We want contradictory things from medical professionals. At or near the top of the list are competence and compassion. These characteristics are not mutually exclusive, of course, but they can conflict. You want a surgeon, for example, who can slice through skin, muscle, and bone without flinching or hesitating, someone not distracted by the raw physicality of what is being done to another human being. During pre-surgical consulting, and during aftercare, however, sound medical reasons exist for wanting someone with a generous measure of sympathy and sensitivity.
In Better: A Surgeon’s Notes on Performance, Atul Gawande examines both the utilitarian and the human sides of medical practice. In 11 chapters, most previously published in either The New Yorker (where Gawande is a staff writer) or the New England Journal of Medicine, he examines what goes right in American medical care, what goes wrong, how things either succeed or fail, and what might be done to improve the system.
The book is divided into three sections: “Diligence,” “Doing Right,” and “Ingenuity.” The first section chronicles a number of areas in which attention to fundamentals — such as how consistently caregivers wash their hands — impacts the success of medical interventions. The second examines issues related to the ethical obligations and quandaries which physicians face. The third examines some of the avenues via which patient outcomes can be improved.
The Surgeon as Anthropologist
Gawande’s use of language is consistently crisp. At times, he does an excellent job of putting us “behind the surgeon’s eyes,” making clear the appeal of his craft, illuminating medical procedures for the reader in graphic language that has an odd and touching poetry to it. He describes a Caesarian section for example, as “among the strangest operations I have seen,” writing in part: “You cut through the peritoneum, a thin, almost translucent membrane. And the uterus — plum-colored, thick, and muscular — gapes into view. You make a small, initial opening in the uterus with the scalpel, and then you switch to bandage scissors to open it more swiftly and easily. It’s as if you’re cutting open a tough, leathery fruit.” That facility with language, however, is only one facet of what makes Better an interesting and worthwhile work.
Better is Gawande’s second book. His first, Complications, came out in 2002 and was a finalist for the National Book Award. Even an abbreviated list of his credentials and accomplishments is impressive: He is a surgeon at the Brigham and Women’s Hospital in Boston, Mass., an assistant professor at Harvard Medical School, from which he received both an MD and an MPH, and a 2006 MacArthur Fellow. As a Stanford undergraduate, he was a Rhodes Scholar and studied at Oxford.
The more mundane facts of his biography may tell us just as much — or more — about the influences that formed him, both as a physician and as a writer. Born in Brooklyn, the child of Indian immigrants — his father a urologist, his mother a pediatrician — Gawande grew up in southern Ohio and medicine was “the family business,” something with which he was in regular contact, sometimes casual, sometimes intimate. It was also something against which he rebelled as a child: He didn’t want to be a doctor, he wanted to be a rock star.
Arguably, that lifelong contact with medicine –- as profession, as business, as way of life –-expands the number of angles from which he can view things. Gawande’s status as a first-generation American –- he refers to India as his ancestral home and focuses two sections of the book on medical issues in that country –- may further sharpen his powers of observation. He doesn’t take things for granted; he sees both the forest and the trees.
Doing More with Less
One of the case studies he relates in the section on diligence is of a polio “mop up” operation in the southern Indian state of Karnataka, in 2003. Globally, progress against polio has been impressive. “In 1988,” Gawande writes, “more than 350,000 people developed paralytic polio, and at least 70 million were infected with the virus. By 2001, only 498 cases were identified.”
Still, periodic flare-ups in Asia and Africa threaten this progress. When they happen, the World Health Organization helps coordinate the response, using local government resources. Working in concentric circles around an outbreak, they need to re-immunize 90% or better of all children under the age of five. In Karnataka, this meant employing “thirty seven thousand vaccinators and four thousand health care supervisors, rent[ing] two thousand vehicles, [supplying] more than eighteen thousand insulated vaccine carriers, and [having] the workers go door to door to vaccinate 4.2 million children. In three days.”
We follow a variety of Indian healthcare workers as they pursue this goal, watching over Gawande’s shoulder, as it were. He notes both the shortfalls of the medical infrastructure in India and the strong points, what the doctors have to work with and what they accomplish, what works and what doesn’t. Ultimately, he tells us, they were able to vaccinate 4 million of the children, a success rate of better than 95%.
Doing What Works and Doing It Consistently
A lot of what Gawande writes amounts to systems analysis; Total Quality Management (TQM) comes to mind. That analogy holds in a number of circumstances where he points out that the road to improvement is something strikingly similar to quality circles: actually asking the people involved in a system how they think it might be improved, rather than dictating to them what is to be done. But he consistently points out as well the ways in which human foibles impact system functioning.
In looking at advances in treating wounded soldiers, and reducing the physical damage wrought by war, for example, he points to studies of the wound registries during the Persian Gulf War. The data clearly show that body armor does an excellent job of protecting vital organs and saving lives. But a large percentage of soldiers didn’t wear their Kevlar vests. “So orders were handed down holding commanders responsible for ensuring that their soldiers always wore the vests,” Gawande writes, “however much they might complain about how hot or heavy or uncomfortable the vests were. Once the soldiers began wearing them more consistently, the percentage killed on the battlefield dropped instantly.”
In some ways more interesting is a similar anecdote he relates from the current Iraq War. As the use of Improvised Explosive Devices (IEDs) went up, so did the percentage of U.S. troops suffering blinding injuries. They had been issued eye protection, but, as with the vests, did not employ it consistently. The obstacle this time, however, was not comfort but fashion. He quotes one soldier as saying, “They [the eyewear they were issued] look like something a Florida senior citizen would wear.” Gawande writes: “So the military bowed to fashion and issued cooler looking Wiley ballistic eyewear. The rate of eye injuries decreased markedly.”
Freedom of Information
That emphasis on following the data, to trace cause and effect, to see what works and what doesn’t, is a recurring theme through much of the book. Both diligent and ingenious physicians, he shows us in the first and last sections, pay attention to what works. It’s one of those simple truisms: Successful people, in any field of endeavor, do what works. Very successful people are often what he refers to as “positive deviants.” They do what works above and beyond currently accepted practice.
In the middle section, Gawande focuses on transparency, emphasizing how counter-productive suppressing information is when things go wrong. It impedes the medical profession from learning as quickly as it might how to avoid tragic errors. It also has an unfortunate chilling effect on the doctor/patient relationship.
“Here’s where we in medicine have failed,” he says, with characteristic bluntness and a welcome use of the personal pronoun. “When something bad happens in the course of care and a patient and family want to know whether it was unavoidable or due to a terrible mistake, where are they to turn? Most people turn first to the doctors involved. Doctors have an ethical responsibility to tell patients when an error has harmed them. But what if they aren’t responsive — what if they seem to be worrying more about a lawsuit than about the patient — or what if their explanation doesn’t sound quite right? People often call an attorney just to get help in finding out what happened.”
Changing Doctors, Changing Outcomes
The book ends with a section adapted from a lecture which Gawande gave to a class of medical students. In it, he expounds on a list of five suggestions “for how one might make a worthy difference, for how one might become, in other words, a positive deviant.”
The points that he makes reinforce the core contradiction around which much of the book spins. Improving medical care is a matter of improving systems, of diligence, of efficiency, of learning basic lessons and applying them without fail. Just as important, however, he stresses the human dimension, for doctors as much as for patients.
Here are just the final two suggestions he gives. The fourth one is “write something,” a suggestion understandably congenial to a writer. “By soliciting modest contributions from the many,” he argues, “we have produced a store of collective know-how with far greater power than any individual could have achieved.” Thus we improve the system.
But he adds, on a personal note, “Writing lets you step back and think through a problem. Even the angriest rant forces the writer to achieve a degree of thoughtfulness.” Thus we improve ourselves.
The fifth suggestion is simple: Change. “I am not saying you should embrace every new trend that comes along,” Gawande cautions. “But be willing to recognize the inadequacies in what you do and to seek out solutions. As successful as medicine is, it remains replete with uncertainties and failure. This is what makes it human, at times painful, and also so worthwhile.” As true as that might be in medicine, it applies to so much else in human endeavors.