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Doctors Who Write

September 2003
Doctors Who Write

The Firm, The Pelican Brief and The Client are just some of the thrillers that were not only best selling novels, but also blockbuster films that raked in huge profits. These are the work of one man, John Grisham a small town lawyer who rose to dizzying heights of fame and success in a few short years by phasing out his ?real' profession in law, to become a? writer! It is doubtful he may have attained such success had he continued as a small town lawyer instead of following his heart and his calling to write.

In intense careers such as law and medicine, non-professional writing is not too common. Hence, when one does find examples of people who have been able to break loose from the rigors of their daily professional grind to write, it may be safe to assume that there is a real passion at work.

In recent years, a few medical doctors of Indian origin, mostly living in the U.S., have found considerable success as authors of books for the general reader. The ability to juggle two such challenging and disparate professions, one supposes, requires not only talent but also tremendous discipline and energy. Moreover, whether it's nonfiction or fiction, a medical background is an invaluable asset for these doctor-cum-writers. Apart from giving them a fascinating subject to write on, medical training emphasizes at least three skills that are crucial to good writing: observation, attention to detail, and empathy.

In Complications: A Surgeon's Notes on an Imperfect Science, Atul Gawande displays these qualities in ample measure, and by writing with uncommon grace and clarity, he makes the work all the more engaging. For curious readers who want an inside or behind-the-scenes view of medicine, especially surgery, this book provides a crisp introduction. Here is a practicing surgeon who knows how to use his pen with the same clinical precision as his scalpel.

The book is divided into three parts: Fallibility, Mystery, and Uncertainty of contemporary medicine and health care. The first section examines "how mistakes happen, how a novice learns to wield a knife, what a good doctor is, how it is that one could go bad." Dr. Gawande shows, with unflinching honesty, the imperfections of his profession by pointing out that inadequate information and the uncertainty of medicine can sometimes cause mistakes. Although highly skilled, a surgeon is only human and is prone to errors from time to time; and as in many other occupations, constant training and practice can make an appreciable difference over time. However, there is one big difference when it comes to this field. Since these surgeons operate on human beings, the stakes are often unusually high.

Most of the articles collected in this book, written when Dr. Gawande was a surgical resident, originally appeared in The New Yorker, where he is a staff writer. A graduate of Harvard Medical School and the Harvard School of Public Health, he now lives and works as a surgeon in the Boston metro area. As the son of immigrant physicians from India, Dr. Gawande was not a stranger to medicine when he and his sister were growing up in Athens, Ohio. For a long time, even during his medical training, Dr. Gawande thought one stopped learning after achieving a certain level of proficiency; but relentless advances in knowledge and technology made him realize that he was wrong. "Three-quarters of what I do today I never learned in residency," his father once told him.

In another chapter, while discussing the effects of technology on medicine, Dr. Gawande mentions that a lot of doctors like to rely on their own experience and well-honed instincts when making a diagnosis. However, as he points out, studies have shown that machines consistently beat man when performing diagnostic tests (it was by 20 percent in one study). Of course, doctors are always needed to heal and provide that all-important human connection. As Dr. Gawande comments, "Yet compassion and technology aren't necessarily incompatible; they can be mutually reinforcing." Then, there is candid discussion of how medical malpractice suits can become counterproductive by affecting the quality of medicine delivered to patients.

At a huge convention in Chicago, where 9312 surgeons attended from all over the U.S., Dr. Gawande watched some films of operations, based on which, he describes the skill and ingenuity of surgery: "? a team from Strasbourg, France, removed a colon cancer from deep in a patient's pelvis and then reconnected her bowel entirely laparoscopically ? through tiny incisions that required only Band-Aids afterward. It was a startling, Houdini-like feat ? something akin to removing a model ship from a bottle and constructing a working car in its place using just chopsticks."

The middle section (Mystery), which provides a fascinating look at some unusual cases. Perhaps the most interesting and moving case in this section involves "the man who couldn't stop eating." As Dr. Gawande points out, more than 5 million adult Americans are morbidly obese, which can lead to all kinds of health problems. Increasingly, after a losing battle with weight-loss programs, many of these people are opting for gastric-bypass surgeries, which have doubled in number since 1999. One of the pleasures of Dr. Gawande's prose is that he is often able to convey his point in an apt phrase or sentence. For instance, while reflecting on the difficulty of losing weight permanently, he writes: "We are a species that has evolved to survive starvation, not to resist abundance." Another example, from an earlier chapter, reads: "Skill, surgeons believe, can be taught; tenacity cannot."

The final section (Uncertainty) is the most gripping in some ways, although squeamish readers may shy away from the more graphic details. In a discussion of autopsies and their continuing relevance today, Dr. Gawande notes that misdiagnosis is still a major factor when determining the cause of death. Despite the advances in medicine, the figure was around 40 percent in 1998 and 1999. As he remarks, "There is still room enough to get better, to ask questions of even the dead, to learn from knowing when our simple certainties are wrong."������

Another piece ("Whose Body Is It, Anyway?") is a thoughtful look at the shift in decision-making over the years from doctors to patients, and the challenges it has posed to everyone concerned. Not surprisingly, one study "found that the ill were often in a poor position to make good choices: they were frequently exhausted, irritable, shattered, or despondent." Especially when it comes to life-and-death situations, Dr. Gawande says, this burden can be insupportable for many patients and their families. He writes about one such tragic case, where the patient ? after insisting on making the choice ? ends up choosing badly. Frequently, though, Dr. Gawande finds that patients don't want the freedom that's given to them, and they are happier to let doctors make the important decisions.

The last case, perhaps the most terrifying one in the book, reads more like a suspenseful tale by Robin Cook or Michael Crichton, two former physicians who have found enormous success as authors of popular fiction. But, of course, this heartbreaking story narrated by Dr. Gawande is entirely true. It deals with nacrotizing fasciitis, more commonly referred to as a disease of "flesh-eating bacteria." This dreaded disease, although thankfully rare, rapidly kills 70 percent of the people who are unfortunate enough to get it. Since there is no known cure, the only way to stop it from spreading is to catch the disease early, and this frequently involves amputations. The only information that will be revealed here is that all the doctors involved in the case battled heroically.

Dr. Gawande once suggested that his goal as a writer was to "demystify" medicine. In this compulsively readable volume, which was a finalist for the National Book Award in 2002, he has done that with admirable flair and acuity. And he has also shown us how medicine remains one of mankind's noblest professions.

Abraham Verghese and Sanjay Nigam are two other working doctors who have found wide recognition as writers. Almost a decade ago, Dr. Verghese was perhaps the first Indian physician to have a major impact in this country as an author. His book, My Own Country: A Doctor's Story, was published to critical and popular acclaim in 1994, and it's now being taught at medical schools across the nation. In it, Dr. Verghese writes compassionately about the young AIDS patients he cared for in rural Tennessee in the 1980s. Named by Time magazine as one of the best books of 1994, it was later made into a Showtime film by Mira Nair and starring Marisa Tomei. His next book, The Tennis Partner: A Doctor's Story of Friendship and Loss, which is about a drug-addicted physician who commits suicide, also became a bestseller and is now being made into a film. Dr. Verghese, who was raised by his Indian parents in Ethiopia, pursued his medical studies in India and the U.S. He is now a professor of medicine and the chief of infectious diseases at Texas Tech University in El Paso.

Currently, in the world of fiction, Sanjay Nigam is probably the most notable desi writer who is also a doctor. His first book (The Non-Resident Indian and Other Stories) was published only in India, but this debut novel (The Snake Charmer) attracted wide attention in this country. It's a fable-like story about the struggles of his protagonist in India, Bhola Ram, who kills his snake in a fit of rage after being bitten by it. With his latest novel, Transplanted Man, Dr. Nigam has become more inventive and ambitious. Set in the U.S. this time, it deals with a young medical resident, Sonny Seth, and a mysterious Indian politician and patient, whose body has seven organs that originally belonged to people of differing faiths. Although Dr. Nigam mostly grew up in the States, he has spent a lot of time in India, even to the point of studying there briefly. Therefore, as his work demonstrates, he is very much at home in both cultures. After completing his medical education, he worked as a research scientist at Harvard Medical School. Now he is on the faculty at the University of California in San Diego.

One of the most tantalizing questions is, why do these overworked doctors feel so compelled to write? A few years ago, in an interview with Salon magazine, Dr. Verghese offered an answer. "My feeling is that given how privy we are to the intimate details of people's lives," he said, "it's a surprise that more of us aren't writing . . . These stories take place every day in hospitals all over the world. To not tell them is to feel an unbearable sense of loss."

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