PDF | Author-surgeon's book describes the limitations of surgery and Gawande's research interest is in improving surgical care in the US and. We note Gawande's observation that the exer- cise of autonomy means being able to relinquish it. 10 Par- ticipation in shared decision-making is defined as a. COMPLICATIONS: A SURGEON'S NOTES ON AN IMPERFECT SCIENCE. 53 Pages · · KB · Downloads ·English. by Gawande, Atul. Preview.
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Complications: A Surgeon's Notes on an Imperfect Science, by Atul Gawande. Picador, (Page references are to this paperback edition.) Pressed for time. 'Gawande is an accomplished author and doesn't shy away. from hot topics like Complications: A Surgeon's. Notes on an . Size Report. DOWNLOAD PDF. [PDF] Complications: A Surgeon's Notes on an Imperfect Science by Atul Gawande ePub^ Online^. 1. PDF Complications: A Surgeon's Notes.
It was a lot tougher and springier than I thought it would be, so I had to cut twice. He asks: How much input should a patient have? How can young doctors gain hands-on experience without endangering lives? And how responsible are these doctors for their mistakes? The son of two physicians, Gawande attended Oxford on a Rhodes scholarship, then worked in a research laboratory and as an adviser to the Clinton administration on health policy before earning his M.
Soon after, Slate editor Jacob Weisberg, a friend, approached him about writing a column on being a doctor. Gawande had never tried journalism before and struggled with it at first, though he says he enjoyed the process. No Downloads. Views Total views. Actions Shares. Embeds 0 No embeds. No notes for slide. PDF Complications: A Surgeon's Notes on an Imperfect Science 2.
Sometimes in medicine the only way to know what is truly going on in a patient is to operate, to look inside with 3.
This book is exploratory surgery on medicine itself, laying bare a science not in its idealized form but as it actually is -- complicated, perplexing, and profoundly human..
A Surgeon's Notes on an Imperfect Science, click button download in the last page 5. Download or read Aqualeo's The Book of Complications: You just clipped your first slide! Clipping is a handy way to collect important slides you want to go back to later. One, she said. He asked to see the child. No, she said. He asked if her boy had received routine immunizations before today. Had she heard about the polio case in town?
She had. Had she heard about the vaccination team before the workers arrived at the door? She had not. He thanked her and wrote all the information down on a form before moving on. But he was disturbed that no one knew the vaccinators were coming that day.
Without that warning, some people would turn away the vaccinators knocking on their doors. Pankaj asked the vaccinators to open their cold box. He checked the freezer packs inside—still frozen, despite the heat. He inspected the individual vaccine vials—still fresh. There was a gray-and-white target sign on each vial. Did they know what it meant? That the vaccine was still good, they said. What does it look like when the vaccine expires?
The white inside the target turns gray or black, they said.
Right answer. Pankaj moved on. The girl was eighteen months old and silent. The mother, pregnant and with a three-year-old boy clinging to her side, laid her down on her back so that we could examine her. Neither leg would move. Only four weeks had passed since she was stricken.
She almost certainly was still contagious. Pankaj found three children visiting the house. He checked each of their hands. None had received polio drops yet. It was a drab, unpainted, three-room concrete building. About forty years old, with ironed slacks, a buttoned short-sleeve shirt, and the only college education in the area, he seemed eager to have our company.
He offered tea and tried to make small talk. But Pankaj was all business. It is the key to how the operation is organized. Pankaj looked at the map—the villages in the area were spread out over more than ten miles. The other was a rented car. More silence. He did not know. Pankaj went on. Twenty-two teams would require about a hundred ice packs per day, or three hundred ice packs altogether.
Pankaj opened it up and pulled out the thermometer, which revealed that the temperature was above freezing. Pankaj is not a physically imposing man. He has a boyish mop of thick black hair, parted almost down the center, and sometimes it sticks up. He has programed his cell phone to play the James Bond theme when it rings. He makes jokes. He laughs with his head tilted back.
He keeps everyone on edge. Siriguppa is a dense, urbanized town of windowless concreteblock tenements, rusting corrugated-metal lean-tos, and some forty-three thousand people. The two hot cases, we found, were in a small Muslim enclave that had sprouted up a few months earlier. Some of the families seemed suspicious of us, answering questions tersely or trying to avoid us altogether.
We found one boy whom the vaccinators had missed. Pankaj was concerned other children might have been hidden. The previous year, rumors had circulated among Muslims that the Indian government was giving different drops to their male children in order to make them infertile. The rumors were thought to have been quashed by an education campaign and greater Muslim involvement in the immunization program.
But one had to wonder. Later, walking with a local doctor and a vaccination team through a village called Balkundi, we came to the home of a small, pretty woman who had rings on her toes and a baby held loosely on her hip. Another child, a boy of about three, stood nearby, staring at our little crowd.
Neither child had been vaccinated, so Pankaj asked if we could give them the polio drops. She did not appear angry or afraid. Pankaj asked if she knew that a case of polio had appeared in her neighborhood. Yes, she said. She would not say. Pankaj said OK, thanked her for her time, and moved on to the next house. Your children will become paralyzed.
They will die. He walked back and confronted the doctor. But now? And neither will a story going around that we are forcing drops on people. A single nasty rumor could destroy the whole operation. One difficult question came up repeatedly—from local doctors, from villagers, from workers trudging house to house.
The question was: We saw neighborhoods that had had outbreaks of malaria, tuberculosis, cholera. But no one important had come to visit in years. Now one case of polio occurs and the infantry marches in? There are some stock answers. We can do it all, goes one. In reality, though, choices are made.
For that whole week, for instance, doctors in northern Karnataka had all but shut down their primary health clinics in order to carry out the polio vaccination work. Pankaj relies on a somewhat more persuasive line of argument: There was only so much they could do, Pankaj said. So far the campaign has cost three billion dollars worldwide, more than six hundred dollars a case. Even if the campaign succeeds in the eradication of polio, it is entirely possible that more lives would be saved in the future if the money were spent on, say, building proper sewage systems or improving basic health services.
WHO has had to extend its target date for eradication from to to and now is having to extend it again. A certain weariness is bound to settle in. The eradication of smallpox will last as an enduring gift to all who are to come, and now, perhaps, the eradication of polio can, too.
Otherwise, the efforts of the hundreds of thousands of volunteers, and the billions spent will have amounted to nothing—or maybe worse than nothing. To fail at this venture would put into question the very ideal of eradication. Beneath the ideal is the gruelingly unglamorous and uncertain work. If the eradication of polio is our monument, it is a monument to the perfection of performance—to showing what can be achieved by diligent attention to detail coupled with great ambition.
There is a system, and it has eradicated polio in countries with far worse conditions than I was seeing in India—for example, in Bangladesh, in Vietnam, in Rwanda, in Zimbabwe. Polio was eradicated from Angola in the midst of a civil war. In , new mop-ups took place in northern Nigeria, where polio remains endemic and periodically spills into neighboring countries.
During our own mop-up, we covered about a thousand miles in the three days of going town to town. Pankaj worked his mobile phone almost constantly. Four miles outside the village of Balkundi, we came upon a cluster of makeshift shanties for migrant laborers, not seen on any maps.
With some searching, we discovered a few children here and there. Every one of them had received the vaccine, too. Television, radio, and local newspapers had been blanketed with public service announcements. And 4 million of the targeted 4. In , India had just sixty-six new cases of polio. And as India goes, so might the world. Still, there is no denying the dimensions of what Pankaj and his colleagues are up against.
Pankaj says that he has seen more than a thousand cases of polio in his career as a pediatrician.
When we drove through the villages and towns, he could pick out polio victims at a glance. They were everywhere, I began to realize: On the second day of the mop-up, we reached Upparahalla, the village where the Karnataka outbreak had started. But when his mother put him down on his stomach you could see that his legs were withered. With the exercises the nurses had taught her to do with him, he had regained enough movement in his left leg to be able to crawl, but his right leg dragged limply behind him.
She was eighteen months old, with a big, worried face, perfect white teeth, and short, spiky hair. She was wearing small gold earrings and a yellow-and-brown checked dress. Her mother wore an impassive expression as she stood before us in the sun, holding her paralyzed child. The mother said that a health worker had come around with polio drops a few weeks before her daughter became sick.
But she had heard from other villagers that children were getting fevers from the drops. So she refused the vaccination. A look of profound sadness now swept over her. She had not understood, she said, staring down at the ground. Eventually, Pankaj continued onward, checking on the vaccinators going door to door. The road heading out of the village was a red dirt track and we rattled over it with our wheels in the ruts that the bullock carts had made.
Department of Defense provides an online update of American military casualties from the wars in Iraq and Afghanistan. According to this update, as of December 8, , a total of 26, service members had suffered battle injuries. Of these, 2, died; 10, lived but could not return to duty; and 13, were less severely wounded and returned to duty within seventy-two hours.
When U. Both, however, are weak proxies. A key mitigating factor appears to be the trauma care provided: Mortality from gun assaults has fallen from 16 percent in to 5 percent today.
We have seen a similar evolution in war. In World War II, American soldiers were hit with grenades, bombs, shells, and machine guns, yet only 30 percent of the wounded died. By the Korean War, the weaponry was certainly no less terrible, but the mortality rate for combat-injured soldiers fell to 25 percent. Over the next half century, we saw little further progress. Through the Vietnam War with its , combat wounded and 47, combat dead and even the —91 Persian Gulf War with its wounded and dead , mortality rates for the battle injured remained at 24 percent.
The most promising approach was to focus on discovering new treatments and technologies. In the previous century, that was where progress had been found—in the discovery of new anesthetic agents and vascular surgery techniques for World War I soldiers, in the development of better burn treatments, blood transfusion methods, and penicillin for World War II soldiers, in the availability of a broad range of antibiotics for Korean War soldiers.
The United States accordingly invested hundreds of millions of dollars in numerous new possibilities: Few if any of these have yet come to fruition, however, and none were responsible for what we have seen in the current wars in Iraq and Afghanistan: Although more U. Just 10 percent of wounded American soldiers have died. How military medical teams have achieved this is important to think about. They have done it despite having no fundamentally new technologies or treatments since the Persian Gulf War.
And these surgeons and their teams have been up against devastating injuries. The case list for discussion the day I visited included one gunshot wound, one antitank-mine injury, one grenade injury, three rocket-propelled-grenade injuries, four mortar injuries, eight improvised explosive device IED injuries, and seven with no cause of injury noted. The least seriously wounded was a nineteen-year-old who had sustained extensive blast and penetrating injuries to his face and neck from a mine.
Other cases included a soldier with a partial hand amputation; one with a massive blast injury that amputated his right leg at the hip, a through-knee amputation of his left leg, and an open pelvic wound; one with bullet wounds to his left kidney and colon; one with bullet wounds under his arm requiring axillary artery and vein reconstruction; and one with a shattered spleen, a degloving scalp laceration, and a throughand-through tongue laceration.
These are terrible and formidable injuries. Nonetheless, all were saved. George Peoples is a forty-two-year-old surgical oncologist who was my chief resident when I was a surgical intern. He returned after service there only to be sent to Iraq, in March , with ground forces invading from Kuwait through the desert to Baghdad.
He had gone to the U. Anderson Cancer Center in Houston for a cancer surgery fellowship. In , he was assigned to Walter Reed, where he soon became chief of surgical oncology. Peoples was known in training for three things: He was not known, however, for any particular expertise in trauma surgery. His practice at Walter Reed centered on breast surgery. Yet in Iraq, he and his team managed to save historic numbers of wounded. I asked his colleagues, too.
I asked everyone I met who had worked on medical teams in the war. The doctors told me of simple, almost banal changes that produced enormous improvements. One such change involved Kevlar vests, for example. There is nothing new about Kevlar. It has been around since the late s.
Urban police forces began using Kevlar vests in the early s. American troops had them during the Persian Gulf War. But researchers examining wound registries from the Persian Gulf War found that wounded soldiers had been coming in to medical facilities without their Kevlar on.
So orders were handed down holding commanders responsible for ensuring that their soldiers always wore the vests—however much they might complain about how hot or heavy or uncomfortable the vests were. A second, key discovery came in much the same way, by looking more carefully at how the system was performing. And once they got to surgical care, only 3 percent died. Outcomes for the wounded were in danger of getting worse rather than better. The army therefore turned to an approach that had been used in isolated instances going back as far as World War II: These are small teams, consisting of just twenty people: They hold sterile instruments, anesthesia equipment, medicines, drapes, gowns, catheters, and a handheld unit that allows clinicians to measure a complete blood count, electrolytes, or blood gases with a drop of blood.
All of this is ordinary medical equipment. The teams must forgo many technologies normally available to a surgeon, such as angiography and radiography equipment. Orthopedic surgeons, for example, have to detect fractures by feel. But they can go from rolling to having a fully functioning hospital with two operating tables and four ventilator-equipped recovery beds in under sixty minutes.
Peoples led the th FST, which traveled 1, miles with troops during the invasion of Iraq. According to its logs, the unit cared for U. Some days were quiet, others overwhelming. On one day in Nasiriyah, the team received ten critically wounded soldiers, among them one with rightlower-extremity shrapnel injuries; one with gunshot wounds to the stomach, small bowel, and liver; another with gunshot wounds to the gallbladder, liver, and transverse colon; one with shrapnel in the neck, chest, and back; one with a gunshot wound through the rectum; and two with extremity gunshot wounds.
Peoples described to me how radically the new system changed the way he and his team took care of the wounded. On the arrival of the wounded, they carried out the standard Advanced Trauma Life Support protocols that all civilian trauma teams follow. They packed off liver injuries with gauze pads to stop the bleeding, put temporary plastic tubes in bleeding arteries to shunt the blood past the laceration, stapled off perforated bowel, washed out dirty wounds—whatever was necessary to control contamination and stop hemorrhage.
They sought to keep their operations under two hours in length. Then, having stabilized the injuries, they shipped the soldier off—often still anesthetized, on a ventilator, the abdominal wound packed with gauze and left open, bowel loops not yet connected, blood vessels still needing repair—to another team at the next level of care.
These are bed hospitals typically with six operating tables, some specialty surgery services, and radiology and laboratory facilities.
Mobile hospitals as well, they arrive in modular units by air, tractor trailer, or ship and can be fully functional in twenty-four to forty-eight hours.
The maximal length of stay is intended to be three days. Iraqi prisoners and civilians, however, remain in the CSHs through recovery. The system took some getting used to. Gradually, however, surgeons embraced the wisdom of the approach. And the system has worked. One airman I met during my visit to Washington had experienced a mortar attack outside Balad on September 11, , and ended up on a Walter Reed operating table just thirty-six hours later.
He received exploratory abdominal surgery and, because a ruptured colon was found, a colostomy. His abdomen was left open, with a clear plastic covering sewn on.
He was then taken to Landstuhl by an air force critical care transport team. When he arrived in Germany, army surgeons determined that he would require more than thirty days of recovery, if he made it at all. Resuscitation was continued, a quick further washout performed, and then he was sent on to Walter Reed. There, after weeks in intensive care and multiple operations to complete the repairs, he survived. This sequence of care is unprecedented, and so is the result. Injuries like his were unsurvivable in previous wars.
But if mortality is low, the human cost remains high. The airman lost one leg above the knee, the other at the hip, his right hand, and part of his face. How he and others like him will be able to live and function remains an open question.
His abdominal injuries prevented him from being able to lift himself out of bed or into a wheelchair. With only one hand, he could not manage his colostomy. We have never faced having to rehabilitate people with such extensive wounds.
We are only beginning to learn what to do to make a life worth living possible for them. The marines staged a second attack seven months afterward, on November 9. During the two battles for Fallujah, American forces suffered more than 1, casualties in all, the insurgents a still-untold number.
To care for the wounded, fewer than twenty trauma surgeons were in the vicinity; just two neurosurgeons were available in the entire country. Marine and army forward surgical teams received some of the wounded but were quickly overwhelmed.
Others were transported by two-hundred-mile-per-hour Blackhawk medevac helicopters directly to combat support hospitals, about half of them to the 31st CSH in Baghdad. Another of the surgeons I had trained with in Boston, Michael Murphy, was a reservist on duty there at the time. A North Carolina vascular surgeon, he had signed up with the army reserves in June In October, he got a call from central command. The moment he arrived at the 31st CSH—he still had his bags in his hands—Murphy was sent to the operating room to help with a soldier who had shrapnel injuries to the abdomen, both legs missing, and a spouting arterial injury in one arm.
It was the worst injury Murphy had ever seen. The physicians, nurses, and medics took him in like a wet pup. But they made do. Surgeons and emergency physicians saw the worst casualties as they came in. Family physicians, pediatricians, and even ophthalmologists—whoever was available—stabilized the less seriously injured. The surgical teams up in the operating rooms stuck to damage control surgery to keep the soldiers moving off the operating tables.
Once stabilized, the American wounded were evacuated to Landstuhl. One-third of the patients were Iraqi wounded, and they had to stay until beds in Iraqi hospitals were found, if they were civilians or security forces, or until they were recovered enough to go to prison facilities, if they were insurgents.
In the thick of it, Murphy says, he and his colleagues worked for forty-eight hours with little more than half-hour breaks here and there, grabbed some sleep, then worked for forty-eight hours more.
Nonetheless, the military teams managed to keep the overall death rate at just 10 percent. Of 1, American soldiers wounded during the twin battles for Fallujah, the teams saved all but —a stunning accomplishment. Ask a typical American hospital what its death and complications rates for surgery were during the last six months and it cannot tell you.
Few institutions ask their doctors to collect this information. But then I remember those surgeons in Baghdad in the dark hours at their PCs. Knowing their results was so important to them that they skipped sleep to gather the data.
They understood that such vigilance over the details of their own performance—the same kind of vigilance practiced by WHO physicians working to eradicate polio from the world and the Pittsburgh VA hospital units seeking to eliminate hospital infections—offered the only chance to do better. As the war continued, medical teams were forced to confront numerous unanticipated circumstances. The war went on far longer than planned, the volume of wounded soldiers increased, and the nature of the injuries changed.
Surgeons following the trauma logs began to see, for example, a dismayingly high incidence of blinding injuries. Soldiers had been directed to wear eye protection, but they evidently found the issued goggles too ugly. The rate of eye injuries decreased markedly. IEDs often produce a combination of penetrating, blunt, and burn injuries. The shrapnel include not only nails, bolts, and the like but also dirt, clothing, even bone from assailants. Victims of IED attacks can exsanguinate from multiple seemingly small wounds.
A newer bandage impregnated with a material that can clot blood more quickly was distributed. The surgical teams that receive blast injury victims learned to pack all the bleeding sites with gauze before starting abdominal surgery or other interventions. And they began to routinely perform serial operative washouts of wounds to ensure adequate removal of infectious debris. This is not to say military physicians always found solutions. The logs have revealed many problems for which they do not yet have good answers.
Early in the war in Iraq, for example, Kevlar vests proved dramatically effective in preventing torso injuries. Military surgeons used to rely on civilian trauma criteria to guide their choices. Examination of their outcomes, however, revealed that those criteria were not reliable in this war. Possibly because the limb injuries were more extreme or more often combined with injuries to other organs, attempts to salvage limbs by following the criteria frequently failed, resulting in life-threatening blood loss, gangrene, and sepsis.
Surgeons began to see startling rates of pulmonary embolism and lower-extremity blood clots deep venous thrombosis , for example, perhaps because of the severity of the extremity injuries and reliance on long-distance transportation of the wounded.
Initial data showed that 5 percent of the wounded arriving at Walter Reed developed pulmonary emboli, resulting in two deaths. There was no obvious solution. Using anticoagulants—blood thinners—in patients with fresh wounds and in need of multiple procedures seemed unwise.
Mysteriously, injured soldiers from Iraq also brought an epidemic of infections from a multidrug-resistant bacteria called Acinetobacter baumanii.
No such epidemic appeared among soldiers from Afghanistan, and whether the drug resistance was produced by antibiotic use or was already carried in the strains that had colonized troops in Iraq is unknown. The organism infected wounds, prostheses, and catheters in soldiers and spread to at least three other hospital patients. Later, medical evacuees from Iraq were routinely isolated on arrival and screened for the bacteria.
Walter Reed, too, had to launch an effort to get health care personnel to be better about washing hands. These were just the medical challenges. This shift brought increasing numbers of Iraqi civilians seeking care, and there was no overall policy about providing it. Some hospitals refused to treat civilians for fear of suicide bombers hiding among them in order to reach an American target. Others treated Iraqis but found themselves overwhelmed, particularly by pediatric patients, for whom they had limited personnel and few supplies.
Requests were made for additional staff members and resources at all levels. As the medical needs facing the military increased, however, the supply of medical personnel got tighter. Interest in signing up for military duty dropped precipitously. In , according to the army, only fourteen other surgeons besides Murphy joined the reserves.
Many surgeons were put on a second or extended deployment. Planners began to contemplate ordering surgeons to take yet a third deployment.
But the strategy did not succeed. By the middle of , the wars in Iraq and Afghanistan had stretched longer than American involvement in World War II—or in any war without a draft. Nonetheless, they have, at least thus far. At the end of , medical teams were still saving an unbelievable 90 percent of soldiers wounded in battle. Military doctors continued to transform their strategies for the treatment of war casualties.
They did so through a commitment to making a science of performance, rather than waiting for new discoveries. One surgeon deserves particular recognition. On March 20, , outside Fallujah, four days from returning home, the forty-one-year-old surgeon was hit in a rocket-propelled-grenade attack while trying to make a phone call outside his barracks. No doctor has paid a greater price. They are separated by a dark blanketlike screen hung between them. Behind it, the woman is covered from head to foot by her burka.
The two do not talk directly to each other. She has a stomachache, he says. For the purposes of examination, there is a two-inch circle cut in the screen. The boy does. She brings her mouth to the opening, and through it he looks inside. And so the exam goes. Such, apparently, can be the demands of decency.
When I started in my surgical practice, I was not at all clear what my etiquette of examination should be. There are no clear standards in the United States, expectations are murky, and the topic can be fraught with hazards. Physical examination is deeply intimate, and the way a doctor deals with the naked body—particularly when the doctor is male and the patient female—inevitably raises questions of propriety and trust.
No one seems to have discovered the ideal approach. An Iraqi surgeon told me about the customs of physical examination in his home country. He said he feels no hesitation about examining female patients completely when necessary, but because a doctor and a patient of opposite sex cannot be alone together without eyebrows being raised, a family member will always accompany them for the exam. Women do not remove their clothes or change into a gown. Instead, only a small portion of the body is uncovered at any one time.
A nurse, he said, is rarely asked to chaperone: In Caracas, according to a Venezuelan doctor I met, female patients virtually always have a chaperone for a breast or pelvic exam, whether the physician is male or female.
The chaperone, however, must be a medical professional. So the family is sent out of the examination room, and a female nurse brought in. If a chaperone is unavailable or the patient refuses to allow one, the exam is not done. A Ukrainian internist from Kiev told me that she has not heard of doctors there using a chaperone. I had to explain to her what a chaperone was. Both patient and doctor wear their uniforms—the patient a white examining gown, the doctor a white coat.
Last names are always used. There is no effort at informality to muddy the occasion. These practices, she believes, are enough to solidify trust and preclude misinterpretation of the conduct of care.
A doctor, it appears, has a range of options. No attending physician supervising in the room or getting ready to come in; no bustle of emergency room personnel on the other side of a curtain. Just a patient and me. Then the time would come to have a look. There were, I will admit, some inelegant moments. I had an instinctive aversion to examination gowns.
They seem designed to leave patients exposed and cold. I decided to examine my patients while they were in their street clothes, for the sake of dignity. An exam for a breast lump one could manage, in theory: But in practice, it just seemed weird. Even checking pulses could be a problem. Pant legs could not be pushed up high enough to check a femoral pulse. The femoral artery is felt at the crease of the groin. Try pulling them down over shoes, however, and. I asked a female urologist friend of mine whether she had her male patients change into a gown for a genital or rectal examination.
Both of us just have them unzip and drop. I was completely inconsistent about rectal exams. I surveyed my colleagues about what they do and received a variety of answers. Others have a chaperone for breast and pelvic exams but not for rectal exams.
Some do not have a chaperone at all. If the patient prefers to have her sister, boyfriend, or mother stay for the exam, he does not object— but he is under no illusion that a family chaperone offers protection against an accusation of misconduct. Instead, he relies on his reading of a patient to determine whether bringing in a nurse witness would be wise.
One of our residents, who was trained partly in London, said he found the selectivity here strange. But in the emergency room here, when I asked to have a nurse come in when I needed to do a rectal exam or check groin nodes on a woman, they thought I was crazy. The chaperone should be a female member of the medical team, and her name should be recorded in the notes. If the patient refuses a chaperone and the examination is not urgent, it is supposed to be deferred until it can be performed by a female physician.
In the United States, where we have no such guidelines, our patients have little idea of what to expect from us. To be sure, some minimal standards have been established. Any patient can be led to wonder: Did the doctor really need to touch me there?