Read Complications Online

Authors: Atul Gawande

Complications (34 page)

45 Herzlinger, R.,
Market-Driven Health Care: Who Wins, Who Loses in the Transformation of America’s Largest Service Industry
(Reading, Mass.: Addison-Wesley, 1997).

WHEN DOCTORS MAKE MISTAKES

57 Brennan, T. A., et al., “Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I,”
New England Journal of Medicine
324 (1991), pp. 370–76.

Leape, L. L., “Error in medicine,”
Journal of the American Medical Association 272
(1994), pp. 1851–57.

Bates, D. W., et al., “Incidence of adverse drug events and potential adverse drug events,”
Journal of the American Medical Association
274 (1995), pp. 29–34.

Localio, A. R., et al., “Relation between malpractice claims and adverse events due to negligence: results of the Harvard Medical Practice Study III,”
New England Journal of Medicine
325 (1991), pp. 245–51.

63 Reason, J.,
Human Error
(Cambridge: Cambridge University Press, 1990).

64 The history of anesthesia’s success against error is described in Pierce, E. C., “The 34th Rovenstine Lecture: 40 years behind the mask—safety revisited,”
Anesthesiology
84 (1996), pp. 965–75.

65 Cooper, J. B., et al., “Preventable anesthesia mishaps: a study of human factors,”
Anesthesiology
49 (1978), pp. 399–406.

69 The work of the Northern New England Cardiovascular Disease Study Group has been published in numerous studies, but a summary can be found in Malenka, D. J., and O’Connor, G. T., “The Northern New England Cardiovascular Disease Study Group: a regional collaborative effort for continuous quality improvement in cardiovascular disease,”
Joint Commission Journal on Quality Improvement
24 (1998), pp. 594–600.

70 Brooks, D. C., ed.,
Current Review of Laparoscopy
, 2nd ed. (Philadelphia: Current Medicine, 1995).

NINE THOUSAND SURGEONS

75 One can find information about the annual American College of Surgeons convention at
www.facs.org
.

WHEN GOOD DOCTORS GO BAD

88 The tale of Harold Shipman is described in detail in Eichenwald, K., “True English murder mystery: town’s trusted doctor did it,”
New York Times
, 13 May 2001, p. A1.

Prosecutors in John Ronald Brown’s trial alleged his involvement also included attempting to plug a Los Angeles woman’s leaking breast
implants with Krazy Glue. He was convicted of second-degree murder in the death of Philip Bondy, whose leg was amputated, and sentenced to fifteen years. For more details see Ciotti, P., “Why did he cut off that man’s leg?” LA
Weekly
, 17 December 1999.

For the story of James Burt see Griggs, F., “Breaking Tradition: Doctor Steps in to Stop Maiming ‘Surgery of Love,’ ”
Chicago Tribune
, 25 August 1991, p. 8.

94 For data on substance abuse in doctors see Brook, D., et al., “Substance abuse within the health care community,” in Friedman, L. S., et al., eds.,
Source Book of Substance Abuse and Addiction
(Philadelphia: Lippincott, 1996).

Two comprehensive sources of information on the occurrence of mental illness in the general population are
Mental Health: A Report of the Surgeon General
(Rockville, Md.: U.S. Department of Health and Human Services, 1999); Kessler, R. C., et al., “Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: results from the National Comorbidity Survey,”
Archives of General Psychiatry
51 (1994), pp. 8–19.

The estimate of the percentage of problem physicians comes from Marilynn Rosenthal’s review “Promise and reality: professional self-regulation and ‘problem’ colleagues,” in Lens, P., and Van der Wal, G., eds.,
Problem Doctors: A Conspiracy of Silence
(Netherlands: IOS Press, 1997), p. 23.

Marilynn Rosenthal’s book is
The Incompetent Doctor: Behind Closed Doors
(Philadelphia: Open University Press, 1995).

98 Kent Neff presented the data from his work with problem physicians at the Annenberg Conference on Enhancing Patient Safety and Reducing Errors in Health Care, Rancho Mirage, California, 9 November 1998.

FULL MOON FRIDAY THE THIRTEENTH

111 Scanlon, T. J., et al., “Is Friday the 13th bad for your health?”
British Medical Journal
307 (1993), pp. 1584–89.

William Feller’s study of the Nazi bombing of London was published in his book
An Introduction to Probability Theory
(New York: Wiley, 1968).

On Texas sharpshooting, see Rothman, K. J.,
American Journal of Epidemiology
132 (1990), pp. S6–S13.

112 Buckley, N. A., Whyte, I. M., and Dawson, A. H., “There are days . . . and moons: self-poisoning is not lunacy,”
Medical Journal of Australia
159 (1993), pp. 786–89.

113 Guillon, P., Guillon, D., Pierre, F., and Soutoul, J. H., “Les rythmes saisonnier, hebdomadaire et lunaire des naissances,”
Revue Francaise de Gynecologie et d’Obstetrique
11 (1988), pp. 703–8.

The two best summaries on the moon and human behavior are Martin, S. J., Kelly, I. W., and Saklofske, D. H., “Suicide and lunar cycles: a critical review over twenty-eight years,”
Psychological Reports
71 (1992), pp. 787–95; and Byrnes, G., and Kelly, I. W., “Crisis calls and lunar cycles: a twenty-year review,”
Psychological Reports
71 (1992), pp. 779–85.

THE PAIN PERPLEX

118 There is a wide literature on the puzzle of chronic back pain. Among the texts and studies I found useful were Hadler, N.,
Occupational Musculoskeletal Disorders
(Philadelphia: Lippincott Williams and Wilkins, current edition 1999); and Haldeman, S., “Failure of the pathology model to predict back pain,”
Spine
15 (1990), p. 719.

The rather curious findings from back MRIs for people in the general population is from the Cleveland Clinic: Jensen, M. C., et al., “Magnetic Resonance Imaging of the lumbar spine in people without back pain,”
New England Journal of Medicine
331 (1994), pp. 69–73.

119 Hilzenrath, D., “Disability claims rise for doctors,”
Washington Post
, 16 February 1998.

120 Descartes’s description of pain is found in the
Meditations
(1641).

Henry K. Beecher’s studies of battlefield pain were published in two places: “Pain in Men Wounded in Battle,”
Bulletin of the U.S. Army Medical Department
5 (April 1946), pp. 445; and “Relationship of Significance of Wound to Pain Experienced,”
Journal of the American Medical Association
161 (1956), pp. 1609–13.

Ronald Melzack and Patrick Wall’s classic paper describing Gate-Control Theory was “Pain Mechanisms: A New Theory,”
Science
150 (1965), pp. 971–79.

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).

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