Carl Shuker’s books are bound by place and demarcated by time. Whether he is writing about turn-of-the-century Tokyo, middle-class New Zealand and the age when we transition from children to adults, or Lebanon in the Arab Spring, Shuker finds the story to tell. In his most recent novel, A Mistake, Shuker pits his protagonist, Elizabeth Taylor, a gifted surgeon, against large-scale changes in the New Zealand health care system and long-standing sexism. Elizabeth is a formidable opponent who may just be able to survive this turbulent environment—until the death of one of her patients. When the media and the family enter the battlefield, Shuker reminds us that there are always larger forces at work as we try to make our way in the world.

Carl Shuker is the author of Method Actors, which won the 2006 Prize in Modern Letters, The Lazy Boys, which is currently being developed into a major motion picture, and Anti Lebanon. A Mistake is his fourth novel.

Please See Me: A Mistake has an interesting structure where you have interwoven paragraphs describing the US Space Shuttle Challenger disaster with the world of your protagonist, Elizabeth Taylor, a renowned surgeon, whose young patient Lisa Williams dies after surgery. Can you talk about your inspiration for this structure?

Carl Shuker: I’ve been fascinated by the Challenger disaster since I was a boy and watched it happen on TV. The fact that this gigantic disaster on the hugest scale came down to a few degrees and a tiny strip of rubber had a huge resonance for me, particularly in how this might be represented in a person. The single flaw in a person that derails everything—and whether and how we recognize that and address it in ourselves, or use it (or mistakenly inflate its importance). For Elizabeth it might be her undeveloped ability to be with people, to charm them, make herself likeable and approachable, to play politics. In some people that’s seen as a strength, but because she is a woman it’s often not.

So tracking the process of the Challenger’s breakup over the Atlantic Ocean, all stemming from this tiny flaw in an 8-mm piece of rubber, the implications of which are amplified by context—politics, pressure to launch, the matter of a tiny change in temperature—was an obvious correlative to Elizabeth’s story. I made it intrinsic to the narrative because the story is Elizabeth’s obsession, she teaches it to students, it is verging on her own insight into her tragic flaw.

PSM: Elizabeth is a complicated character, curt and reserved, as well as a complex feminist. She often speaks her mind and is unapologetic. She will, at times, take up the flag, but she doesn’t advise other women to follow her lead. Why structure her character this way?

CS: Elizabeth is a survivor, and she has survived in surgery by developing what might or might not be viewed as some problematic strategies. In the service of her patients she is demanding, perfectionist, dedicated. She is intolerant of failure, fools and half-measures. In life these traits can be hard to deal with. She is also very individualistic. So her feminism is fairly unreconstructed—it is more of an expectation of others that they measure up, and perhaps an expectation that they will. Toward the end of the book I give her a small foray toward supporting another woman who negotiates a routine bit of sexual harassment—routine for women in health, and many other fields. She’s not good at it, but the implication is she might get better.

In answer to your question why, though, the answer would be that this is the more interesting story to me. The story of a successful professional woman with a large web of protégées and connections—and thus a support network—who is undermined professionally via a mistake is quite a different novel to me. I like how Elizabeth—or the narrator over her shoulder, at least—puts it in the book, in the particular context she is in, the beach she has been asked to surf: “Women surgeons usually found two ways to be: they became men or they became something else entirely.”

PSM: Elizabeth is one of the few female surgeons in New Zealand and sexism plays a huge part in the fallout from the death of her patient. Is this type of blatant sexism a true phenomenon and is your novel a way to help identify and address it?

CS: Every book needs an irritant, which is another word for a conflict—a danger, an instability that makes us curious. It’s this tension—often between two incompatible ideas—that both interests us as readers but also that drives me and keeps me interested as a writer. How do I solve this problem I don’t know the answer to? How do I link these two unlinkable things? The novel itself becomes that bridge.

I started this book out with a male surgeon, you know the type—competent, strong, individualistic, a type A personality. The idea would be that after a mistake he would find himself an outlier on this soon-to-be published mortality data. I was almost instantly bored. I looked around myself at my place of work and realized I was surrounded by incredibly competent, hardworking, brilliant women coping and excelling in a sexist system aligned—historically and structurally—against them. Women were running health care but often they weren’t running it, in terms of leadership roles. So as soon as I had that hook—a brilliant woman surgeon (modeled on a woman I knew) who defined herself by her success in a masculine field with all the complex adaptations that have gone along with that, but is suddenly told she’s not as good as she thinks she is—I got very interested.

The sexism is real and it varies by specialty and location—each silo of medicine has a different culture. Surgery has historically been particularly bad, as the case of Caroline Tan and Chris Xenos illustrates.

In 2015, the Royal Australasian College of Surgeons published a report on discrimination, bullying and sexual harassment in surgery. Nearly half of all fellows, trainees and international medical graduates reported being subjected to discrimination, bullying or sexual harassment. Also, 71 percent of hospitals reported discrimination, bullying or sexual harassment by a surgeon in their hospital in the past five years, with bullying the most frequently reported issue. The report says explicitly, “Bullying is endemic in surgery; common in training and the surgical workplace; and central to the culture of surgery.”

But the point is not just the prevalence of this kind of behavior. In the case of Caroline Tan the years-long process of fighting for vindication and justice derailed her career and brought her life to a standstill.

Dr. Gabrielle McMullin bravely illustrated this by saying publicly, in a satirical thought experiment a lot of people willfully misunderstood: “What I tell my trainees is that if you are approached for sex, probably the safest thing to do in terms of your career is to comply with the request.” What she was really signaling was that the process of addressing this kind of behavior has been so grueling, undermining and unrewarding for people affected that they might in fact be better off not fighting it. Which is obviously wrong and absurd, and which is her point that a lot of people intentionally missed.

PSM: Medical care, preference for certain types of health systems, and recommended practices have gone international. In A Mistake there is a lot of discussion about the US and UK health care systems versus the health care in New Zealand. Is this globalization and standardizing of medicine a trend you noticed working for the British Medical Journal?

CS: I think what I’ve noticed lately is countries coming to the limits of standardization. The classic example is of the use of a “bundle” of care practices to reduce life-threatening infections from “central lines” inserted with the best possible intentions into patients in ICUs. Peter Pronovost was made a MacArthur Fellow and one of Time’s top 100 people of the year for showing that doing five things right, all the time, could eliminate these infections, and save thousands of lives. Half the world set about replicating these results, then trying to apply this bundle approach to other big problems of harm to patients.

But the general sense now seems to be the low-hanging fruit have been plucked and we’re left with the “wicked” problems of health care that are very complex and usually unique and responsive to the contexts they’re found in.

Right now in New Zealand we’ve engaging strongly with the massive inequity in health outcomes for Māori, New Zealand’s indigenous people. Not just outcomes though—lower quality of care. Though some of the causes will be the same—entrenched, institutionalized racism with deep historical foundations, for example—how we address this might be very difficult or downright impossible to replicate in Canada, the US, or Australia. For one, our government signed the Treaty of Waitangi with Māori tribal representatives in 1840, and that treaty guaranteed Māori equal rights under the law to the new European arrivals. That includes equal rights to health. A possible foundation from which to work, but one that doesn’t apply elsewhere.

PSM: Journalists and journalism are viewed poorly by the doctors in your book. You write, “Nothing a journalist loves more than a bloodied-up surgeon.” With all of the avenues now available for publication, what do you think the role of medical journalism or medical narrative is?

CS: I was careful to attribute that phrase to a UK émigré! In the UK there’s a rampant tabloid culture that is far more powerful than it ought to be—so powerful it can create the context for public inquiries to occur.

But there’s terrible journalism with zombie statistics trotted out year after year, and there’s deep, investigative journalism that’s intelligent and strategic. The latter is what brought transparency around health care data and outcomes onto the radar in New Zealand and there are great examples of it. Off the top of my head right now, much of Atul Gawande’s work, Ben Goldacre’s Bad Pharma, Maya Dusenbery’s Doing Harm and Ella Gabler’s investigations for the New York Times into a buried scandal in pediatric cardiac surgery at the UNC Children’s Hospital in North Carolina. We are lucky to have the latter work but it’s hard and long and expensive and sometimes it’s the former—the oversimplifications and the willfully inflammatory—that generates the most clicks.

PSM: Your novel takes a dim view of the sensational side of media. “The story five down from the top was from a website she didn’t recognize. ‘Angel of Death surgeon played death metal in botched op that killed our Lisa’. There were half a dozen blatant factual errors and five photographs threaded through the story.” Was this type of misreporting modeled after a real-life case?

CS: I was definitely drawing on UK-style tabloid reporting here—the personal op-ed attempting to illustrate or illuminate larger issues has become a very popular form. There are dozens of examples. What is not further explored is that there is some pathos here—the article is an attempt by the boyfriend of the dead woman to get some attention for her case in a clogged and slow system that protects itself. He is desperately looking for justice where it might not be possible to be found.

PSM: One of the major themes in A Mistake is the political nature of medicine. In the novel, New Zealand is at the inception of a major change in medical reporting, the reporting of the surgical numbers—specifically the number of deaths—like a batting average. Can you talk more about why you wanted to cover this theme and how that relates to the pressure that doctors and surgeons are already under?

CS: No one ever got fired for calling for more transparency. I’m fascinated by the debate around publishing the numbers of operations surgeons do, and publishing their individual mortality and complications rates. Partly because the right answer—what to do to be “transparent”—remains so uncertain.

In the UK they’ve produced a scheme where rates are shown on a website but usage numbers are very low. In the US there’s a huge number of different schemes but then again there’s a market-based approach to health care that doesn’t square with the UK, or New Zealand, where we are slowly trying to come up with something sensible and appropriate to how things are set up here.

To be brief, though—scandals lead to calls for transparency, and for some reason (probably the history of quite effective transparency around cardiac bypass graft mortality in New York state) transparency seems to start with surgeons and their death rates. Doctors and surgeons are often rightly concerned that publishing their death rates may make the most experienced doctors trusted with the sickest patients look appalling compared to their peers. Does it drive better results? The jury’s out on care in general but in select specialties and situations the answer is sometimes unequivocally yes. Mortality for cardiac bypass grafting in New York state dropped 41% after public reporting of named surgeons’ results. People find it hard to ignore or dismiss such results when typically fine margins are everything.

PSM: The idea of transparency comes up often as it relates to the medical field, specifically in the way that doctors and colleges and big health care should be as transparent as other industries, like the airlines. What do you think drives the public perception behind the lack of transparency?

CS: Well for one the lack of transparency around health care is very real. Every country’s health system sits inside a society’s social contract, so that for most people the idiosyncrasies of that system are almost invisible. In New Zealand, in the absence of a market economy for health care, and with a public hospital system provided by government free of cost to the patient but absent choice of physician, we rely largely on trust—trust that our doctors and surgeons are competent.

In part this stems from the fact that the majority in fact are, and much more than just competent. But in part it stems from the history of medicine not only in New Zealand but in the UK, which we inherited—a history characterized by a massive imbalance of power, information, and agency between patient and doctor. It is a history of self-regulation and a shop closed to the public that has only recently been challenged or, if only slightly and variably, undermined.

PSM: A Mistake tackles the idea of class, not only with regard to the patient care, but within the medical community itself: rank and file surgeons, doctors, and other medical staff, and even whether they work at public or private institutions. What made you what to tackle that issue?

CS: I had to make sure the novel felt real and it felt real by drawing on the real. Health care is intensely political, sometimes class-based, very hierarchical and competitive. It is so by virtue of the people drawn to practice it. It’s also huge. As a percentage of GDP it’s like a major state of the US. And I think for me the three-part combination of the intensity and complexity of the internal relations and politics, the simple and profound outcomes for people—for patients—and the essential guiding altruism at the heart of the whole enterprise is an incredibly fascinating dynamic. At its core health care is idealistic and the ideals sustain it. But people are people and ideals can drift and corrupt once exposed to time and complexity.

Avedis Donabedian, father of health care quality measurement, once said an amazing thing and I’d like to quote it at length:

“Health care is a sacred mission. It is a moral enterprise and a scientific enterprise but not fundamentally a commercial one. We are not selling a product. We don’t have a consumer who understands everything and makes rational choices—and I include myself here. Doctors and nurses are stewards of something precious. Their work is a kind of vocation rather than simply a job; commercial values don’t really capture what they do for patients and for society as a whole. Systems awareness and systems design are important for health professionals but are not enough[…]. It is the ethical dimension of individuals that is essential to a system’s success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system.”

A. M. Larks is the fiction editor of Please See Me.