by Atul Gawande
It was a routine gallbladder operation, on a routine day: on the operating table was a mother in her forties, her body covered by blue paper drapes except for her round, antiseptic-coated belly. The gallbladder is a floppy, finger-length sac of bile like a deflated olive-green balloon tucked under the liver, and when gallstones form, as this patient had learned, they can cause excruciating bouts of pain. Once we removed her gallbladder, the pain would stop.
There are risks to this surgery, but they used to be much greater. Just a decade ago, surgeons had to make a six-inch abdominal incision that left patients in the hospital for the better part of a week just recovering from the wound. Today, we’ve learned to take out gallbladders with a miniature camera and instruments that we manipulate through tiny incisions. The operation, often done as day surgery, is known as laparoscopic cholecystectomy, or “lap chole.” Half a million Americans a year now have their gallbladders removed this way; at my hospital alone, we do several hundred lap choles annually.
When the attending gave me the go-ahead, I cut a discreet inch-long semicircle in the wink of skin just above the belly button. I dissected through fat and fascia until I was inside the abdomen and dropped into place a “port,” a half-inch-wide sheath for slipping instruments in and out. We hooked gas tubing up to a side vent on the port, and carbon dioxide poured in, inflating the abdomen until it was distended like a tire. I inserted the miniature camera. On a video monitor a few feet away, the woman’s intestines blinked into view. With the abdomen inflated, I had room to move the camera, and I swung it around to look at the liver. The gallbladder could be seen poking out from under the edge.
We put in three more ports through even tinier incisions, spaced apart to complete the four corners of a square. Through the ports on his side, the attending put in two long “graspers,” like small-scale versions of the device that a department store clerk might use to get a hat off the top shelf. Watching the screen as he maneuvered them, he reached under the edge of the liver, clamped onto the gallbladder, and pulled it up into view. We were set to proceed.
Removing the gallbladder is fairly straightforward. You sever it from its stalk and from its blood supply, and pull the rubbery sac out of the abdomen through the incision near the belly button. You let the carbon dioxide out of the belly, pull out the ports, put a few stitches in the tiny incisions, slap some Band-Aids on top, and you’re done. There’s one looming danger, though: the stalk of the gallbladder is a branch off the liver’s only conduit for sending bile to the intestines for the digestion of fats. And if you accidentally injure this main bile duct, the bile backs up and starts to destroy the liver. Between 10 and 20 percent of the patients to whom this happens will die. Those who survive often have permanent liver damage and can go on to require liver transplantation. According to a textbook, “Injuries to the main bile duct are nearly always the result of misadventure during operation and are therefore a serious reproach to the surgical profession.” It is a true surgical error, and, like any surgical team doing a lap chole, we were intent on avoiding this mistake.
Using a dissecting instrument, I carefully stripped off the fibrous white tissue and yellow fat overlying and concealing the base of the gallbladder. Now we could see its broad neck and the short stretch where it narrowed down to a duct—a tube no thicker than a daisy stem peeking out from the surrounding tissue, but magnified on the screen to the size of major plumbing. Then, just to be absolutely sure we were looking at the gallbladder duct and not the main bile duct, I stripped away some more of the surrounding tissue. The attending and I stopped at this point, as we always do, and discussed the anatomy. The neck of the gallbladder led straight into the tube we were eyeing. So it had to be the right duct. We had exposed a good length of it without a sign of the main bile duct. Everything looked perfect, we agreed. “Go for it,” the attending said.
I slipped in the clip applier, an instrument that squeezes V-shaped metal clips onto whatever you put in its jaws. I got the jaws around the duct and was about to fire when my eye caught, on the screen, a little globule of fat lying on top of the duct. That wasn’t necessarily anything unusual, but somehow it didn’t look right. With the tip of the clip applier, I tried to flick it aside, but instead of a little globule, a whole layer of thin unseen tissue came up, and, underneath, we saw that the duct had a fork in it. My heart dropped. If not for that little extra fastidiousness, I would have clipped off the main bile duct.
Here was the paradox of error in medicine. With meticulous technique and assiduous effort to insure that they have correctly identified the anatomy, surgeons need never cut the main bile duct. It is a paradigm of an avoidable error. At the same time, studies show that even highly experienced surgeons inflict this terrible injury about once in every two hundred lap choles. To put it another way, I may have averted disaster this time, but a statistician would say that, no matter how hard I tried, I was almost certain to make this error at least once in the course of my career.
But the story doesn’t have to end here, as the cognitive psychologists and industrial error experts have demonstrated. Given the results they’ve achieved in anesthesiology, it’s clear that we can make dramatic improvements by going after the process, not the people. But there are distinct limitations to the industrial cure, however necessary its emphasis on systems and structures. It would be deadly for us, the individual actors, to give up our belief in human perfectibility. The statistics may say that someday I will sever someone’s main bile duct, but each time I go into a gallbladder operation I believe that with enough will and effort I can beat the odds. This isn’t just professional vanity. It’s a necessary part of good medicine, even in superbly “optimized” systems. Operations like that lap chole have taught me how easily error can occur, but they’ve also showed me something else: effort does matter; diligence and attention to the minutest details can save you.
This may explain why many doctors take exception to talk of “systems problems,” “continuous quality improvement,” and “process re-engineering.” It is the dry language of structures, not people. I’m no exception: something in me, too, demands an acknowledgment of my autonomy, which is also to say my ultimate culpability. Go back to that Friday night in the ER, to the moment when I stood, knife in hand, over Louise Williams, her lips blue, her throat a swollen, bloody, and suddenly closed passage. A systems engineer might have proposed some useful changes. Perhaps a backup suction device should always be at hand, and better light more easily available. Perhaps the institution could have trained me better for such crises, could have required me to have operated on a few more goats. Perhaps emergency tracheostomies are so difficult under any circumstances that an automated device could have been designed to do a better job.
Yet although the odds were against me, it wasn’t as if I had no chance of succeeding. Good doctoring is all about making the most of the hand you’re dealt, and I failed to do so. The indisputable fact was that I hadn’t called for help when I could have, and when I plunged the knife into her neck and made my horizontal slash my best was not good enough. It was just luck, hers and mine, that Dr. O’Connor somehow got a breathing tube into her in time.
There are all sorts of reasons that it would be wrong to take my license away or to take me to court. These reasons do not absolve me. Whatever the limits of the M & M, its fierce ethic of personal responsibility for errors is a formidable virtue. No matter what measures are taken, doctors will sometimes falter, and it isn’t reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.
Nine Thousand Surgeons
“Are you going to the convention?” the attending asked.
“Me?” I said. He was speaking of the upcoming American College of Surgeons convention. It had never occurred to me that I could go.
Conventions are big deals in medicine. My doctor parents have gone to their conventions faithfully for thirty years, and I vaguely remembered, from the occasions in my childhood when they ha
d brought me along, how dense and enormous and exciting they seemed. As a resident, I had gotten used to the operating schedule suddenly emptying out each mid-October, when the faculty surgeons packed off to their annual convention en masse. But we residents would stay behind, along with a skeleton crew of unlucky attendings (usually the most junior ones), to manage the trauma cases and other random emergencies that still came in. A lot of the time was spent kicked back in the residents’ lounge—a dim musty den with flat brown carpeting, a moldering couch, a broken rowing machine, empty soda cans, and two televisions—watching end-of-year baseball on the one television that worked and eating take-out Chinese.
Each year, however, a few senior residents have gotten to tag along to the convention. And in my sixth year I was told that I had now reached the stage in training that allowed me to be one of them. The hospital turned out to have a small fund that would pay for the trip. Within a few days I had a plane ticket to Chicago, a reservation at the Hyatt Regency, and an admission badge for the eighty-sixth annual Clinical Congress of Surgeons. It was not until I was at twenty-seven thousand feet in a Boeing 737 somewhere over New Hampshire, my wife settled back home for a week in sole possession of our three children, that I finally thought to wonder what on earth one goes to these things for.
I arrived at Chicago’s massive McCormick Place convention center to find that I was but one of nine thousand three hundred and twelve surgeons in attendance. (A daily newspaper just for the convention reported the daily count.) The building looked like an airport terminal and felt like Penn Station at rush hour. I took an escalator up to a deck above the main hall and looked out upon the sprawl. There were, it struck me, nearly as many people milling around this one building talking surgery as live in the Ohio towns around where I grew up. The surgeons—mostly men and middle-aged, a little shlumpy, in navy jackets, wrinkled shirts, conservative ties—were gathering in clumps of two and three, everyone smiling, shaking hands, catching up. Nearly all wore glasses and stood with a slight operating-table stoop. A few stood alone, leafing through their program books, deciding what to see and do first.
Each of us, upon arriving, had been handed a three hundred and eighty-eight–page schedule of programs we could attend—from a course that first morning on how to do advanced image-guided breast biopsies to a panel presentation on the sixth and final day entitled “Office-Based Treatment of Ano-Rectal Disease—How Far Can We Go?” Eventually, I too settled down with my book, diligently scanning it page by page and circling in blue ballpoint pen anything that caught my eye. This was, I decided, the place where the new and better could be found—the place where the more nearly perfect was being taught—and it seemed almost an obligation to attend as much of the proceedings as I could. Before long my book was blue with circles. The first morning alone, I had more than twenty instructive-looking programs to choose from. I debated going to a lecture on the proper way to dissect a neck or a session on new advances in managing gunshot wounds to the head, but finally decided on a panel debate about the best way to repair hernias of the groin.
I arrived early, and already the auditorium’s fifteen hundred seats were filled. Hernias were SRO. I found a place to stand in a crowd along the back wall. I could hardly see the lectern up front, but a giant video screen provided close-ups of each of the talking heads. Eleven surgeons, one after another, took the podium to flash up Powerpoint slides and argue about data.
Our research indicates, the first surgeon intoned, that the Lichtenstein method is the most reliable way to repair hernias. No, the next surgeon rejoined, the Lichtenstein method is inadequate; the Shouldice technique has proven best. Then a third surgeon stepped forward: Both of you are wrong—it should be done laparoscopically. Now another surgeon was up: I’ve got an even better way to do it, using a special device that I happen to have patented. Things went on this way for two and a half hours. Tempers sometimes flared. Pointed questions were thrown out from the audience. And no answers were reached. But at the end the room was as full as it was at the very beginning.
In the afternoon, I went to the movies. The organizers had set up three theaters seating three or four hundred people each to show reel upon reel of actual operations all day, every day. I scooted into one darkened room and was instantly riveted. I saw daring operations, intricate operations, ingeniously simple operations. The first movie I caught was from Memorial Sloan Kettering Cancer Center in Manhattan. It began with a close-up of a patient’s open abdomen. The surgeon, unseen but for his gloved and bloody hands, was attempting an exceedingly difficult and dangerous operation—the excision of a cancer in the tail of a patient’s pancreas. The tumor lay deep, enveloped by loops of bowel, a latticework of blood vessels, the stomach, and the spleen. But the surgeon made getting it out seem like play. He plucked at fragile vessels and slashed through tissue millimeters from vital organs. He showed us a couple of tricks for avoiding trouble, and the next thing we knew he had half the pancreas on a tray.
In another film, 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 audience watched wide-eyed and incredulous.
The most elegant clip, however, was from a Houston, Texas, surgeon who unveiled a procedure for repairing a defect of the esophagus known as Zenker’s diverticulum. This is an abnormality that normally requires an hour or more to repair and an incision in the side of the neck, but in the film the surgeon managed to do it through a patient’s mouth in fifteen minutes with no incision at all. I stayed and watched movies for almost four hours. And when the lights went up, I walked out into the day silent, blinking, and exhilarated.
The clinical sessions were lined up until 10:30 each night, and they seemed to all go like those first two I attended—veering between the pedantic and the sublime, the mundane and the remarkable. If such programs were supposed to be the meat of the meeting, however, it was often hard to tell. The convention, one soon realized, was as much trade show as teaching conference. Ads for cool new things you had never heard of—a tissue-stapling device that staples without staples, a fiber-optic scope that lets you see in three dimensions—ran night and day on my hotel room television and even on the shuttle bus to and from the convention center. Drug and medical device companies offered invitations to free dinners around town nightly. And there were over five thousand three hundred salespeople from some twelve hundred companies registered in attendance here—more than one for every two surgeons.
The centerpiece of their activity was a teeming, soccer field–size “technical exhibit” hall where they had set up booths from which to market their wares. The word “booth” does not come close to capturing what they had built. There were two-story-high kiosks, pulsing lights, brushed-steel displays, multimedia presentations—one company had even assembled a complete operating room on-site. Surgeons are people who buy two hundred–dollar scissors, sixteen thousand–dollar abdominal retractors, and fifty thousand–dollar operating tables as a matter of course. So the courting can be intense and elaborate.
It was also unavoidable. The convention organizers had given—or more precisely, sold—the salespeople the convention’s most prime real estate: their exhibit hall was adjacent to the registration desk, making it the first thing surgeons saw upon arriving at the convention, and our only path to the scientific exhibits was through the glittery maze. Heading through to see a molecular biology exhibit the following afternoon, I never made it to the other side. Everywhere you looked was something to stop you in your tracks.
Sometimes it was just chintzy, free stuff. Booths were offering free golf balls, fountain pens, penlights, baseball caps, sticky pads, candy—all stenciled with company logos, of course, and handed over with a spiel and a brochure about some new technology a comp
any was marketing. You might think six-figure surgeons would be oblivious to this kind of petty bribery. But you would be wrong. A drug manufacturer ran what seemed to be one of the busiest booths in the place handing out sturdy white canvas bags with the name of one of its drugs emblazoned in four-inch blue letters along the side. Doctors lined up for the bags, even when they had to give away their phone numbers and addresses, just to get something to hold all the free merchandise they were collecting. (Still, I heard one physician muttering that the pickings were not as good as in previous years. He’d gotten Ray-Ban sunglasses once, he said.)
Sometimes the companies relied on more subliminal methods to draw surgeons in—putting three smiling young women at a booth, say. “Have you seen our skin?” one leggy brunette with eyelashes like springboards and a voice as vaporous as smoke breathed to me. She meant her company’s new artificial skin for burn patients, but how could I resist? The next thing I knew, I was poking with a pair of forceps at an almost translucent white sheet of engineered skin in a petri dish (ninety-five dollars for a four-by-six-inch piece) thinking, “This stuff is pretty neat, actually.”