by Atul Gawande
The companies’ most effective tactic, however, was simply to put out the goods and let surgeons play. The salespeople would bring out a tray of raw meat and their latest gizmo, and we would flock around like crows. I was sucked in that afternoon by a fresh, yellowy, thirteen-pound turkey on a cookie sheet (cost: about fifteen dollars) and a line of harmonic scalpels (cost: about fifteen thousand dollars)—electronic scalpels that cut through tissue with ultrasonic shock waves. For ten whole and happy minutes, I stood at a glass counter, slicing through layers of turkey skin and muscle, raising thin flaps and thick flaps of tissue, trying deep gouges and intricate dissections, and testing the heft and feel of the various models. At another booth, I donned surgical gloves and tried sewing closed an incision in chicken meat with several lengths of a new fifty-dollar-a-yard suture. I would have stayed throwing knots and practicing my locking stitches for half an hour if four other surgeons hadn’t been stacked in line behind me. In the course of the afternoon, I cauterized cold cuts, used advanced laparoscopic equipment to remove “gallstones”—actually, peanut M&Ms—from inside a mannequin’s abdomen, and used an automated suturing device to sew closed a wound in a weirdly human-looking piece of flesh. (The salesman was coy and would not tell me what it actually was.)
Having given up totally on making it to anything else that day, I spotted a crowd of some fifty surgeons swarming around a projection screen and a man wearing a suit and a headset microphone. I went up to see what all the fuss was about, and what I found was the live televised image of a patient undergoing excision of a large, prolapsed, internal hemorrhoid in an operating room somewhere, apparently, in Pennsylvania. The manufacturer was showing off a new disposable device (cost: two hundred fifty dollars) that it claimed shortens the usual half-hour procedure to one that takes less than five minutes. The emcee in the headset fielded questions from the crowd which he then put to the surgeon as he operated a thousand miles away.
“You are putting in a purse-string suture now?” the emcee asked.
“Yes,” the surgeon replied. “I am putting in the purse-string suture in five or six bites, two centimeters from the base of the hemorrhoids.”
Then he put the device before the camera. It was white and shiny and lovely. Against any high-minded desire to stick to hard evidence about whether the technology was actually useful, effective, and reliable, we were all transfixed.
When the show was over, I noticed just a few steps away a forlorn-looking pockfaced man in a rumpled brown suit sitting alone at a tiny booth. People flowed past him like minnows, not one stopping to examine his merchandise. He had no video screens, no brushed-steel displays, no free stenciled golf tees—just a computer-printed logo-less paper sign (“Scientia,” it read) and several hundred antiquarian books of surgery. Feeling pity for him, I stopped to browse and was stunned to discover what he had on offer. He had, for example, Joseph Lister’s actual 1867 articles in which he had detailed his revolutionary antiseptic method of surgery. He had the first 1924 edition of the great surgeon William Halsted’s collected scientific papers and the original 1955 proceedings of the world’s first conference on organ transplantation. He had an 1899 catalogue of surgical instruments, a two-centuries-old surgical textbook, and a complete reproduction of a medical text by Maimonides. He even had the 1863 diary of a Union Army Civil War surgeon. There was a trove of jewels in his crates and on his shelves, and I ended up absorbed in them for the rest of the afternoon.
Leafing through those yellowed and brittle pages, I felt I had finally discovered something genuine. Throughout the convention—on the commercial floor, to be sure, but in the lecture halls as well—I noticed myself having to be constantly alert to the possibility that someone was taking me for a ride. There were undoubtedly new drugs and instruments and machines of real and lasting value to be found. With all the glitz and showmanship surrounding them, however, you could never be sure which they were. This was one place where I knew I had found something worthy of awe.
There was another place at the convention where you could be confident of seeing great things going on. Well away from the main halls—where the movies were shown, the practical sessions were held, and the merchandise was hawked—was a cluster of small meeting rooms where the “Surgical Forums” took place. Here each day researchers of all sorts discussed the work they had under way. The subjects ranged from genetics to immunology to physics to population statistics. The discussions were sparsely attended and mostly went over my head: it is impossible nowadays to have a working understanding of even the basic terminology in all of the fields under consideration. But as I sat there listening to the scientists talking among themselves, I caught a glimpse of where the edges of knowledge were, the approachable frontiers.
A recurring topic this year was tissue engineering, a line of research devoted to grasping precisely how organs develop and then using that knowledge to one day grow new organs from scratch that could replace injured or diseased ones. Progress, it became clear, was occurring surprisingly quickly. A couple years before, there had been pictures in all the newspapers of the famous ear grown in a petri dish and implanted on the back of a mouse. But more complex structures, and certainly human trials, seemed a decade or more away. Now, however, scientists were presenting photographs of heart valves, of lengths of blood vessel, and of segments of intestine they had already grown in their laboratories. The problems they discussed were no longer how to do such things but how to do such things better. The heart valves, for example, worked well when experimentally implanted in the hearts of pigs, but didn’t last as long as they would need to for humans. Likewise, the intestinal segments proved to be amazingly functional when transplanted into rats, but they did not absorb nutrients as well as desired, and the researchers still had to figure out how to grow them in lengths of feet rather than inches. A team at Cedars-Sinai Hospital in Los Angeles had actually gotten far enough along to begin human trials of a temporary, bioengineered liver.
The researchers presented data from their first dozen patients. Each of the patients had reached the end stage of liver failure, a stage in which 90 percent usually die waiting for a liver transplant. But with the bioengineered liver, the researchers reported, all of them survived long enough to find a donor liver—in many cases ten days or more, which was an unheard-of accomplishment. More remarkably, four patients who had been in end-stage failure from drug overdoses wound up never needing a transplant. The bioengineered liver had kept each going long enough for his or her own liver to recover and regenerate. Sitting in the audience, I experienced a sudden giddiness upon realizing what these doctors had done. And I began to wonder if it was at all like what Joseph Lister’s colleagues at the Royal College of Surgeons had felt when he first presented his findings on antisepsis, nearly a century and a half ago.
Was any of this—the teaching, the trade show, the research—what brought thousands of surgeons to spend a week of hard-to-find vacation time in overcast Chicago? There was another convention taking place in town that very same week: the Public Relations World Congress, “the annual meeting of the planet’s public relations professionals.” (Theme: “Building Our Talent in a World of Tough Issues.”) They too came in droves. Between the surgeons and the flacks, the hotels were booked solid. And our proceedings were almost identical. The publicists had, just as we had, a slew of educational sessions. (Among the events were workshops on managing Internet PR disasters and on starting your own PR firm, as well as a lecture entitled “Conference Calls: A Cost-Effective Tool to Reach Clients and the Press.”) They too devoted a full day to research presentations. They had corporate ads everywhere and a lobby filled with exhibits from PR firms, media release services, and the makers of ultrahigh-speed fax machines. Their week closed, just like ours, with a semi-celebrity keynote address. The elements of the conventions were so weirdly alike that you had to think that they were the core of what drew people to come. Wandering the publicists’ convention one morning, though, I found their meeting rooms no
more than half-filled and the crowds instead out in the halls. Even at our convention, you could sense the enthusiasm for actually learning something quickly wearing thin. By midweek, finding a seat at lectures was no problem. And among those attending, a large chunk either dozed off or left early to stroll the corridors.
The anthropologist Lawrence Cohen describes conferences and conventions not so much as scholarly goings-on but as carnivals—“colossal events where academic proceedings are overshadowed by professional politics, ritual enactments of disciplinary boundaries, sexual liminality, tourism and trade, personal and national rivalries, the care and feeding of professional kinship, and the sheer enormity of discourse.” Certainly, in surgery, this seems apt. It did not take long here to realize that some had come just to be seen, others to make their name, still others for the spectacle of it all. There were battles for office (a new president and board of governors were elected) and muckety-mucks meeting behind closed doors. There were residency reunions. There were nights out at Spago and no doubt some love affairs, too.
Yet, true as all of this was, one still had the sense that the draw was deeper than mere carnival. You could see it, for example, on the bus. Every day we surgeons rode back and forth between the convention center and our hotels in fleets of long tour buses. (They were like the ones Greyhound runs to Atlantic City, except ours had drop-down mini-televisions running ads for the “Surgical Zipper.”) We were by and large strangers—I never knew anyone on those bus rides—but if you had watched us, it wouldn’t have seemed that way. Consider the simple matter of seating. Normally, people boarding a bus, plane, or train distribute themselves like repelling magnets, keeping a respectful, anonymous distance from one another and sharing seats only if they have to. But embarking our buses, we found ourselves choosing to sit two-by-two, even as other seats were empty. Somehow, without anyone saying so, the social rules had been inverted. On any other bus in Chicago, you would have felt almost physically threatened by a stranger sidling up to you when three-quarters of the seats sat empty. Here, however, it would have been the person who set himself apart who provoked the most unease. You were, you felt, among your tribe—connected though knowing no one. You felt the need to say hello. Indeed, it seemed impolite not to do so.
On one shuttle ride, I sat down next to a forty-something-looking man in a blazer and open-collared shirt. We started talking almost immediately. He was, I learned, from a town of thirty-five hundred on the northernmost tip of Michigan’s lower peninsula, where he was one of only two general surgeons for fifty miles. Together he and his partner handled everything: pickup-truck crashes, perforated ulcers, appendectomies, colon cancers, breast cancers, even the occasional emergency childbirth. He’d been there for some two decades, he said, and like my parents was a native of India. I was impressed that he had learned to tolerate the winters. I told him of how, almost thirty years before, my parents had narrowed their choices of where to take up practice to either Athens, Ohio, or Hancock, Michigan, in the upper peninsula. Arriving in Hancock by prop plane for a mid-November visit, however, they found three feet of snow already on the ground. Stepping out in her sari, my mother nixed the place immediately and chose Athens, though she had yet to visit it. My seatmate burst out laughing and then said what all deep northerners say about the bitter cold, “Oh, it’s really not so bad.” Our conversation drifted from weather to our children to my residency to his residency to a piece of laparoscopic equipment he had seen and was thinking of buying. In the seats around us, it was much the same. Bright chatter filled the bus. There were people arguing about baseball (the Mets-Yankees Subway Series was on), politics (Gore versus Bush), and the morale of surgeons (up versus down). On shuttle rides that week, I traded trauma stories with a general surgeon from Sleepy Eye, Minnesota, learned about Chinese hospitals from a British-accented vascular surgeon from Hong Kong, discussed autopsies with the University of Virginia’s chairman of surgery, and got movie recommendations from a Cleveland surgical resident.
This is, I suppose, what the public relations professionals would call networking. But the word misses the essential hungriness of the doctors on those buses, and throughout the convention, for contact and belonging. We may have each had good practical reasons for coming here: the new ideas, the stuff to learn, the gizmos to try, the chasing of status, the break from the grind of unending responsibilities. But in the end, I came to think, there was also something more vital and, in a certain way, poignant drawing us in.
Doctors belong to an insular world—one of hemorrhages and lab tests and people sliced open. We are for the moment the healthy few who live among the sick. And it is easy to become alien to the experiences and sometimes the values of the rest of civilization. Ours is a world even our families do not grasp. This is, in certain respects, the experience of athletes and soldiers and professional musicians. Unlike them, however, we are not only removed, we are also alone. Once residency is over and you’ve settled in Sleepy Eye or the northern peninsula of Michigan or, for that matter, Manhattan, the slew of patients and isolation of practice take you away from anyone who really knows what it is like to cut a stomach cancer from a patient or lose her to a pneumonia afterward or answer the family’s accusing questions or fight with insurers to get paid.
Once a year, however, there is a place full of people who do know. They are everywhere you look. They come and sit right next to you. The organizers call the convention its annual “Congress of Surgeons,” and the words seem apt. We are, for a few days, with all the pluses and minuses it implies, our own nation of doctors.
When Good Doctors Go Bad
Hank Goodman is a former orthopedic surgeon. He is fifty-six years old and stands six feet one, with thick, tousled brown hair and outsize hands that you can easily imagine snapping a knee back into place. He is calm and confident, a man used to fixing bone. At one time, before his license was taken away, he was a highly respected and sought-after surgeon. “He could do some of the best, most brilliant work around,” one of his orthopedic partners told me. When other doctors needed an orthopedist for family and friends, they called on him. For more than a decade, Goodman was among the busiest surgeons in his state. But somewhere along the way things started to go wrong. He began to cut corners, became sloppy. Patients were hurt, some terribly. Colleagues who had once admired him grew appalled. It was years, however, before he was stopped.
When people talk about bad doctors, they usually talk about the monsters. We hear about doctors like Harold Shipman, the physician from the North of England who was convicted of murdering fifteen patients with lethal doses of narcotics and is suspected of killing some three hundred in all. Or John Ronald Brown, a San Diego surgeon who, working without a license, bungled a series of sex-change operations and amputated the left leg of a perfectly healthy man, who then died of gangrene. Or James Burt, a notorious Ohio gynecologist who subjected hundreds of women, often after they had been anesthetized for other procedures, to a bizarre, disfiguring operation involving clitoral circumcision and vaginal “reshaping,” which he called the Surgery of Love.
But the problem of bad doctors isn’t the problem of these frightening aberrations. It is the problem of what you might call everyday bad doctors, doctors like Hank Goodman. In medicine, we all come to know such physicians: the illustrious cardiologist who has slowly gone senile and won’t retire; the long-respected obstetrician with a drinking habit; the surgeon who has somehow lost his touch. On the one hand, strong evidence indicates that mistakes are not made primarily by this minority of doctors. Errors are too common and widespread to be explained so simply. On the other hand, problem doctors do exist. Even good doctors can go bad, and when they do, colleagues tend to be almost entirely unequipped to do anything about them.
Goodman and I talked over the course of a year. He sounded as baffled as anyone by what had become of him, but he agreed to tell his story so that others could learn from his experience. He even put me in touch with former colleagues and patients. His only r
equest was that I not use his real name.
One case began on a hot August day in 1991. Goodman was at the hospital—a tentacled, modern, floodlit complex, with a towering red-brick building in the middle and many smaller facilities fanning out from it, all fed by an extensive network of outlying clinics and a nearby medical school. Situated off a long corridor on the ground floor of the main building were the operating rooms, with their white-tiled, wide-open spaces, the patients laid out, each under a canopy of lights, and teams of blue-clad people going about their business. In one of these rooms, Goodman finished an operation, pulled off his gown, and went over to a wall phone to respond to his messages while waiting for the room to be cleaned. One was from his physician assistant, at the office, half a block away. He wanted to talk to Goodman about Mrs. D.
Mrs. D was twenty-eight years old, a mother of two, and the wife of the business manager of a local auto-body shop. She had originally come to Goodman about a painless but persistent fluid swelling on her knee. He had advised surgery, and she had agreed to it. The week before, he had done an operation to remove the fluid. But now, the assistant reported, she was back; she felt feverish and ill, and her knee was intolerably painful. On examination, he told Goodman, the knee was red, hot, and tender. When he put a needle into the joint, foul-smelling pus came out. What should he do?
It was clear from this description that the woman was suffering from a disastrous infection, that she had to have the knee opened and drained as soon as possible. But Goodman was busy, and he never considered the idea. He didn’t bring her into the hospital. He didn’t go to see her. He didn’t even have a colleague see her. Send her out on oral antibiotics, he said. The assistant expressed some doubt, to which Goodman responded, “Ah, she’s just a whiner.”
