Complications

by Atul Gawande

  122 The various studies described on pain in different populations include Tajet-Foxell, B., and Rose, F. D., “Pain and Pain Tolerance in Professional Ballet Dancers,” British Journal of Sports Medicine 29 (1995), pp. 31–34; Cogan, R., Spinnato, J. A., “Pain and Discomfort Thresholds in Late Pregnancy,” Pain 27 (1986), pp. 63–68; Berkley, K. J., “Sex Differences in Pain,” Behavioral and Brain Sciences 20 (1997), pp. 371–80; Barnes, G. E., “Extraversion and pain,” British Journal of Social and Clinical Psychology 14 (1975), pp. 303–8; Compton, M. D., “Cold-Pressor Pain Tolerance In Opiate And Cocaine Abusers: Correlates of Drug Type and Use Status,” Journal of Pain and Symptom Management 9 (1994), pp. 462–73; and Bandura, A., et al., “Perceived Self-Efficacy and Pain Control: Opioid and Nonopioid Mechanisms,” Journal of Personality and Social Psychology 53 (1987), pp. 563–71.

  123 Frederick Lenz published his two cases in two separate papers: Lenz, F. A., et al., “Stimulation in the human somatosensory thalamus can reproduce both the affective and sensory dimensions of previously experienced pain,” Nature Medicine 1 (1995), pp. 910–13; and “The sensation of angina can be evoked by stimulation of the human thalamus,” Pain 59 (1994), pp. 119–25.

  125 Melzack’s new theory is described in his article “Pain: Present, Past, and Future,” Canadian Journal of Experimental Psychology 47 (1993), pp. 615–29.

  127 Information on new drugs is changing quickly, so I’d recommend looking for the most up-to-date references. But the studies described are from Miljanich, G. P., “Venom peptides as human pharmaceuticals,” Science and Medicine (September/October 1997), pp. 6–15; and Bannon, A. W., et al., “Broad-Spectrum, Non-Opioid Analgesic Activity by Selective Modulation of Neuronal Nicotinic Acetylcholine Receptors,” Science 279 (1998), pp. 77–81.

  128 The tale of Australia’s repetitive stress injury epidemic in the 1980s can be found in Hall, W., and Morrow, L., “Repetition strain injury: an Australian epidemic of upper limb pain,” Social Science and Medicine 27 (1988), pp. 645–49; Ferguson, D., “ ‘RSI’: Putting the epidemic to rest,” Medical Journal of Australia 147 (1987), p. 213; and Hocking, B., “Epidemiological aspects of ‘repetition strain injury’ in Telecom Australia,” Medical Journal of Australia 147 (1987), pp. 218–22.

  A QUEASY FEELING

  130 For a nice summary of the physiology of vomiting see chapter 1 in Sleisinger, M., ed., Handbook of Nausea and Vomiting (New York: Parthenon Publishing Group, 1993).

  133 Watcha, M. F., and White, P. F., “Postoperative nausea and vomiting: its etiology, treatment, and prevention,” Anesthesiology 77 (1992), pp. 162–84.

  Griffin, A. M., et al., “On the receiving end: patient perceptions of the side effects of cancer chemotherapy,” Annals of Oncology 7 (1996), pp. 189–95.

  Jewell, D., and Young, G., “Treatments for nausea and vomiting in early pregnancy,” Cochrane Database of Systematic Reviews, 4 March 2000.

  134 Profet, M., “Pregnancy sickness as adaptation: a deterrent to maternal ingestion of teratogens,” in Barkow, J. H., Cosmides, L., and Tooby, J., The Adapted Mind (Oxford: Oxford University Press, 1992).

  135 The classic text on motion sickness is Reason, J. T., and Brand, J. J., Motion Sickness (New York: Academic Press, 1975).

  A short and useful summary of more recent research on motion sickness, including space sickness, can be found in Oman, C. M., “Motion sickness: a synthesis and evaluation of the sensory conflict theory,” Canadian Journal of Physiology and Pharmacology 68 (1990), pp. 294–303.

  138 Studies described include Fischer-Rasmussen, W., et al., “Ginger treatment of hyperemesis gravidarum,” European Journal of Obstetrics, Gynecology, and Reproductive Biology 42 (1991), pp. 163–64; O’Brien, B., Relyea, J., and Taerum, T., “Efficacy of P6 acupressure in the treatment of nausea and vomiting during pregnancy,” American Journal of Obstetrics and Gynecology 174 (1996), pp. 708–15.

  A valuable summary reference on care for those with hyperemesis of pregnancy is Nelson-Piercy, C., “Treatment of nausea and vomiting in pregnancy: When should it be treated and what can be safely taken?” Drug Safety 19 (1998), pp. 155–64.

  140 For a short and balanced summary of marijuana’s uses in medicine see Voth, E. A., and Schwartz, R., “Medicinal applications of Delta-9-Tetrahydrocannabinol and marijuana,” Annals of Internal Medicine 126 (1997), pp. 791–98.

  For more on the peculiar entity of rumination syndrome see Malcolm, A., et al., “Rumination syndrome,” Mayo Clinic Proceedings 72 (1997), pp. 646–52.

  The study of Zofran and nausea from Gary Morrow’s research group is Roscoe, J. A., et al., “Nausea and vomiting remain a significant clinical problem: trends over time in controlling chemotherapy-induced nausea and vomiting in 1,413 patients treated in community clinical practices,” Journal of Pain & Symptom Management 20 (2000), pp. 113–21.

  An excellent review of the psychology of nausea is Morrow, G. R., “Psychological aspects of nausea and vomiting: anticipation of chemotherapy,” in Sleisinger, ed., 1993.

  142 The groundbreaking report on a substance P antagonist in nausea was Navari, R. M., et al., “Reduction of cisplatin-induced emesis by a selective neurokinin-i-receptor antagonist,” New England Journal of Medicine 340 (1999), pp. 190–95.

  For a summary of the evidence for benefit from palliative care specialists see Hearn, J., and Higginson, I. J., “Do specialist palliative care teams improve outcomes for cancer patients?: a systematic literature review,” Palliative Medicine 12 (1998), pp. 317–32.

  144 Information about Bendectin is reviewed in Koren, G., Pastuszak, A., and Ito, S., “Drug therapy: drugs in pregnancy,” New England Journal of Medicine 338 (1998), pp. 1128–37.

  Cassell, E. G., The Nature of Suffering and the Goals of Medicine (New York: Oxford University Press, 1991).

  CRIMSON TIDE

  149 The Freudian arguments are presented in Karch, F. E., “Blushing,” Psychoanalytic Review 58 (1971), pp. 37–50.

  Charles Darwin’s essay on blushing is in his book The Expression of the Emotions in Man and Animals (1872).

  Michael Lewis details his demonstration of embarrassment from being stared at in “The self in self-conscious emotions,” Annals of the New York Academy of Sciences 818 (1997), pp. 119–42.

  The science and psychology of blushing described here, including Leary and Templeton’s study, comes from three sources: Leary, M. R., et al., “Social blushing,” Psychological Bulletin 112 (1992), pp. 446–60; Miller, R. S., Embarrassment: Poise and Peril in Everyday Life (New York: Guilford Press, 1996); and Edelmann, R. J., “Blushing,” in Crozier, R., and Alden, L. E., eds., International Handbook of Social Anxiety (Chichester: John Wiley & Sons, 2000).

  153 The Göteborg surgeons’ results with ETS for blushing were published in Drott, C., et al., “Successful treatment of facial blushing by endoscopic transthoracic sympathicotomy,” British Journal of Dermatology 138 (1998), pp. 639–43. For chary view of the surgery, see Drummond, P. D., “A caution about surgical treatment for facial blushing,” in British Journal of Dermatology 142 (2000), pp. 195–96.

  160 The Web site for Christine Drury’s organization is www.redmask.org.

  THE MAN WHO COULDN’T STOP EATING

  162 The statistics on the number of gastric-bypass operations being done comes from Blackburn, G., “Surgery for obesity,” Harvard Health Letter (2001), no. 884.

  169 The National Institutes of Health’s depressing findings on the longterm, almost universal failure of dieting is in its publication “Methods for voluntary weight loss and control,” Annals of Internal Medicine 119 (1993), pp. 764–70

  A fairly comprehensive listing of the various surgical treatments that obese people have been subjected to, and their results, can be found in Kral, J. G., “Surgical treatment of obesity,” in Bray, G. A., Bouchard, C., and James, W. P. T., eds., Handbook of Obesity (New York: M. Decker, 1998); together with Munro, J. F., et al., “Mechanical treatment for obesity,” Annals of the New York Academy of Sciences 4
99 (1987), pp. 305–11.

  170 The research on dieting for obese children described is in Epstein, L. H., et al., “Ten-year outcomes of behavioral family-based treatment for childhood obesity,” Health Psychology 13 (1994), pp. 373–83.

  Information on Prader-Willi syndrome comes from Lindgren, A. C., et al., “Eating behavior in Prader-Willi syndrome, normal weight, and obese control groups,” Journal of Pediatrics 137 (2000), pp. 50–55; and Cassidy, S. B., and Schwartz, S., “Prader-Willi and Angelman syndromes,” Medicine 77 (1998), pp. 140–51.

  The “fat paradox” is explained in Blundell, J. E., “The control of appetite,” Schweizerische 129 (1999), p. 182.

  171 One study demonstrating the “appetizer effect” is Yeomans, M. R., “Rating changes over the course of meals: What do they tell us about motivation to eat?” Neuroscience and Biobehavioral Reviews 24 (2000), pp. 249–59.

  The French chewing study is published in Bellisle, F., et al., “Chewing and swallowing as indices of the stimulation to eat during meals in humans,” Neuroscience and Biobehavioral Reviews 24 (2000), pp. 223–28.

  171 The study of eating in densely amnesiac people is published in Rozin, P., et al., “What causes humans to begin and end a meal?” Psychological Science 9 (1998), pp. 392–96.

  173 Information on the long-term failure of just stomach stapling surgery to maintain weight loss is from Blackburn’s 2001 article, cited above, and Nightengale, M. L., et al., “Prospective evaluation of vertical banded gastroplasty as the primary operation for morbid obesity,” Mayo Clinic Proceedings 67 (1992), pp. 304–5.

  174 For information on the psychological and social experiences of obesity surgery, see Hsu, L. K. G., et al., “Nonsurgical factors that influence the outcome of bariatric surgery: a review,” Psychosomatic Medicine 60 (1998), pp. 338–46.

  Two excellent summaries of the research on the sustained longterm weight loss from obesity surgery are Kral’s 1998 article and Blackburn’s 2001 article, both cited above.

  181 For data on the high prevalence of morbid obesity, see Kuczmarski, R. J., et al., “Varying body mass index cutoff points to describe overweight prevalence among U.S. adults: NHANES III (1988 to 1994),” Obesity Research 5 (1997), pp. 542–48.

  FINAL CUT

  191 The faltering war on the nonautopsy is recounted in Lundberg, G. D., “Low-tech autopsies in the era of high-tech medicine,” Journal of the American Medical Association 280 (1998), pp. 1273–74.

  192 Information on the history of autopsy comes from two sources: Iserson, K. V., Death to Dust: What Happens to Dead Bodies (Tucson, Ariz.: Galen Press, 1994); and King, L. S., and Meehan, M. C., “The history of the autopsy,” American Journal of Pathology 73 (1973), 514–44.

  197 The three recent studies evaluating autopsy are Burton, E. C., Troxclair, D. A., and Newman III, W. P., “Autopsy diagnoses and malignant neoplasms: How often are clinical diagnoses incorrect?” Journal of the American Medical Association 280 (1998), pp. 1245–48; Nichols, L., Aronica, P., and Babe, C., “Are autopsies obsolete?” American Journal of Clinical Pathology 110 (1996), pp. 210–18; and Zarbo, R. J., Baker, P. B., and Howanitz, P. J., “The autopsy as a performance measurement tool,” Archives of Pathology and Laboratory Medicine 123 (1999), pp. 191–98.

  The review of autopsy studies described is from Hill, R. B., and Anderson, R. E., The Autopsy: Medical Practice and Public Policy (Newton, Mass.: Butterworth-Heinemann, 1988), pp. 34–35.

  The classic comparison of autopsies over the decades is Goldman, L., et al., “The value of the autopsy in three medical eras,” New England Journal of Medicine 308 (1983), pp. 1000–5.

  198 Gorovitz and Maclntyre’s explanation of necessary fallibility is in their article “Toward a theory of medical fallibility,” Journal of Medicine and Philosophy 1 (1976), pp. 51–71.

  201 The disappearance of data on the autopsy is described in Burton, E., “Medical error and outcome measures: Where have all the autopsies gone?” Medscape General Medicine, 28 May 2000.

  THE DEAD BABY MYSTERY

  202 The details of the case come mainly from two sources: the affidavit for Marie Noe’s arrest and Stephen Fried’s disturbing article, “Cradle to Grave,” Philadelphia Magazine, April 1998.

  203 On the reduction of sudden infant deaths associated with the national “Back to Sleep” campaign, see Willingner, M., et al., “Factors associated with the transition to nonprone sleep positions of infants in the United States,” Journal of the American Medical Association 280 (1998), pp 329–35.

  204 A comprehensive source for information on patterns of child abuse is Sedlak, A. J., and Broadhurst, D. D., The Third National Incident Study of Child Abuse and Neglect (Washington: U.S. Department of Health and Human Services, 1996).

  WHOSE BODY IS IT, ANYWAY?

  210 Katz, J., The Silent World of Doctor and Patient (New York: Free Press, 1984).

  220 The study of what cancer patients prefer is Degner, L. F., and Sloan, J. A., “Decision making during serious illness: What role do patients really want to play?” Journal of Clinical Epidemiology 45 (1992), pp. 941–50.

  222 Schneider, C. E., The Practice of Autonomy (New York: Oxford University Press, 1998).

  THE CASE OF THE RED LEG

  233 Information on necrotizing fasciitis comes from Chapnick, E. K., and Abter, E. I., “Necrotizing soft-tissue infections,” Infectious Disease Clinics 10 (1996), pp. 835–55; and Stone, D. R., and Gorbach, S. L., “Necrotizing fasciitis: the changing spectrum,” Infectious Disease in Dermatology 15 (1997), pp. 213–20. A useful source of information for patients is also the National Necrotizing Fasciitis Foundation Web site, www.nnff.org.

  236 For a comprehensive summary of research on the quality of health care (including the heart attack studies described), see Institute of Medicine, Crossing the Quality Chasm (Washington, D.C.: National Academy of Sciences Press, 2001).

  Naylor, C. D., “Grey zones of clinical practices: some limits to evidence-based medicine,” Lancet 345 (1995), pp. 840–42.

  238 The Medical College of Virginia study: Poses, R. M., and Anthony, M., “Availability, wishful thinking, and physicians’ diagnostic judgments for patients with suspected bacteremia,” Medical Decision Making 11 (1991), pp. 159–68.

  The University of Wisconsin study: Detmer, D. E., Fryback, D. G., and Gassner, K., “Heuristics and biases in medical decision making,” Journal of Medical lEducation 53 (1978), pp. 682–83.

  The Ohio study: Dawson, N. V., et al., “Hemodynamic assessment in managing the critically ill: Is physician confidence warranted?” Medical Decision Making 13 (1993), pp. 258–66.

  239 The first installment of David Eddy’s startling series on the problems with decision making in medicine is “The challenge,” Journal of the American Medical Association 263 (1990), pp. 287–90.

  247 Gary Klein’s magnificent book on his research into intuitive decision making is Sources of Power (Cambridge: M.I.T. Press, 1998).

  248 One can look up information about the patterns of what doctors in one’s own area do relative to doctors in other areas in Jack Wennberg and his research team’s publication, Dartmouth Atlas of Health Care (Chicago: American Hospital Publishing, Inc., 1999). Their findings are also available online at www.dartmouthatlas.org.

  Acknowledgments

  Being the child of two doctors, I have been familiar with medicine since I was small. The dinner talk at home was as often about local doctor gossip and cases (the badly asthmatic boy my mom was taking care of, for instance, whose parents were not giving him his medication; my dad’s first successfully reversed vasectomy; the guy who’d gone to bed drunk and shot his penis off thinking there was a snake under the covers) as about school and politics. As soon as we were old enough, my sister and I were taught to field phone calls from patients. “Is this an emergency?” we learned to ask. If callers said yes, that was easy. We were to tell them to go to the emergency room. And if they said no, that was easy, too. We were to take a message. Only one time did I get an �
��I don’t know.” It was from a man with a rather strained voice calling for my father because he’d “injured himself” while shoveling. I told him to go to the emergency room.

  Once in a while, I’d be out with my mom or dad when an emergency page would come through. We’d go to the hospital together, and I’d be put in a chair in the ER hallway to wait. I’d sit watching the sick children crying, the men bleeding into rags, the old ladies breathing funny, and the nurses scurrying everywhere. I got more used to the place than I realized. Years later, as a medical student entering a Boston hospital for my first time, I realized I already knew the smell.

  I came to writing, however, only much later and with the help of a lot of people whom I owe a deep debt of gratitude. My friend Jacob Weisberg was the one who first encouraged me to write seriously. He is the chief political correspondent for the Internet magazine Slate, and during my second year of surgical residency he pushed me to give a try at some medical writing for his publication. I agreed. He helped me through multiple drafts of that first piece. And then, over the next two years, he and Michael Kinsley, Slate’s editor-in-chief, along with my editors Jack Shafer and Jodie Allen, gave me both space and guidance to create what became a regular column on medicine and science. The opportunity changed everything for me. Residency is a grueling experience, and in the midst of all the paperwork and pages and sleep deprivation, you can forget why what you do matters. The writing let me step back and, for a few hours each week, remember.

  In my third year of residency, another friend, the New Yorker writer Malcolm Gladwell, introduced me to his editor Henry Finder. And for this I consider myself one of the luckiest writers there could be. A mumbling, astonishingly widely read boy genius who at the age of thirty-two was already editor to several of the writers I most admired, Henry took me under his wing. He had the patience and persistence and optimism to pull me through seven complete rewrites of the first article I submitted to The New Yorker. He pushed me to think harder than I had ever thought I could. He showed me which of my instincts in writing I could have confidence in and which ones I should not. More than that, he has always believed that I had stories worth telling. Since 1998, The New Yorker has engaged me as a staff writer. Many of the chapters in this book originated as articles I published there. In addition, Henry has read and provided invaluable advice on everything written here. This book would not have been possible without him.