exactly, will be slicing you up later on that day.

3. Cookbook medicine is not a bad thing.

Number three is a hugely contentious point in the field of veterinary medicine. Vets, proud of their reputation as stubborn and independent, invariably bristle at the suggestion that strict adherence to protocol improves outcomes. After all, we come from the James Herriot/MacGyver worldview of medicine, where in the throes of a 2 am emergency you might have to deliver a calf with only a funnel, a Slinky, and a moldy orange at your disposal. We like the romantic idea of solemnly looking at a pet, diagnosing an abscessed tooth based on good ol’ intuition and know-how, and saving the day with our wit and creativity.

Clients who subscribe to this vision also contribute to the problem. At least once a week- no, make that once a day- I have someone complain about the need to perform diagnostics in order to, well, make a diagnosis. “Ol’ Doc Johnson down the street can diagnose a bad heart from across the room!” they’ll puff, “and he does it for $5 and a jar of jam!” Ol’ Doc Johnson is retired, sadly. And probably missed a heck of a lot of things with his x-ray vision and his bottle of Vetalog, unless he secretly had one of those cool Star Trek TNG diagnosis gadgets that Dr. Crusher used. (Uh oh, I just outed myself as a major nerd. Ignore that.)

We all want to think we’re smart, and that is how we got where we are. Because our gigantic brains are so gifted and amazing that, like a brainy blimp, the sheer antigravitational force of our genius lifted us by our cranium and plopped us into our office, perfect and infallible from day one. The mystique of the medical profession doesn’t do much to dispel that myth, truth be told. But the real truth is, repetition and hard work makes the man, usually despite our ego, not because of it. Despite the hard to shake belief that protocols and standardization squash one’s ability to perform medical works of art and magnificence, the evidence has shown consistently that following the routine the same way over and over improves your outcomes.

I remember doing a rotation in surgery my senior year with a resident from Australia. I don’t know that anyone would call him a genius, truth be told, including himself. While I retracted for him, he’d turn on AC/DC and tell me about his prior career as a mechanic and his love of brawling. I’m pretty sure he never made it through War and Peace. What he did do, however, was practice his technique for hours on end at home, practicing maneuvers with a Dremel and a dowel. His work, like that of all great doctors, was systematic and meticulous, and his outcomes were excellent.

On the other hand, there was a girl in my graduating class who was by her own admission, a card carrying Mensa genius. She didn’t study. She had a near-perfect GPA. She never had to try hard to succeed at anything- until she graduated. I heard that she quit veterinary medicine, her passion since childhood, not 2 years after graduation because she couldn’t stand the pressure of imperfection and making mistakes. What a shame, because I’m sure she was great.

I wonder how often that happens. We’re all scared to admit our fallibility to ourselves, let alone others- which is why I was so intrigued to read this book where the doctor admits it to the whole world.

Filed: Daily Life, Musings
  • Kristie

    There’s an interesting article (and one that I think all parents should read) about that subject here: http://nymag.com/news/features/27840/

    • http://www.pawcurious.com Dr. V

      So, so true. Great article.

  • http://www.hiddenexposures.com hidden exposures

    it is a great book and i became a big fan of his writing after having read it. what i like most about him is not so much that he lays out the imperfect science for everyone to see but that he applies such a human element to it. he strikes me as being one of the odd surgeons out there that actually has a bedside manner. most of them, i’ve found, don’t, but it is largely because they go straight from high school to pre-med to med school to specialty and never are able to spend a lot of time in the social world the rest of us live in.

    which brings me to veterinary medicine. as i am in medicine myself, i can be a tough customer when it comes to my dog and cat because i work hard to educate myself and ask the questions that the average person doesn’t ask. my favorite vet is someone who can answer those questions (and if they don’t know, say that they don’t know rather than try to snowball me) but also is one that will get down on the floor with my dog to say hello before an exam. i don’t expect every vet bonds with every animal, but to feel as if my vet at least tries to have a rapport with my animal goes leaps and bounds over what scientific information they can impart at a key point in time. i guess what it comes down to for me is the belief that i put something i love in the hands of someone who i think will care – often easier said than done!

    to go back to atul gawande, if you like “complications”, i would also recommend you read “better”. on a somewhat different note, you might be interested in jerome groopman’s “anatomy of hope” – certainly many things from that book can be translated to veterinary medicine.

    • http://www.pawcurious.com Dr. V

      I tackled Better last year and loved it. I agree, Dr. Gawande seems unusually introspective for one in that field, and that’s what makes him so unique. Great writer.

      I have not read Anatomy of Hope, but thank you for the recommendation- I’m going to put that on my list to look for at the library.

  • http://www.examiner.com/x-24028-Houston-Cats-Examiner Robyn Broyles

    I’m reading another human-medicine book you may like called How Doctors Think by Jerome Groopman. (You’ll probably be jealous when he talks off-handedly about the sophisticated diagnostics available to human doctors, though…) In medical school, the vogue is to teach something called Bayesian analysis as a systematic way of working through differentials. While he acknowledges the obvious value of protocols and thoroughness (check out the radiology chapter, whew!) he also demonstrates the value of lateral thinking, or keeping part of your mind on other possibilities even once a diagnosis is made. This helps catch the zebra diagnoses, obviously, but more importantly it helps cut down on the errors in thinking typical of doctors. I’m not a doctor myself but I do not expect perfection from mine—or from my cats’ doctor either!