Lessons from a surgeon

Atul Gawande gives us a sneak peek into the modus operandi of surgeons. He concludes that despite the progress we've achieved in the field of medicine, it remains a complex field that is prone to the vagaries and vicissitudes of fallible humans and a limited science that doesn't provide all the answers.

How do surgeons become experts? by practicing.. on humans. In the part titled Education of a knife, the author states that the only way to gain experience is by operating on humans and mistakes are bound to be made, but in the long run, it's for the benefit of society. But when is the surgeon's training completed? the answer is never. Novel methods to practice medicine are always introduced from new tech to more effective ways of operating.. etc, so it behooves the expert surgeon to be constantly learning and training on new ways of doing things. When it comes to our loved ones, we want the best doctor possible to be taking care of them and we never tolerate any mistake. If people always chose the best doctor, how would new doctors learn? it seems like resident doctors get to practice on the people that belong to a certain demographics like the poor and the uninsured. But the solution would be to eliminate choice for everyone. Experience has mostly been acquired behind the curtains. But if mistakes are inevitable, can we minimize the number of mistakes committed? One instance of  machine competing with surgeons was in detecting hernia cases  Machine was able to beat man by 20% at analysing EKGs readings. Expertise has been gradually moving all the problem solving into the automatic realm.  When it comes to performance, Team members who train together for an extended period showed better results as opposed to team whose members kept changing.  Since Doctors' intuition is fallible, machines can help, which gives room for doctors to focus on the human side of the equation more. The author recounts several stories of doctors making mistakes during operation. He pleads that we shouldn't punish the surgeons, but rather improve the process/system( e.g, the anthestiology machines and the insertion of oesophagus instead of trachea tube).  People are not airplanes to get error rates down to zero.  Author talks about the special factory type systems where doctors perfect one thing( think hernia operations in Toronto) and become the best at it, but when surgeons get so good as to do things perfectly, latent errors loom large( errors that happen when new situations are encountered). When it comes to the relationship between doctors and patients, Doctors can't possibly be candid with patients when they make a mistake, because that could potentially be used against them in court, so they keep things hidden. Fortunately, there is a strict form of accountability through weekly conducted meeting behind doors where doctors can present their mistakes to more experienced ones and everyone can think of what  they could have done better in similar situations. Conference is called Morbidly and mortality conference. Surgeons belong to an insular category of people, they're alien to the the rest of civilization so they find the  yearly congress a place where they all meet, learn from each other, and connect.

Bad doctors: Doctors are human. They make mistakes and no matter how experienced they have become, some might get very bad after years of experiences because of reasons like depression, alcoholism, and other diseases that affect performance. The tight environment wherein they work makes it hard to hold these doctors accountable( Experienced doctors are revered by the less experienced) until it is too late. Independent accountability systems must be put in place. When it comes to superstitions, doctors don't believe in them, and studies show no correlation between moon, Friday the 13th, and bad luck. Doctors sometime come across cases that fly in the face of everything they've experienced before. Take Back pain. Patients would experience chronic back pain that  can not possibly be explained by the Physicality and pain theory. Cases like these can be attributed to loneliness, depression, mind confabulations. Pain# injury. Brain gate theory to pain in the brain sometimes can not explain pain. Pain is the product of the mind. It is believed that a Happy marriage, a support network, and satisfying employment can alleviate back pain more than avoiding lifting heavy things. Pain is more what goes around us than what goes on inside us.

Whose body is this: Respecting individuals' Autonomy is a recent thing. Doctors used to make decision on behalf of patients bc they assumed they know better. But patients now decide their fate. But what if the stakes are high and patients are making a grave mistake. Doctors should cajole patients into doing the right thing by listening to them and even get arbiters involved like family and other physicians. Patients tend to relinquish their autonomy to doctors because they can't live with the consequences of their decision. Even then, patients need to ask lots of questions and understand what the plan is.  Kindness is crucial in the medicine profession.  Sometimes doctors override patient's decision if they think they can save them.

Medicine is an imperfect science. Doctors decision making strategies vary widely depending on numerous factors. Sometimes they make decisions based on a strong gut instinct, sometimes they make a decision analysis tree weighing what the highest utility probability is. But they mostly operate under uncertainty. The time of day, the case they had recently seen, the city they're in, their habits and other factors might influence what decisions they make. They hope things will work out and mostly they do but they re most of the time shocked when they do.

Hyperemesis: a condition of recurring nausea and vomiting. Nausea# vomiting. Lots of drugs to fight vomiting.

Crimson red is the story of a TV news anchor with severe blushing problem. The anchor finally decides to go to Sweden for an operation that removes blushing. No one really know what the cause of this condition is. Is it physiological or psychological. Operation has some minor side effects but for desperate people, it is the last resort.

Man who couldn't stop eating; How much we eat depends on the result of the conflicts between hypothalamus produced signals and gut signals. Appetizer effect( foods triggering mouth receptors making hypothalamus signalling rapid intake( gulping) until the gut signal is received. Or the prader willi syndrom where you eat slowly for long periods of time. Gastric bypass surgery to reduce appetite and lose weight is 80% successful . Forces that make you hungry: mouth receptors, smell  receptors, visions of trauma pushing one way and gut receptors pushing another. Leptons n neuropeptides saying you have too much fat stored or too little  plus social and personal sense.

Autopsies are frowned upon by society and it is hard to ask the bereaved for permission. Autopsies have increasingly become so rare. Despite the advent of imaging techs, doctors sill need to look for themselves(autopsy) to see the reason of the death ( a quarter of the cases get misdiagnosed at first). Author likens humans to a place between hurricane and ice cubes. You can derive general patterns of diseases but the mystery of the human body still prevails and there is always room for error and misdiagnosis.

Babies instant death phenomenon happens a lot for reasons that might be mysterious. But what people say in these circumstances reveal a lot. Science can help. Babies should be placed on their back to avoid suffocation through bed sheeting.

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