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Atul Gawande Atul Gawande n the book-jacket photograph of than people expect them to be, but also Complications: A Surgeon’s Notes on more extraordinary than they under- Ian Imperfect Science, Atul Gawande stand, is the balance I’ve tried to show”. looks 20-ish (he is actually 37). In per- These big ideas, which could so easily son, he appears to be about 13. The lend themselves to high-handed and Wunderkind seated before me is a utterly impenetrable academic analysis, surgery resident, a Rhodes scholar, a are instead embedded in scenes that are, staff writer for The New Yorker, the as his editor says, filled with the “small author of this new book, a father of memorable details of real life”. Once three, and, oh yeah, was a health-policy you’ve read a Gawande essay, for exam- advisor to former US President Bill ple, nausea is not just the miserable result Clinton. That last bit is ancient history, ubiquitous in Gawande’s writing. He is, of “unanticipated sensory input”. of course, having taken place when he according to Henry Finder, his editor at Instead, it becomes the indelible and was all of 26. the New Yorker, “peculiarly drawn to seemingly endless central problem of the Gawande, a graduate of Stanford paradoxes, tragic choices”. (Gawande story of Amy Fitzpatrick. Her hypereme- University and Harvard Medical School, writes four essays a year for the maga- sis, which began in the eighth week of her worked for the Clinton campaign and zine, with each piece taking him 3–4 pregnancy with twins, is treated with then moved on to the White House to months and between five and 22 drafts intravenous fluids, dry crackers, Reglan, work for 8 months on the ill-fated to finish.) The medicine he writes about Compazine, Phenergan suppositories, health-care reform task force led by is a very human endeavour, with all its Zofran, bedrest, herbal therapy, Chinese Hillary Clinton and Ira Magaziner, a job dirty laundry on full display; it is not, massage, water with lemon, ginger, acu- Gawande’s wife declares more intense says Finder, “priestly, ethereal, or purely pressure wristbands, intravenous nutri- and difficult than surgical training. In the theoretical”. His arguments are deeply tion, psychiatric consultation, a Clinton White House there were two grounded in narrative, in story. Of his continuous infusion of droperidol, and, kinds of people: FOBs (friends of Bill) interests Gawande comments, “it wasn’t finally, a suggestion to terminate the and SOBs (staff of Bill). With a president policy I was interested in; it was illumi- pregnancy. Fitzpatrick declined the last who slept only 4 hours a night-no snick- nation”. option and after 26 weeks, refused fur- ering here, please-the SOBs got only 3. But how was it that error and uncer- ther therapies. It is a measure of Gawande didn’t get a single day off in a tainty came to be the themes he obses- Gawande’s capacity for vividness that year, except for his honeymoon, when sively illuminates? when she finally gives birth to a boy and a he, nonetheless, participated in a 2-hr “It was the missing leg that clued us girl, both small but healthy, the reader is conference call every morning. in!” practically limp with relief. But I’m getting ahead of myself. Ah, the waiter is a wag. Happily, he For obvious reasons, I try to put Amy We’re in Boston, the city of the bean exits the interview after bringing the oys- out of my head during this meal, which and the cod, but we’re eating rather ters. has now progressed through every food higher on the hog this evening, if techni- Gawande notes that his essays reflect a group known to man, including “carrot- cally porkless, in a venerable old Back long “tradition of discussion of compli- juice nage”—just like Mom used to Bay establishment. (Yes, ’tis true: the cations and error and inquiry” in medi- make. Clearly, we are in the presence of very first Lunch with The Lancet is actu- cine. Still, he says, “I think that when culinary genius. ally dinner. Have you ever known a resi- people hear what I’m writing about, it Is the guy across the table another kind dent who could get out in the middle of makes them intensely uncomfortable”. of genius? He demurs, saying he claims the day?) We plunge in immediately on Two of his chapter titles, “When no special expertise. “I write as someone Gawande’s arrival, as we’ve nearly as Doctors Make Mistakes” and “When who got a chance as a young doctor to many topics to cover as courses to come Good Doctors Go Bad”, starkly illus- ask all the questions that a doctor won- in this meal. trate why that might be so. But Gawande ders about and also a patient wonders Medicine seems a long way from his argues that he strives for “a measured about. I write as someone who is, in the life in politics, I observe. He disagrees. tone”: “On the one hand, I’ve tried to be end, simply a young physician and trying Both ventures are filled with “incredible very forthright about how it is that things to make sense of things. It’s been my way uncertainty and a lot of poor data for work and about what is good about med- of sorting through all those things you making decisions. You’re having to make icine and what is bad about it. But at the wonder about—especially when you’re a decisions that deeply affect people’s lives same time I’ve tried to convey some of young doctor—but don’t feel you have despite that poor data—and no sci- the sense of how incredibly difficult it is answers to”. ence—without anything more than per- as a profession, that this is the most And on that charmingly self-effacing sonal experience to guide you.” And ambitious endeavour mankind has ever note, because it is late and the procession politics remains inextricably bound to his attempted—to take the entire range of of dishes seems finally to have come to an thinking about medicine. What, he human misery and illness and provide end, I bid goodnight to Atul Gawande. muses, is the role of surgery in public for every single person on an individu- Even for a brilliant, accomplished, young health? What is the balance between alised basis the best possible care. It’s doctor-writer whose future bears close costs and resources? striking that we can succeed at all, espe- watching, rounds still start awfully early. This notion of the trade-off, that every cially given how hard it is. And so to con- medical choice comes at some price, is vey that sense that things are less perfect Faith McLellan THE LANCET • Vol 361 • January 11, 2003 • http://image.thelancet.com/extras/02bkr111web.pdf For personal use. Only reproduce with permission from The Lancet Publishing Group..
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