What the doctor ordered

Lunch With BS

As I search for Dr Atul Gawande among the marigold garlands and wedding guests, both to be found in profusion at the Ahuja Residency, I reflect that he might actually have been easier to locate in the swirl of humanity at the All India Institute of Medical Sciences (AIIMS).

He shows up in the nick of time, just before a woman clad in a sky-blue silk sari takes me off to meet the bride's sister, and his presence rescues me from becoming a small molecular part of the great Ahuja Residency Wedding, for which I am very grateful.

Atul Gawande looks younger than you'd expect of a surgeon who's at present at the Harvard Medical School at the Centre for Improving Surgery and Public Health, who writes for The New Yorker, and whose book, Complications, was warmly received by the literary world last year.

"The writings of Atul Gawande convey the quiet assurance and tone of the doctor acting as both observer and participant," said the New York Review of Books, while Time called him "the writer with a scalpel pen and an X-ray eye".

Complications, subtitled "Notes from the life of a young surgeon", grew out of a series of articles Gawande had written for The New Yorker and Slate.

"The book's title comes not just from the unexpected turns that can result in medicine but also, and more fundamentally, from my concern with the larger uncertainties and dilemmas that underlie what we do. This is the medicine that one cannot find explained in textbooks but that has puzzled me, sometimes troubled me, sometimes amazed me, as I've joined the profession's ranks."

Some of his case studies are downright bizarre "" Tales from the Surgeon's Crypt, if you like, as he unfolds the mysteries of flesh-eating bacteria, tells you all about the TV newsreader who couldn't stop blushing and the man who couldn't stop eating.

But these are the frills: Complications is really about the ethics that govern the last profession on earth from which we demand infallibility, it is about the fact that doctors mess up just as often as other humans do and it is about the changing role of the patient.

As we head for Swagath, the comfortable South Indian restaurant in the Defence Colony market that offers more than the usual idli-dosa routine, Gawande explains that his present stint with AIIMS counts as his first "non-touristy" trip to India.

His parents, also doctors, emigrated from India and lived in Ohio, where he grew up. And previous visits to India have been on the usual Agra-Jaipur circuit. AIIMS, the hospital that looks more like a micro-city within Delhi, threw him initially and exploded a few myths.

On his first day, he says, he looked at the crowds of patients and decided he was in the middle of a classic public health nightmare "" it didn't seem possible that all their needs would be met. After a few days, he realised that as improbable as it seemed, AIIMS did work, even if it turned waiting rooms into veritable triage areas.

Gawande had come here with an open mind, and instead of the knee-jerk reflex that many have when exposed to the scale of chaos in India, he saw AIIMS as an illustration of private versus public systems at work rather than Third World inefficiency.

"Private health care in India provides all the conveniences that the middle class who come to AIIMS are denied; AIIMS patients must put up with lines that crawl and the lack of privacy, but they get the doctors, they receive the treatment they need."

For him, one statistic in particular illustrates the far wider gap between the US and India. As we order what will turn out to be far too much food "" prawns in butter garlic, appams and vegetable stew for me, surmai gassi, Malabar parathas, vegetable pulao for him "" he explains. "Fifteen per cent of the US economy is health care oriented "" in India the figure's under 2 per cent."

This opens up one of his key areas of interest, as he levels his scrutiny at the differences in the public health systems of both countries. Gawande arrived at his specialisation through a curious and circuitous route.

Stanford opened up worlds he'd never dreamed of while he was in the relative backwaters of Ohio; Oxford, where he read for a PPE (Political Science, Philosophy and Economics), enlarged his horizons even more.

"I saw the possibilities in the world open up; I met people who were confident enough to assume that they would find endless possibilities within themselves." He briefly contemplated doing a PhD in philosophy, but backed off: "It was all I could do to understand the questions, let alone go looking for the answers."

That early interest in ethics is perhaps what allows Gawande to explore the present-day ramifications of the Hippocratic oath, placing his stethoscope on the body medical and looking for questions, even ones to which neither he nor the medical community has the answer.

In the essay that opens Complications, "Education of a Knife", Gawande drily expands on the length of time that it took him to learn how to insert a simple IV line, a procedure that took endless hours of practice, where patients rather than, say, oranges, would inevitably suffer from his newbie ineptitude.

"This is the uncomfortable truth about teaching," he writes. "By traditional ethics and public insistence..., a patient's right to the best care possible must trump the objective of training novices. We want perfection without practice. Yet everyone is harmed if no one is trained for the future. So learning is hidden, behind drapes and anaesthesia and the elisions of language."

The food is excellent, but we have both exhausted our appetites faster than the embarrassment of riches before us. The discussion swerves from the public to the private, again; in addition to his stint at AIIMS, Gawande is here to pursue a more private quest. He'll be going back to his father's village in Maharashtra, a dot on the map called Uti, where his father's story began and so, by extension, did his own.

"He grew up in this village in eastern Maharashtra, and when he was a 10-year-old, decided that he wanted to be a doctor. He has no idea why; he can't remember a conscious chain of thought, he just knew that he wanted to be a doctor, and that in order to do this, he needed to go to school."

At the age of 10, Gawande's father moved to the slightly larger village that had a school, where a married sister took him in. He became only the second person from his college to go to the US for further medical training.

"He met my mother, who was from Ahmedabad originally, in New York; she's a paediatrician. They eventually got married and settled in Ohio." The gaps in the story, the silences, hang behind his bald words; perhaps his trip, part pilgrimage, part wary journey, will put some flesh on its bare bones.

Over coffee, we're discussing life after Complications "" Gawande has no intention of writing the same book twice, but isn't sure what the subject of his next book will be. He pulls out his Palm Pilot.

From where I'm sitting, it looks incongruous; it's silhouetted against the waving legs of crabs being presented for selection to diners at the next table. He maintains a list of ideas on the gadget that might turn into New Yorker stories, or even into his next book.

"Fear of Technology... this needs more work, but it's there because I don't know what I think about it." "International Disaster Management." I like his final idea. "The Science of Itching," he announces deadpan. "(And Yawning Too)."