Atul Gawande - Complications: A Surgeons Notes on an Imperfect Science

B eing the child of two doctors, I have been familiar with medicine since I was small. The dinner talk at home was as often about local doctor gossip and cases (the badly asthmatic boy my mom was taking care of, for instance, whose parents were not giving him his medication; my dads first successfully reversed vasectomy; the guy whod gone to bed drunk and shot his penis off thinking there was a snake under the covers) as about school and politics. As soon as we were old enough, my sister and I were taught to field phone calls from patients. Is this an emergency? we learned to ask. If callers said yes, that was easy. We were to tell them to go to the emergency room. And if they said no, that was easy, too. We were to take a message. Only one time did I get an I dont know. It was from a man with a rather strained voice calling for my father because hed injured himself while shoveling. I told him to go to the emergency room.

Once in a while, Id be out with my mom or dad when an emergency page would come through. Wed go to the hospital together, and Id be put in a chair in the ER hallway to wait. Id sit watching the sick children crying, the men bleeding into rags, the old ladies breathing funny, and the nurses scurrying everywhere. I got more used to the place than I realized. Years later, as a medical student entering a Boston hospital for my first time, I realized I already knew the smell.

I came to writing, however, only much later and with the help of a lot of people whom I owe a deep debt of gratitude. My friend Jacob Weisberg was the one who first encouraged me to write seriously. He is the chief political correspondent for the Internet magazine Slate, and during my second year of surgical residency he pushed me to give a try at some medical writing for his publication. I agreed. He helped me through multiple drafts of that first piece. And then, over the next two years, he and Michael Kinsley, Slates editor-in-chief, along with my editors Jack Shafer and Jodie Allen, gave me both space and guidance to create what became a regular column on medicine and science. The opportunity changed everything for me. Residency is a grueling experience, and in the midst of all the paperwork and pages and sleep deprivation, you can forget why what you do matters. The writing let me step back and, for a few hours each week, remember.

In my third year of residency, another friend, the New Yorker writer Malcolm Gladwell, introduced me to his editor Henry Finder. And for this I consider myself one of the luckiest writers there could be. A mumbling, astonishingly widely read boy genius who at the age of thirty-two was already editor to several of the writers I most admired, Henry took me under his wing. He had the patience and persistence and optimism to pull me through seven complete rewrites of the first article I submitted to The New Yorker. He pushed me to think harder than I had ever thought I could. He showed me which of my instincts in writing I could have confidence in and which ones I should not. More than that, he has always believed that I had stories worth telling. Since 1998, The New Yorker has engaged me as a staff writer. Many of the chapters in this book originated as articles I published there. In addition, Henry has read and provided invaluable advice on everything written here. This book would not have been possible without him.

There is a third person at The New Yorker besides Henry and Malcolm to whom I owe particular thanks: David Remnick. Despite my unpredictable schedule as a resident, and the reality that my patient responsibilities must come first, he has stuck with me. He has built a great and special magazine. And most of all, he has made me feel part of it

In writing this book, I have found two new kinds of people in my life. One is an agent, which seems like something everyone should haveespecially if you can have one like Tina Bennett, who has looked after both me and the book with dedication, unshakable good cheer, and eminently sound judgment in everything (even as she carried and gave birth to a child in the midst of the project). The other is a book editor, which turns out to be a species as different from magazine editors as surgeons are from internists. With an uncommon combination of tenacity and gentleness, Sara Bershtel at Metropolitan Books got me to find the broader frame that caught what it is I write and think about, showed me how a book could be more than I imagined it to be, and somehow kept me going though at times the task seemed overwhelming. I am immensely fortunate to have her. My thanks, too, to her colleague Riva Hocher-mann, for her careful reading of the manuscript and invaluable suggestions.

Trying to write as a surgical resident is a sensitive and tricky matter, particularly when one is as interested, as I am, in writing about how things go wrong as how things go right. Doctors and hospitals are usually suspicious of efforts to discuss these matters in public. But to my surprise I have found only encouragement where I am. Two people in particular have been instrumental in this. Dr. Troy Brennan, a professor of medicine, law, and almost anything else you can think of, has been a mentor, a sounding board, a collaborator in research, and an unstinting advocate for what I have attempted to do. He even gave me the office space, computer, and phone that let me get this work done.

Dr. Michael Zinner, my hospitals chairman of surgery, has likewise given me his backing and protection. I remember approaching him after I had written my story trying to explain what happens when doctors make mistakes, intending to publish it in The New Yorker. I knew it was something I could not publish without permission from him. So I gave him the manuscript and then, a few days later, walked into his office braced for the worst. As it turned out, he didnt love it. How could he? No hospital public relations department in the world would have let an essay like that go out. But he did a remarkable thing: he supported me anyway. The article could easily backfire, he warned me, with the public or with other doctors. But if there was flak he would help me, he promised. And he let me go ahead.

In the end, there never was any flak. Even when my colleagues from work have disagreed with what Ive written, they have been constructive and engaged and have held nothing against me. We are all, Ive found, in the process of trying to understand how much of what we do is good, how much of it can be better.

To the patients and families who go named and unnamed in this book, I wish to extend a great and special thanks. Some I am fortunate to still keep up with. Others I was never given the chance to know as well as I wish I could have. All of them have taught me more than any could know.

There is just one person, however, who has been involved in all the parts of what is herethe writing, the doctoring, and the struggling to succeed at both: my wife, Kathleen. Shes stuck with me through the long hours and turmoil of surgical training and bolstered me when my confidence and resilience have failed me. Then, when Ive come home, shes helped me to talk through the ideas Ive had for writing and stayed up late with me to help hammer them into words. A magnificent editor herself, she has red-penciled this entire manuscript and, though Ive sometimes not wanted to admit it, made everything better. She has also, most critically, kept our sweet and demented children in my lifeeven bringing them to the hospital to see me when Ive missed them and been away for too long. This book exists thanks to her love and dedication. So it is dedicated to her.

T he stories here are true. In order to tell them while protecting peoples confidentiality, however, I have needed to change the names of some patients, their families, and a few of my colleagues. In certain instances, I have also needed to change minor identifying details of individuals. Nonetheless, wherever such changes were made, I have indicated so in the body of the text.