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Congressional Report: Congress Has Some Unfinished Business as New Term Begins AAMC Efforts Help Roll Back CMS Paperwork Requirements Innovations in Medical Education: Doctors-in-Training Learn How to Tell Stories Healing Deep Wounds: Program at Bellevue / NYU Provides Care for Torture Survivors Nursing Shortage Prompts Creative Solutions Author Q&A: 'Sometimes Wrong, Never in Doubt' 'Flagging' Debate Continues; Data Show Score Fluctuations A Word from the President "A Day in the Life of a Medical Student"
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Author Q&A: 'Sometimes Wrong, Never in Doubt'
Atul Gawande, M.D., M.P.H., is an eighth-year surgical resident at Brigham and Women's Hospital in Boston. He has had five years of clinical practice, and did three years of research at the Harvard School of Public Health. Dr. Gawande will complete his residency in June and will practice general and endocrine surgery. He served for two years in the AAMC's Organization of Resident Representatives (ORR). Dr. Gawande's real claim to fame in 2002, however, was the astounding success of his book, Complications: A Surgeon's Notes on an Imperfect Science [Henry Holt and Company, 2002]. The work drew rave reviews for its at times painful honesty in describing both the power and the limits of a modern physician: "There is a saying about surgeons, meant as a reproof: 'Sometimes wrong; never in doubt.' But this seemed to me their strength. Every day, surgeons are faced with uncertainties. Information is inadequate; the science is ambiguous; one's knowledge and abilities are never perfect. Even with the smallest operation, it cannot be taken for granted that a patient will come through better off - or even alive." Such detailed description of surgeons and their training pushed 'Complications' to the best-seller lists, and it was nominated for a National Book Award, which Dr. Gawande admits "shocked" him. Although it did not win, the book continues to sell briskly and will be published internationally and in paperback this year, translated into 13 languages, and distributed in more than 60 countries. Q: What first inspired you to write about medicine and when did you begin to write 'Complications'?A: The book started through cases I had come across during my training. The first article I wrote was as a second-year resident for an Internet magazine, which nobody read. The beauty of that was I could work on my writing; I wrote a monthly Internet column for two years. I originally started writing because I had worked in policy and wanted to stay sharp on policy issues. But instead, I found I was writing more about patients I had taken care of who had problems that puzzled me or that I didn't find answers to in textbooks. I wrote about what to make of the fact that, despite your best efforts, you make mistakes, and people can be harmed by that. I couldn't find many good answers about what a doctor does in situations in which we don't have very good answers. Out of that came a series of articles I wrote for The New Yorker; from that, I was offered a chance to pull the essays into a book, which took me three years to write. Q: In 'Complications,' you do not shy away from recounting your uncertainties as you began your surgical training. Was it difficult to write about your own mistakes and "learning process"?A: It was very hard! The problem is, you can't write credibly about what happens in medicine if you only talk about your 'great saves.' I do talk about my great saves, but a lot of people want to focus on things that have gone wrong. Part of what I was trying to do was to be forthright about the fact that every one of us makes terrible mistakes. And if the physician makes a mistake, the patient thinks they must be a bad doctor. If you're going to be able to argue credibly about that, you have to explain your own experiences and fallibilities and how you are going to take responsibility for that. Q: How have your colleagues reacted to your book?A: The idea of the book - writing about 'complications' and what really happens in surgery - is enough to raise the suspicion of any physician. A lot of colleagues thought it was not a good idea. But it turns out I am not the only one struggling with how to explain medicine and that it's imperfect. We have had an old way of talking about things, which is to profess a kind of perfection beyond question, but now we're in a new world where patients ask for second opinions, question your decisions, and we've almost lost a way of talking to one another. When people have read the book, they have been surprisingly supportive. I have been asked to speak - at the AAMC, at surgical conventions, at other places - and that has been gratifying to me. Q: In addition to your residency, you are married with three children-how do you find time to write?A: I don't a lot of the time! I am extremely lucky in that my wife not only puts up with my surgical residency but also lets me write. I write on mornings when I'm off, then I take the kids in the afternoon. I go in an hour early each day to try to write. I've also been lucky in that part of our surgical training is to do a significant amount of time in the research lab, and that's more controlled time. I didn't moonlight like many people did; I wrote in my spare hours. That was my moonlighting. Q: What is the mindset of a surgeon?A: The saying I mention in the book - 'sometimes wrong, never in doubt - is also usually the criticism of surgeons. To me, the fascination about surgeons is they are people who are able to take situations in which the stakes are high, information is imperfect, and yet decisions must be made. The ability to make decisions confidently, to live with the consequences, and to do it wisely is what always seemed intriguing to me about surgeons. It's as much the character of surgeons that drew me to surgery as it was the chance to do something technical with my hands. Q: What do you think about the resident system and how residents are trained - could it be improved?A: I don't really talk about that much in the book, and it's hard, because I'm a product of that system. There's a lot to be said for the process of slow, graduated increases in responsibility. There are areas in which, obviously, we're struggling to make it better. One is over [duty] hours and our concern about how you teach the ethic of personal responsibility to physicians at the same time that you avoid exploiting them. The other is the reality that medicine has become so incredibly complex and super-specialized - from medical school right on through residency. There are lots of areas in which we are still struggling with this complexity. Q: What is the best recommendation you could make to a new resident?A: I think it would be finding a way to remember why you went into this. The thing about the training process is that it makes you forget what's important about what you do, what you care about when you're seeing people. You can become part of the 'machine.' For me, writing was the way to step back at the end of each day. I would suggest finding a way to stay 'whole' - some residents do it by staying close to their families. For others, it's anything from books to movies to doing research. I think that's very important. I never went into residency thinking about how this was going to be a period in which I ended my life for the next decade and waited for it to begin again. - Michael G. Malloy, mmalloy@aamc.org |
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