Complications: A Surgeon’s Notes on an Imperfect Science – Atul Gawande

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Complications - Atul Gawande

A surgeon’s notes

Surgeon Atul Gawande (and now CEO of Haven Healthcare) compiled a collection of essays, written during his general residency, in his book Complications: A Surgeon’s Notes on an Imperfect Science. The book provides insight into the fallibilities, mysteries and uncertainties of medicine. This includes Gawande’s reflections on the challenges and choices we face when making decisions under uncertainty. Complications is both an insightful and educational book. It contains a myriad of lessons, not only for those in healthcare, but for those in business as well. In this post, we’ll review some of the messages that I took from Gawande’s work.

Jump ahead:

The complications with practice

Gawande describes medicine as a messy field. Messier than we’d like to believe. For all its knowledge and procedures, medicine is an imperfect science, characterised by changing knowledge, incomplete information and fallible individuals. It’s science mixed with habits, intuition and occasional guessing. The field brings its share of doubts, missteps, failures and surprises. In Gawande’s view, great surgeons will act decisively, but recognise the limitations of their science and skill. The higher the stakes, the more necessary and prudent this becomes.

Practice, not talent

Gawande recalls as a young surgeon his early discomfort with jabbing needles into patients. He was also amazed with the surgeon’s ability to use a scalpel with unwavering confidence. He observes how surgeons develop their skills and confidence through experience. Experience helps them to grapple with incomplete information, ambiguous science, and the limitation in their knowledge and ability. Sometimes, these experiences must involve abject failures and occasional humiliations.

It’s for these reasons that Gawande believes in practice, rather than talent. Gawande suggests that people who are ‘conscientious, industrious and boneheaded’ enough to practice consistently, and dedicate themselves to the craft, are more likely to succeed in surgery. While we can teach skill, we cannot teach tenacity. So one’s desire to continue with training and practice is critical to success.

Perfection without practice

Gawande also observes how society demands ‘perfection without practice’. When it comes to healthcare for themselves and their loved ones, people insist on ‘professionals’ over ‘novices’ (and fairly so). But preferences at the individual level can create problems in the aggregate. If ‘novices’ do not receive the opportunities to build experience, then there’ll be less experienced professionals in sum. To navigate society’s demands in surgery, according to Gawande, necessary learning in surgery is often hidden, whether by anaesthesia or plays in language.

The mental game

With regards to learning, Gawande describes how we sometimes have to get worse before we can get better. Sports psychologist Jared Tendler shared a similar view in his book The Mental Game of Poker. He parallels human ability to an inchworm, a probability distribution to describe the variance in our performance. As with atheletes, it is very difficult for us to perform at our best at all times. Instead, the learning process involves moving our inchworm, or bell curve of results, in the right direction. In other words, we want to improve the frequency and degree of good performance over bad.

This is a simple but important idea since it reframes the way we judge our performance. That is, we should compare our current average to our prior averages, and our good (bad) decisions to our prior good (bad) decisions, at some reasonable interval of time. People will find themselves demotivated if they always compare their worst decisions today to their prior best.

Expertise and progress in conflict

While we demand expertise and progress in medicine, Gawande highlights how these factors can be in conflict with one another. Knowledge in medicine and surgery is far from fixed. New science and technologies can make current knowledge and skills outdated. Since learning takes time, the introduction of new procedures and innovations may produce suboptimal results, at least initially. However, this upfront cost allows society to realise greater net benefits in the future as the profession moves along its learning curve. Gawande describes how good policy and practice must grapple with the cost-benefit mix that comes with learning, innovation and progress. Unfortunately, in a field where incomplete information and uncertainties are rife, the best course of direction is rarely obvious.

Fallibility in an imperfect science

As in finance and investing, there are opportune moments in which doctors or surgeons should act decisively (e.g. performing an operation before the patient’s condition worsens). However, Gawande describes how he and his peers will sometimes let opportunities pass, whether due to “hubris, inattention, wishful thinking, hesitation, or the uncertainty of the moment”. While we tend to associate terrible mistakes or malpractice with incompetent, unethical and/or negligent practitioners, Gawande notes that every doctor will make mistakes.

While everyone is prone to making mistakes, some mistakes are more obvious and costly than others (e.g. mistakes in medicine, aviation, etc.). Some errors result from our tendency to rely on intuition and heuristics for decision making. At other times, we imagine and act on patterns that don’t actually exist. Authors like Daniel Kahneman in Thinking, Fast and Slow, or Annie Duke in Thinking in Bets, have also discussed these behaviours in length. They describe how motivated reasoning, anchors and associations can sometimes impair the quality of our decision making.

Novel problems

Mistakes are also more likely to arise in novel situations where more nuance is required to solve the problem. Where the stakes and time pressures are high, we’ll find it more difficult to develop and implement solutions. Likewise, mistakes become more likely when we rely exclusively on unchecked intuition. Gawande describes how we’re often inconsistent, and susceptible to suggestions, distractions and the framing of information itself. We’re short-sighted, poor at weighing competing factors, and stubborn to change when wrong.

System failures

More disastrous errors tend to emerge in complex systems, where many individually improbable mistakes occur and compound together. Gawande notes that systems or processes that depend on human perfection contain errors that are bound to arise eventually. Contributing factors such as insufficient experience, familiarity, timeframes, resourcing and communication may exacerbate these risks.

Misplaced confidence

Without hard evidence and fixed processes, practitioners will rely more on intuition to make decisions. This can increase the variability in practice and outcomes. Despite the variance, each of us have a tendency to believe that we have taken the most logical approach. However, this is often little more than an unfounded belief in ourselves. In the aggregate, it is somewhat delusional because we cannot all be making optimal decisions relative to everyone else.

Gawande cites a medical study that found no difference in accuracy between doctors with high confidence in their judgement and those with low confidence. Since our intuitions are sometimes faulty, confidence alone is a poor indicator of the quality of our intuitive judgement. We should remember that sound intuition depends upon reliable but unconscious pattern recognition (and a little bit of luck). Given its nature, it’s not always easy for us to verify it.

When good goes bad

In one of my favourite chapters, Gawande describes how some previously great doctors become bad practitioners over time. The causes can vary, ranging from senility, to burnout to physical illness. Gawande cites poor control of anger, erratic and/or abusive behaviour, poor workplace boundaries and increases in lawsuits / complaints as potential red flags.

It’s important to have practices and policies in place to help individuals, colleagues and the organisation to recognise, remedy and rectify such problem-points. For example, the threat of punishment alone is unlikely to reduce fallibility over the long-term if more personal factors are the cause.

Good doctoring with less complications

“Good doctoring is all about making the most of the hand you’re dealt”

Atul Gawande, Complications

Given a long enough timespan, we’re bound to make mistakes. We can only endeavour to reduce our tendency for mistakes with attention, diligence, effort and good process. Gawande correlates the severity and frequency of mistakes with the way teams practice. The author observed that high performing teams were more intentional with how they trained and monitored progress. By contrast, poor performing teams were less likely to pre-brief, debrief or track progress at all.

Process over people

When resolving systematic errors, it’s sometimes more productive to focus on addressing the process than the specific individual. Gawande notes that open and honest error reports are vital. If we cannot eliminate individual or process-based errors, we should make efforts to identify them pre-emptively. Again, the threat of punishment alone is unlikely to reduce long-term fallibility. In industries such as aviation and medicine, standardised checklists help to reduce systematic errors.

However, it isn’t easy in medicine to reduce diagnosis for example into simple generalisations. The patient’s unique context matters. So some element of good judgement and problem solving is necessary. While good processes and checklists are helpful, they need to be specific and reflexive to the activity at hand.

Mechanistic perfection

“Extreme specialization is the way to succeed. Most people are way better off specializing than trying to understand the world.”

Charlie Munger

Where mechanistic perfection is necessary, a narrow set of routines and repetition becomes key. There is appeal here in training specialists that excel in specific tasks. Gawande asks that if we’re to task someone with only fixing hernias, should we require them to undertake the entire four years of medical school and five years of residency?

Between hurricanes and ice cubes

Gawande points out the complex systems inherent in imperfect sciences like medicine. The author uses an example of hurricanes and ice cubes to make his point. While hurricanes emerge from known physical laws, we struggle to make good long-term predictions about them. By contrast, we find natural phenomenon such as melting ice cubes far easier to predict. This difference is attribute to differences in complexity and the number of interacting variables.

Gawande believes people are somewhere in between an ice cube and a hurricane. We’re a mix of mystery and knowableness. While we might overcome our deficits in knowledge and skill, there exists a level of natural uncertainty that we cannot overcome.

Wisdom from not knowing

“There are known knowns,… known unknowns [and] unknown unknowns… And if one looks throughout history… it is the latter category that tend to be the difficult ones.”

Donald Rumsfeld

Many experts don’t like to admit when they don’t know the answer. Unfortunately, uncertainty is an unavoidable feature of fields like medicine and economics. We don’t always have complete information, reliable observations, or clear precedents to make informed decisions. In Gawande’s view, wisdom comes with how people grapple with this uncertainty.

Self-doubt and learning

“There’s no way that you can live an adequate life without many mistakes. In fact, one trick in life is to get so you can handle mistakes. Failure to handle psychological denial is a common way for people to go broke.”

Charlie Munger

Even great doctors will have to grapple with the guilt, shame and self-doubt that comes with making mistakes. Some will have to learn to overcome the tentativeness and indecisiveness that these emotions can bring about. However, what is worse in Gawande’s view are the doctors that react to mistakes defensively, observe mistakes in everyone else but themselves, and/or hold zero fears about their abilities. Doctors that do not understand their limitations cannot learn from their mistakes.

Post-mortem discoveries

Many medical practitioners highlight the value of autopsies for discovery and learning. They cite how autopsies can reduce errors and allow doctors to see when their diagnosis is incorrect. However, some practitioners might not want to uncover or learn from their past mistakes. Others might conclude that the chances of misdiagnosis are low and forgo the autopsy altogether. Gawande observes how confident we can feel about our judgements, only to find out we were wrong all along.

Decision trees and analyses

Gawande also discusses the benefits of decision analysis and trees. The practice of laying out our options with an expected likelihood and benefit can help us to make decisions. However, decision trees can grow in complexity very quickly. Sometimes there are too many choices and unknowns to consider. Likewise, the immediacy of some events makes constructing a decision tree impractical. Nevertheless, it is a useful for retrospection at the very least, allowing us to test our intuitions and explore options we did not consider at the time.

Possibilities and probabilities

While decision making under uncertainty is difficult, there are steps we can take to manage it. Gawande offers two more strategies. Firstly, we should try to minimise the uncertainties in our process. Good research, evidence, procedures and checklists can help with this. Secondly, we should map out our desired actions under a variety of uncertain events. This can minimise our dependence on individual intuition if a similar event were to arise. This is particularly valuable if the decision required under these scenarios are time sensitive.

Philip Fernbach and Steven Sloman offer similar advice in their book The Knowledge Illusion. To manage uncertainty and make better decisions, they recommend four things: (1) reduce complexity; (2) simple decision rules; (3) just-in-time education; and (4) a habit for checking facts and intuition.

At the end of the day:

“The possibilities and probabilities are all we have to work with…”

Atul Gawande, Complications

References

Further reading