Some thoughts prompted by Atul Gawande’s ‘Complications’

Some thoughts prompted by Atul Gawande’s ‘Complications’

In medical terminology, a ‘complication’ is an additional disorder or condition that develops during the course of an existing one (OED). During his training as a surgery resident Dr. Gawande became concerned with the uncertainties and dilemmas underlying within the medical system. In his own words: (…) the medicine that one cannot find explained in textbooks but that has puzzled me, sometimes troubled me, sometimes amazed me, as I‘ve joined the profession’s ranks.

complications US editionFrom those concerns, was born in 2002 “Complications: A Surgeon’s Notes on an Imperfect Science”, a book where, with a fluent and engaging narrative, Dr. Gawande weaves, interspersed with a plethora of detailed examples, an engaging discussion on some widespread situations. Homogeneous as a whole, and also within each of its sections, the book can also be read as a collection of unrelated essays where no particular reading order is required; therefore, freeing the reader of any spatial and/or temporal constraints.

The book is structured in three distinct sections: (1) fallibility, where issues involving medical providers, mainly doctors, are discussed; (2) mystery, devoted to themes that puzzled and still puzzle the medical profession; and (3) uncertainty, on rare medical cases where apparently obvious evidences might be conducive to misdiagnose a particular disease.

Insightful as those essays are, they are not merely to be read passively but to be taken as a starting point for deeper discussions on the subjects they bring up. I found especially interesting those chapters where ethical dilemmas arise from given situations that prompted the author to reevaluate cases and the parties involved, putting everything in perspective to allow a discussion from a detached a point of view as possible.

Especially poignant, particularly regarding to surgery, is the need to balance medical training of new surgeons with the patient’s consent to be cared by a trainee, even under the attending’s supervision; mainly when the author himself admits that: One reason I doubt that we could sustain a system of medical training that depended on people saying “Yes, you can practice upon me” is that I myself have said no. (…). On the other hand, it appears that positive outcomes in teaching hospitals tend to be higher than in non-teaching hospitals because in them there is always more than one medical provider evaluating, checking, and rechecking every step in every single case. A chance for errors is always at hand.

Three decades of neurophysiology research have shown us numerous ways in which human judgment, like memory and hearing, is prone to systematic mistakes. The mind overestimates vivid dangers, falls into ruts, and manages multiple pieces of data poorly. It is affected by the order in which information is presented and how problems are framed.

(…)

The fact is that virtually everyone who cares for hospital patients will make serious mistakes, an even commit acts of negligence.

(…)

Operations like that (…) have taught me how easily error can occur, but they’ve also showed me something else: effort does matter; diligence and attention to the minutest details can save you.

Statements as those made me consider our profession as medical interpreters in similar parameters. As all we are aware of, there is a strong need for continuous evaluation. An assessment that should be performed in each and every encounter and not as a detached testing set up; thus, prompting a strong need to conscientious and continuous self-evaluation. This evaluation should entail not only our interpretation performance in itself, but our role as a bridge between provider and patient to facilitate the crossing as easier from one side as from the other. As interpreters, we aim to be considered as part of the caring team, to gain recognition from the medical staff. However, we should be asking to ourselves: Is this recognition going to enhance or jeopardize the benefits a patient might gain from our presence in the encounter? Is this going to favor or endanger the patient’s trust?

Atul Gawande imageThere is the interpreters’ need to be friendly enough to be trusted by the patient. To generate a warmth ambiance where the patient can feel at ease to ask questions, and as many questions as needed, to clarify issues without having the feeling of becoming inconvenient or even intrusive. And at the same time, detached enough from the patient for self protection (too much empathy can be detrimental) without giving the provider a false impression (i.e., that we teaming with the patient against the medical establishment). Therefore, there is a strong need for balance if we aim to succeed in our communication endeavors, both as language and cultural barrier breakers.

I would like to end these thoughts with some of Gawande’s comments on handling doctor-patient interactions as well as in addressing medical decisions. I believe it might as well be convenient to us, interpreters, to bear them in mind during the encounters in which we assist:

(…) I had come into residency to learn how to be a surgeon. I had thought that meant simply learning the repertoire of moves and techniques involved in doing an operation or making a diagnosis. In fact, there was also the new and delicate matter of talking patients through their decisions – something that sometimes entailed its own repertoire of moves and techniques.

(…) As one surgical professor told me, when you sit close by, on the same level as your patients, you’re no longer the rushed, bossy doctor with no time to talk; patients feel less imposed upon and more inclined to consider that you may both be on the same side of the issue at hand.

(…) The doctor should not make all these decisions, and neither should the patient. Something must be worked out between them, one on one – a personal modus operandi.

 

References:

  • Gawande, A. 2002. Complications: A Surgeon’s Notes on an Imperfect Science. Metropolitan Books/Henry Holt & Company, New York; Profile Books Ltd, London
  • Gawande, A.  Personal web page; http://atulgawande.com
  • Oxford English Dictionary (OED); www.oed.com
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