C O L L A B O R A T I V E C A S E M A N A G E M E N T

Review: Complications: A Surgeon’s Notes on an Imperfect Science

by Rebecca Brashler, MSW

Atul Gawande, a surgical resident at a hospital in Boston, Then, switching from the physician perspective to the
is the well-known staff writer on medicine and science for patient’s side of the bed, Gawande shares the dramatic story of
The New Yorker. Complications is a collection of his essays on his own son’s critical illness, which ultimately led him to
medicine and was a finalist for the National Book Award. question how much autonomy he was willing to accept as a
These essays are an honest, sometimes critical, intensely parent facing life and death decisions. He speaks to all our
insightful look at the world of illness, medical care and hospital patients when he writes:
systems. Non-clinicians will be fascinated while case managers
are more likely to react with a spark of recognition as well as “Just as there is an art to
admiration for the author’s capacity to being a doctor, there is an art
examine the world we work to being a patient. You must
in from fresh perspectives. choose wisely when to submit
The book covers a variety and when to assert yourself. …
of topics including gastric You do the best you can, taking
bypass surgery, chronic pain, the measure of your doctors
nausea, impaired physicians, and nurses and your own
medical errors, informed situation, trying to be neither
consent, truth-telling, and the too passive nor too pushy for
art of making diagnoses. Some your own good.”
chapters are in-depth case
studies, a la Oliver Sachs, where Case Managers, often called
Gawande’s storytelling skills upon when patients and their
come to life and we get glimpses physicians disagree, know well that
of his enormous respect for his delayed decision-making often
profession and for his patients. leads to delayed treatment and
Other chapters explore resource utilization problems.
institutional issues We, too, are challenged at times
such as the use of Morbidity & to balance respect for patient
Mortality Rounds to monitor autonomy with a desire to
medical errors and the need protect our patients from harm.
for young physicians to “practice” (Think about the number of
their skills on live patients in times you have struggled to
the clinic. reconcile discharging a patient
In the chapter, “Whose Life is it to an unsafe home
Anyway?”, Gawande brilliantly lays environment but felt compelled
out the complexities involved in to respect the patient’s choice.)
medical decision-making — the Gawande’s thoughtful analysis
subtle way health care professionals can help us all think critically
influence their patients and the about our patients’ rights
dilemmas that arise when patients and the true goals of a
make “bad” choices. He tells the story therapeutic relationship.
of a woman who refused a biopsy of a Ultimately, Gawande
breast mass because she had reminds us that we work in
experienced false positive results in the a world that is utterly complex, at times
past, and the story of a post-operative terrifying, incredibly stimulating and rarely examined with
patient who refused to get out of bed, placing her at risk for such intimacy by insiders.
secondary complications. We read about the patient who was so
fearful of machines that he wanted to forgo short-term ventilation Rebecca Brashler is the Clinical Educator for Care Managers
to manage his acute respiratory infection, even though the and for the Center for the Study of Disability Ethics at the
treatment was very likely to save his life and not result in long-term Rehabilitation Institute of Chicago. She received her
dependence. Gawande, while respecting patient autonomy, feels undergraduate degree from the University of Michigan and her
an obligation as a physician to protect his patients and states: MSW from the University of Maryland with a joint certificate in
rehabilitation from the University of Maryland and Johns Hopkins
“Even when patients do want to make their own Medical School/Kennedy Institute. In addition to her clinical
decisions, there are times when the compassionate thing work in rehabilitation, Ms. Brashler is a clinical instructor at the
to do is to press hard: To steer them to accept an Feinberg School of Medicine at Northwestern University and an
operation or treatment that they fear, or forgo one that adjunct faculty member at the University of Chicago’s School
they’d pinned their hopes on. …” of Social Service Administration.