Jonathan Brun

Medicine, a human endeavour

Just read the book “Complications – A surgeon’s notes on an imperfect science” by Atul Gawade. Largely speaking it is about the practice of medicine. Through tightly written stories, it sweeps away many of our preconceived notions of infallible doctors and western medicine. It is absolutely fantastic.

The conclusions I found most pertinent were:

1. Learning

Short bursts with a team who has work history together is better than learning over a spread out timeframe. This is regardless of the skill or intelligence of the person (or group) who is learning.

Learning throughout a career. 75% (or more) of the information and skills you learn in training (school) will be useless. New technology and better practices will inevitably affect you and if you do not continue to learn, you will lose out.

2. Specialization to perfection

The Shouldice hernia clinic in Toronto is the best place in the world to have a hernia operation. This is because that is all they do – hernias – and have thus nearly perfected the process. This treatment of medicine as an industrial process speaks volumes of the possibilities of perfection through repetition.

Anesthesiology has greatly reduced deaths by standardizing medical equipment and practices; removing human intervention and decision making from the process. This may sound undesirable, but in reality if frees up the doctors for more creative thinking. The field of anesthesiology automated their field (thanks to an engineer) much like the airline industry (which is continually improving their safety record).

3. Mental – Physical connection

Obesity and stomach stapling have become part of American culture. After people have their stomach stapled, they still want to eat junk food, but cannot due to physical limitations. After a year or so their actual desire for junk food disappears and they prefer healthy food. This change in appetite goes hand in hand with their loss of weight. The link is between the mental state and physical state is true for most diseases.

4. People want to be told what to do, relinquish responsibility

In a time of increasing awareness of medical diseases and access to information on the web, patients are have become part of the decision making process. Despite this gift, people still want to be told what treatment they should choose. This has more to do with wanting to give up responsibility than anything else. Should something go wrong, it was not their fault. See the book “Stumbling on Happiness”.

5. Cartesian Limitations

Western medicine is based on Cartesian thought – if we know the symptoms, we can find the physical cause, and thus the cure. It is also factored into decision analysis, particularly in business ventures. If I know the risks of decision x and the payoff of the same decision I can calculate the probability of making money. This has been applied to medicine, but it becomes very difficult very quickly. How much do you value a leg, an eye or a life?

Simple cause and effect is very difficult in medicine where so many factors are at play. According to the author of the book, despite the inventions and uses of MRI, CAT scans, and other tools, incorrect medical diagnosis has not decreased in the past 30 years. Scary.

6. Transparency

The ability to openly discuss mistakes and ways to avoid them is absolutely fundamental to improving a system. But because medical practice involves death and harm, this becomes exceedingly difficult to do with pariah lawyers and cautious insurance companies. Yet, it is inevitable, in some ways doctors need to be granted asylum and only prosecuted when a trend of error becomes apparant. Good doctors make mistakes – blame does no one good


Don’t get sick, if you do, trust few.

Favorite quotes from the book:

Talking about free trinkets and medical conferences (pens, pads, stress balls…), “You might think six-figure surgeons would be oblivious to this petty bribery. But you would be wrong.”

And another lesson from trade-shows, “At booths, let people play.”

Published on September 15, 2007