Surgery under the knife

Between jolts from his pager and rings from his desk phone, Atul Gawande pulls up X-rays on his computer and confers with his officemate, a fellow resident, about how best to handle a patient’s internal laceration. They speak in a seemingly cryptic language run over with acronyms and words ending in “-tosis” and “-itis.” It’s 8:30 p.m. on a Tuesday and patients need beds, tests, and treatments. In the fluorescent light of an office lined with textbooks as big as toaster ovens, there is little of the quietude and serenity that is characteristically associated with a writer’s life.

But Gawande, a Harvard Medical School (HMS) clinical fellow and seventh-year surgical resident at Brigham and Women’s Hospital, has lately been cast in the spotlight of a literary stage. With the recent publication of his essay collection “Complications,” Gawande challenges what readers may typically expect from medical writing. He has a fluid and nimble writing style and a humane, accessible approach to complex, ethically thorny medical issues, characteristics that have been on recent display in articles he’s written for The New Yorker. He has been a staff writer on medicine and science for the magazine since 1998. For the collection, Gawande revised previously published material and added a few new essays in an attempt to present a vivid image of how and why things can – and do – go wrong in doctoring.

In print, Gawande, 36, is frank to the point of brazenness in his approach to topics such as burnout among doctors, fatal errors in the operating room, and the nerve-racking requirement of practicing on living patients. He makes indisputable, substantiated statements that may nonetheless catch you off guard, statements like “the medical arsenal against nausea and vomiting is still fairly primitive”; and, doctors “[have a] hard time acknowledging an awkward truth: patients frequently don’t want the freedom that [doctors have] given them.”

In person, Gawande, youthful and long-limbed with a lithe grace to his movements, exudes a disarming warmth. He speaks in modulated rhythms, looking at you in a way that suggests he’s monitoring how well you’re comprehending him – in other words, his effectiveness in communicating.

“I think I’m actually trying to explain [medicine] in a way that I would understand. The problems that I tackle are usually ones that confuse even me. It gives me a chance to do research and ask other people what they think, then I just try to get down on paper how I would try to understand it … .

“A lot of times technicalities of medicine become – even for doctors – a way of cloaking clarity, of cloaking concrete, specific truths about what really happens. Doctors explain in jargon all the time when sometimes none of us really understand the jargon we’re using,” Gawande concedes with a buoyant chuckle. “Trying to put it in simple terms for myself is a lot of what I’m doing. I just assume that everybody else has the same confusions that I do.”

“Complications” is divided into three sections of essays, most of which blend actual cases and thorough research. Collectively, the essays offer an insider’s perspective on why some things go wrong in medicine, why others go right, and the prickly politics of doctor-patient relationships. Each section is devoted to one of three broad reasons why medical complications occur: fallibility, mystery (despite all the centuries of research and practice and today’s technical diagnostics and treatments, some aspects of medicine remain unexplained), and uncertainty, which Gawande defines as “the sense that even when error is eliminated and even if the science had no holes in it, you’d still have the uncertainty of complexity of individuals.”

Doctors making mistakes? Of course, an unsettling case, like a patient requiring a second surgery to remove a small instrument a doctor left inside, may appear intermittently in the news. But for the most part, hasn’t the doctors’ can-do-no-wrong status become an implicit aspect of medical culture? Isn’t that why we trust them with our lives? According to Gawande, those days are over.

“People no longer think of doctors as gods. Both doctors and patients feel that. I think patients feel a lot of dread about going to hospitals and doctors nowadays, despite the fact that medicine is more capable than it’s ever been. Doctors feel it at the same time because they often feel accused or not trusted or questioned constantly about skills they’ve spent their lives trying to develop. …

“Now patients want to know what’s going on and feel invested in making decisions. At the same time they’re uncertain about what to make of medicine once they’ve begun to understand that doctors and hospitals and everything that goes along with medicine can be fallible. Writing about what goes on – if nothing else – demystifies it. It takes an unnamed dread and makes it something you can comprehend. But also I think it might be able to help doctors and patients understand each other better. (Also, you get to tell some good stories, so what the hell?),” he says as he takes a sip from a jumbo McDonald’s soda delivered moments earlier during a visit from his wife and three young children.

But Gawande openly confesses that up to five years ago, storytelling was not something he would have imagined doing. He sheepishly speaks of a college fiction-writing professor who told him he was “technically acceptable” but didn’t have much to say. As per her suggestion, he pursued another line of work where he encountered enough difficulties and dilemmas to provide plenty of fodder for his writing.

“Over time I found writing became my way of thinking through issues that sometimes had policy dimensions but sometimes just had personal dimensions or moral dimensions in the day-to-day practice of medicine and what I saw when I went about taking care of people and the questions they would ask, the questions that I would ask,” he said.

His career as a writer arose from what he refers to as a “favor.” Early in 1997, a friend was cultivating the now well-known Internet magazine Slate and asked him to contribute an article on medicine. That turned into a nearly regular column: 30 contributions in two years. At the outset, his work was heavily policy-driven. Gawande, who also holds a master of public health degree from the School of Public Health, continues to explore his deep-seated political interests in his writing. Before starting at the Medical School and after studying at Oxford on a Rhodes scholarship, he spent a year and a half working in Washington, D.C., where his then-girlfriend, now wife, lived.

What began as a “low-level advisory job” evolved into a post as a senior health policy adviser in the Clinton administration, a role he served during a leave of absence from medical school. Then, when he was writing for Slate, he got word that a New Yorker editor had been following his work. So he pitched a story and after nine months and seven rewrites, the article was published. Not long after he was signed on as a staff writer.

But being prolific and candid about touchy – if not taboo – issues carries a slight risk. “Talking about our mistakes makes plenty of doctors nervous. It makes me nervous about whether the public will catch on to the measured tone and aim of what I’m trying to do, and not see it simply as an exposé but something that’s trying to be more constructive. But doctors and patients seem to have gotten that and that’s been the most gratifying part for me,” he said.