Surgeon’s Notes on an Imperfect War
The Walter Reed scandal has made headlines. Fingers have been pointed, blame has been assessed, and people have been fired. Having recently read his book Complications: A Surgeon’s Notes on an Imperfect Science, I found myself wondering how Atul Gawande might consider this situation.
Gawande’s book describes the challenges faced by medical professionals ranging from human fallibility to uncertainty. Gawande examines the realities of the medical profession compared with the expectations demanded of it. People demand perfection from their doctors, but mistakes are unavoidable. For instance, while most people would prefer that an experienced surgeon perform their surgery over a resident, if the resident is not allowed to perform surgery (under the guidance of an experienced surgeon, of course), how does one produce an experienced surgeon? Gawande is not satisfied with simply accepting mistakes, and through case studies and research, his book explores how surgeons have and might reduce the fraction of mistakes that occur. Gawande’s modest writing style leaves out his own contributions to improve surgical safety, one of the reasons cited when he was awarded a MacArthur Fellowship.
So what would Gawande have to say about Walter Reed? Back in 2004, Gawande discussed medical response in the Iraq War in the New England Journal of Medicine. Gawande does not hide from the problems. He notes:
As the medical needs facing the military have increased, however, the supply of medical personnel has gotten tighter. Many surgeons have been on a second deployment or an extended deployment, and even this has not been sufficient.
Unlike recent articles published about Walter Reed, however, Gawande does not play off of human emotion. The article outlines the measures the military medical system has taken and gives details as to how it operates. Given the data available at the time, Gawande found that treatment and care appeared to have improved since the first Perisan Gulf War despite increased constraints. Near the end of his article, Gawande writes:
The nation’s military surgical teams are under tremendous pressure, but they have performed remarkably in this war. They have transformed the strategy for the treatment of war casualties. They have saved the lives of an unprecedented 90 percent of the soldiers wounded in battle. And they have done so under extraordinarily difficult conditions and with heroic personal sacrifices.
It’s possible treatment may have deteriorated since 2004, and those outraged by the conditions reported in Walter Reed have every right to be. However, a rush to finger pointing that ignores the constraints on resources, budget, and personnel in the face of increased casualties and does not consider concrete ways to address these issues might obscure a solution that improves the medical care we want our soldiers to have.