Gawande, Atul, Better: A Surgeon’s Notes on Performance
Several years ago, Dr. Gawande published a best-selling book on his experiences as a young surgeon called Complications: A Surgeon’s Notes on an Imperfect Science
Notably, he’s a rare voice of humility amongst his profession in reflecting on the day-to-day practice of medicine. Not just on the larger issues of “what we don’t know” or “what we can’t do” but on the oft-overlooked issues of “what we do poorly, every day, merely out of habit.” That honesty adds particular strength to his writing. In his latest book, he’s assembled his essay-chapters into three larger themes (diligence, doing right, ingenuity) all tied around his reflections on how he wants to improve his own practice as a doctor.
The results are fascinating. As befits a writer for the New Yorker, Gawande makes good use of anecdote and the background research for each topic covered. He writes well and writes for a general audience. A few months ago I listened to a podcast interview with the author and he mentioned that it’s a real struggle for him to get writing done because of his professional obligations. To some extent, that time limitation is reflected in this book. The subject area, improving individual doctor performance, could cover a lot of ground. Gawande doesn’t pretend to do so exhaustively. Instead, we have a series of vignettes on the limitations and successes of medical practice. For any reader interested in a particular chapter’s topic, the results are excellent. Those interested in the “gaps” between chapters may need to head for the academic literature and something closer to a textbook. More’s the pity.
Diligence
In his opening section on Diligence, Gawande looks at three topics — hand-washing in hospitals, the control of polio in India, and the treatment of American battlefield casualties in Iraq.
In the first essay, he outlines the ongoing challenge controlling hospital infections (often by antibiotic-resistant bacteria). Even after ambitious changes to infrastructure by full-time infection control staff, infection rates can stay frustratingly high. Gawande does a tour of his own hospital with the infection control specialist, reviews the few-and-far-between examples of hospitals that have done better, and considers his own responsibility for transmitting infection to his patients. In this area, medicine is barely getting a “pass.”
Traveling with a doctor from WHO in India, Gawande writes his second essay on the identification and “ring” or “saturation” vaccination control of polio. When a new case is spotted, all the children in the surrounding area are vaccinated and then re-vaccinated. In a nation like India, it can involve millions of kids, and thousands of health care workers, and every dose of oral vaccine must be kept refrigerated. The logistics are staggering. A disease that all but disappeared a decade or so back, thanks to heroic efforts and the financial contribution from governments and service clubs like Rotary International, polio’s now making sporadic reappearance in the Third World, often associated with local insistence that the vaccines are dangerous to children. Most impressively, in this essay the author describes the careful saturation of towns and villages around reported cases. Fitting into his larger theme, Gawande describes the methodical unrelenting focus of WHO on vaccinating every single child. Every effort to approach perfection in the vaccination program reduces infection rates just a bit. But the implications of letting polio back out its “cage,” to a world filled with un-vaccinated kids, are too horrible to contemplate.
In Gawande’s final essay on diligence, he travels to Iraq and looks at the pattern of casualties and deaths on the modern American battlefield. By any calculation, American soldiers now have the lowest rates of injury and death in comparison to earlier wars. The addition of medical technology, body armour, and ballistic eyewear have reduced the severity and lethality of injuries dramatically. What has made the biggest difference, however, is an entirely new method of handling casualties. Gawande discovered that injured soldiers were subject to immediate medical care, and just as quickly they might be evacuated to regional or European medical centres with wounds still un-stitched, limbs uncasted. The discovery that lives could be saved by a shift in patient handling was a statistical effort by overworked doctors in dusty compounds all over Iraq. By focusing on what offered incremental improvement in survival, doctors and nurses in the US Army brought death rates down to unprecedented levels. No other military in the world can match that system. Indeed, one wonders if any other army would even have discovered the approach … since it was a bottom-up effort by medical staff. Gawande goes on to consider briefly the flip-side of all this improved medical care: the survival of soldiers with truly devastating injuries. Innovation in battlefield health care will now have to be matched with new breakthroughs in rehabilitation.
Doing Right
Gawande’s second theme is “doing right” … the effort to place medical care and scientific knowledge in the context of people’s lives. His topics are “nakedness” in the examining room, medical malpractice, physician fees and incomes, medical involvement in US death sentences, and when to halt medical treatment.
The essay on “Nakedness” is a reflection on the perils and practicalities of patient examinations, both in other cultures and that of urban America. Some locations are much more concerned about chaperons and propriety than the US, others are much less so. What is clear is that the US does not have clear professional guidelines on the issue that might alleviate concern for physicians and patients alike. More to the point, investigating the question of what standards might work best in a diverse society like America hasn’t been anyone’s priority.
In a second essay, Dr. Gawande looks at medical mistakes and medical realities, introduced through a years-long court case brought against a dermatologist sued by descendants of a skin cancer victim. The doctor had recommended surgery of a growth to a woman. A second opinion suggested it wasn’t needed, and she was upset with the first doctor. Years later, the patient developed skin cancer and felt the original doctor should have insisted on surgical excision over her objections. She instructed her surviving family to sue.
The impact on doctors of such court proceedings, justified or not, and the story of a doctor who left his practice to become a malpractice lawyer help the author to frame the discussion about what is fair and reasonable in a medical practice fraught with risk and uncertainty. It becomes clear that the current adversarial system works poorly. Doctors are resigned to be all being sued at some point in their career, and their malpractice insurance is priced accordingly. Lawyers, on the other hand, are looking for “phone number” (seven digit) settlement cases which means that unappealing complainants and modestly impaired patients need not apply. Where harm is done, it may not be substantial enough or saleable enough to warrant lawyerly attention. Other jurisdictions have gone with no-fault or liability set-asides for medical malpractice or vaccine side-effects. These solutions, which share risk and liability across a society, seem to provide a better balance for remediating the inherent limitations of medicine, practiced by fallible humans.
After completing his residency, Gawande had the interesting experience of being asked to “name his price” for a flat salary at his hospital for his first three years as a board-certified practitioner. He was given no guidance on salary range. His fellow practitioners would not discuss what they were paid. And the institution would not disclose that salary information either. At the end of the three years of salary, he’d start to be compensated as a percentage of his billed services. This unsettling process, after years earning very modest income as a resident doctor, became the basis for the author’s broader essay on how doctors are compensated … and how uncomfortable they are about talking about their compensation. As students and residents, they clearly work long hours and receive relatively dismal pay. As more senior physicians, their income (adjusted for their hours and responsibilities) may still fall short of what lawyers and business professionals make. Why the discomfort at talking about money, and why does everyone feel that the *other* guy’s doctor is ripping off the system?
Costing medical care turns out to be a very complicated process, and health care professionals are just one component of a system that spends elaborate amounts of time and energy trying to determine how things should be priced and paid for. Gawande describes the work life of one woman who makes a living helping large HMOs and hospital systems recover from the brink of bankruptcy through better management of their accounting … pricing, billing, payment, government insurance claims, etc. For many parts of the health care system, it’s a paper “war with insurance.” The skillful prosper. The inept go broke. Gawande’s own quest to figure out what he was worth took him to a happy and successful New York doctor who simply skipped the hassle. He insists on payment in cash and charges what the market will bear. The savings in administrative paperwork are substantial and his take-home pay is, not surprisingly, in the seven figures. Gawande was shaken a bit by that doctor’s high job satisfaction. How does one tease apart the obligations and responsibilities of skilled doctors with their current obligations to fight their way through a forest of legal and administrative paperwork?
The author goes on to describe all the various attempts to control physician costs and increase their job satisfaction through the last few decades. There are some positive stories, but they all seem to be temporary. Little HMOs that work well, become big, hire specialists, and falter in a maze of billing complexity. And in all this, as Gawande relates in the case of his own son’s heart surgery, is a patient base that expects hundreds of thousands of dollars of care at the lowest possible price. A $5 co-pay for his son’s treatment, as it turned out! As medicine gets more complex in order to treat patients with more and more serious, or obscure, ailments, the cost just keeps going up. Without any clear solution in sight.
Ultimately, Gawande arrived a ballpark figure for his salary for the first three years. His administrator accepted the number with alacrity … and now Gawande is among the group of physicians embarrassed to say what they make.
In perhaps the weakest (though still compelling) essay of the book, Gawande writes about the “Doctors of the Death Chamber” … the physicians and skilled nurses who assist US states with executions. Gawande describes the history of the relationship between the medical profession and state executions … and the fact that the AMA has washed its hands of the conundrum by stating that physicians should not be involved in any part of executions. Nonetheless, the slow, and rather monstrous, shift from hanging to firing squads, electrocutions and gas chambers, and finally … to lethal injections … has been fraught will medical issues. It’s certainly a toss-up whether the strangulation and suffocation of hanging has been ameliorated in any of the 20th century’s innovations. Gawande clearly feels that they remain cruel and unusual but he certainly gives a fair and honest treatment to his discussions with the handful of medical professions who would discuss their involvement in executions. All are rather conflicted about their role … and about the inherent imperfections of the methods of execution that they implement and/or witness. There are always anomalies in individual prisoners’ bodies, always system failures, never enough redundancies in equipment. When things go wrong occasionally, the anecdotes make for harrowing reading.
That being said, much of Gawande’s essay comes across as squeamishness, on his part and on the part of society. There’s no mention of the rampant violence and rape of modern prisons. No discussion of the treatment of animals in medical research. Indeed, no discussion of Chinese doctors involved in reputed execution-on-demand organ harvesting. Nor a consideration of the rather more humane bullet to the base of the brain as an alternative to all the elaborate kabuki of executions in the US. So this essay is perhaps more parochial, in jurisdiction, philosophy, and politics than it might be. It does not address the inherent biases and prejudices of the American medical profession … their sensitivity over the pain and suffering of some, and their studied indifference to the suffering of others. “Don’t get your hands dirty” is the AMA credo … and they are mighty selective over what they judge “dirty.” The under-equipped palliative care units. The care of disabled newborns. In face of these broader painful realities, the medical profession’s relationship with executions is as conflicted as that of broader society. For folks that stand daily at the nexus of life and death, they appear rather fastidious and fussy when faced with dealing death on society’s behalf, in broad daylight.
Gawande’s broad them of “Doing Right” concludes with a final essay on the suspension of medical treatment … when to keep fighting … when to say enough is enough. And when it is the physician who wants to continue to “fight” for his or her own reasons and ego. Sorting through this thicket of uncertainty (of solutions and motives), is a daily practice for Gawande and this essay takes us just a first step beyond describing the problem. Families have a role in deciding just how much should be done, at what price in pain, suffering, and cash, for any particular patient. The risks and responsibilities are so weighty, for both physicians and families, that zigzags in decision-making and recriminations after the fact are commonplace. It’s hard to know, without some shared ethical system, just how to draw the line against excessive treatment. The topic is thoughtfully broached however.
Ingenuity
In his final theme in Better, Dr. Gawande looks at “Ingenuity” and the steps that physicians can take that require mental creativity and effort but which need not place a large financial burden on medical care.
His opening essay is a fascinating discussion of the development of the Apgar score for newborn infants. Long disdained as the least rigourous of the medical disciplines, it’s ironic that obstetrics should have the simple 10 point scale, developed by anesthesiologist Virginia Apgar in the 1950s. Now used around the world, the Apgar score has improved the treatment and care of newborns far more effectively than earlier US attempts to improve treatment plans. It is quick, simple, and virtually free. It ranks the skin colour, heart rate, reflex irritability, muscle tone, and respiration of the child (each on a 0 – 2 scale), totals the five values and comes up with a ranking from 0 – 10. Over the last half-century, medicine has used those numbers to improve infant health generally, and improve the treatment of at-risk children from the moment of birth.
Strangely enough, being able to quickly categorize newborn status has led to aggressive pragmatic research by gynecologists and obstetricians, mapping their treatment methods and preventive care to that moment-of-birth score. Obstetrics hasn’t following the idealized approach dictated by “evidence-based medicine” but the author makes a strong case that the near-universal use of this simple scale has underlain its great positive impact on actual health care. “Best” practice is not necessarily “available” practice. Gawande builds his description of the value of the Apgar score around the anecdotal birth experience of one of his colleagues, a fellow doctor. Her harrowing time is the centrepiece of a broader discussion about the changes that have been made in medicine to account for “ordinary” physicians. A case in point is forceps delivery. In the hands of skilled practitioners, it is safer than a Caesarian birth. But developing that skill takes time, effort, and errors. Many physicians do not master it. By contrast, Caesarian sections are more successfully executed by physicians with ordinary skills.
Gawande is a little concerned that we are now building an entire medical system designed to adapt to mediocre doctors. And with the news that one healthy baby in 500 can be saved by using early C-sections (39 weeks), it is entirely possible that the Western medical system will eventually abandon “natural” childbirth entirely, justified by the improved prospects of surgical intervention for mother and child. This essay is by times both unsettling and fascinating. For Gawande, it has inspired him to work on a surgical team to build an equally useful scoring system for his own practice. Clearly, he’s also disturbed by the difference between treatment given by outstanding doctors and that which is safe in the hands of more mediocre practitioners.
Which leads him to his next, and in many ways most thought-provoking, essay on the difference between great medical care and good medical care — “The Bell Curve.” His focus is on the treatment of cystic fibrosis (CF), a debilitating metabolic disorder which once led to death in childhood and adolescent. In simple terms, the mucus of the body becomes sticky and impedes respiration and digestion. Breathing and nutrition falter. In past decades, the treatment of this disease in America was organized around a network of specialized centres. Those centres improved the life expectancy of cystic fibrosis patients dramatically. In a quirk of private foundation funding, the cystic fibrosis centres were also amongst the few disease-focused medical institutions who recorded their success in treatment, nation-wide. The results of those surveys were disturbing. While life expectancy for patients generally was increasing, a handful of treatment centres were showing dramatically better results. Some of this could be accounted for by on-site medical research but it was clear that somehow a handful of centres were using established treatment plans more effectively. Eventually, the differences were so substantial that a case was made to remove the anonymity of the institutional reporting … to identify why these outcome differences persisted.
To illustrate these differences, and to dig deeper into the realities of good versus great care, Gawande contrasts the treatment of a teenage female CF patient at Cincinnati Children’s Hospital and that of a similar patient at Minneapolis’ Fairview Children’s University Hospital. Even to a lay person, the descriptions of doctor-patient interaction are dramatic. It has nothing to do with technology, and everything to do with attitude. At Cincinnati, subpar results in breathing or weight gain are recorded and patients are encouraged to do better. In Minneapolis, the doctor overseeing the centre (Dr. Warren Warwick) overlooks no opportunity to improve respiration and digestion, and patients are confronted directly with their lapses in routine. “Failure is not an option” to use movie lingo. In many cases, his CF patients have lung capacity superior to healthy patients of their age. The results, in lifespan and quality of life, are dramatic. At Minneapolis, patients can live decades longer than at other centres, and they may undertake activities considered impossible by CF patients in other parts of the country. Minneapolis is relentless about its program, and about physicians at their centre building treatment plans carefully based on best practice. Doctors are aggressively discouraged from treatment that can only be anecdotally evaluated. All participants, patients, staff and physicians, are focused on what works.
Surprisingly, even after the differences between centres have been identified, and the “cultures” of these medical institutions highlighted, the upper quartile of centres continues to lead the pack, and indeed are improving fastest. Nothing, apparently, succeeds like success. For Gawande, the challenge in his own practice is to identify where he might be falling down, where being “average” in his approach and treatment plans. As he says himself:
If the bell curve is a fact, then so is the reality that most doctors are going to be average. There is no shame in being one of them, right? Except, of course, there is. … When the stakes are our lives and the lives of our children, we want no one to settle for average. p. 230.
In his final essay on “Ingenuity,” Dr. Gawande returns to the Third World and describes his experiences working with surgeons at an Indian hospital. In face of incredible limitations in facilities and supplies, and limitless demand from an underserved populace, the physicians at the hospital in question are constantly challenged to adapt technologies, tools, time management, and treatment plans. There is never “enough” of anything. For Gawande, it was an eye-opening encounter with what could be done with very little and what must be done when creativity and diligence are the only resources available to extend the physical resources. Nonetheless, the fatigue and stress on the local physicians is evident, and Gawande concludes his essay by wondering whether he would be able to bear the burdens placed on these dedicated doctors. The temptation to take those talents, that diligence, and that creativity, and turn it into a prosperous lifestyle in the West must be great.
In his Afterword, Dr. Gawande tries to epitomize what he learned in the course of his exploration of the three themes in his book: “diligence, doing right, ingenuity.” His personal goal was to improve his own skills but he feels (rightfully, to my mind) that many of the examples which he wrote about can apply to anyone in a field with risk and responsibility. In speaking to students, Gawande has come up with five brief aphorisms that clearly reflect his experiences described in his essays.
1. Ask an unscripted question. (creating a space for new information in patient interactions and removing the “rote” feeling for the physician)
2. Don’t complain. (it’s a cycle which impedes improvement)
3. Count something. (Focusing on what’s important and finding a way to work with it)
4. Write something. (whether for personal reflection or professional communication)
5. Change. (maintain a commitment to adjusting things)
Who Will Enjoy This Book?
As mentioned earlier, the book is written for a general audience. It would certainly be a great gift for undergraduates with an interest in the health and life sciences. Mature high school students (that is, emotional mature kids who can handle some ambiguity in life) would also find Better very thought-provoking. As for buying this book for friends and relatives who are doctors or nurses, that should be a more careful judgment. Gawande’s book describes his efforts to set the bar higher for himself. Not everyone has that interest. If you know someone in the health care professions who is curious and of a literary bent, I think they’d enjoy this book as well.
For general readers, if any individual topic mentioned above seems interesting, by all means borrow the book from the local public library. If you find several of the topics interesting, I’m sure you’ll enjoy reading it from cover to cover.
Gawande has his own personal biases and predispositions, of course. A book of essays is bound to have its stronger and weaker contributions. In terms of the challenges facing doctors … and the challenges facing patients facing doctors … Better offers rather spotty but elegant coverage. Gawande could flesh in the topic more, and perhaps he will. Personally, I’d like to see some consideration of the cultural context of medicine beyond “necessity is the mother of invention.” Some of Dr. Gawande’s predispositions have little or nothing to do with that intersection of “science and others’ lives.” But he writes so well and expresses himself so humanely that I very much look forward to his next book.
Table of Contents
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Introduction [1]
Part I Diligence [11]
On Washing Hands [13]
The Mop-Up [29]
Casualties of War [51]
Part II Doing Right [71]
Naked [73]
What Doctors Owe [84]
Piecework [112]
The Doctors of the Death Chamber [130]
On Fighting [154]
Part III Ingenuity [167]
The Score [169]
The Bell Curve [201]
For Performance [231]
Afterword: Suggestions for Becoming a Positive Deviant [249]
Notes on Sources [259]
Acknowledgments [271]
I realize that Dr. Gawande is speaking poetically but to many people actually think like this. No matter what we do, most people in every field will be average by definition. People forget that an average is a zero sum, relative measure. We will never reach a state of Lake Woebegone medicine wherein all the Doctors are above average.
I think the myopia that effects all who enter into an all encompassing professional subcultures blinds Dr. Gawande. Virtually, all systems are designed around the average or mediocre talent available. Certainly, we design all systems requiring technical talent this way. When you have large numbers of people doing hands on work day-to-day, you have to make the procedures that most people can perform the standards.
I think the only exception to this rule would be in informational fields like art, writing or programming wherein the work of a few highly skilled individuals can be cheaply mass-duplicated. Most of the art, literature, media and programming we use originates from a relatively small number of highly skilled individuals. Most of us do not primarily consume informational products produced by professionals living in our own communities.
The problem with this system in medicine comes from the concept of malpractice. Malpractice really means ‘non-standard.” If a physician does something out of the ordinary, they place themselves at legal risk. So, even if a skilled and experience surgeon could perform a procedure with a 95% positive outcome, if most physicians could only get a positive outcome 20% of the time, the the procedure would be deemed risky and non-standard. Patients that experience the 5% negative outcome could sue the skilled physician for performing a risky and non-standard procedure
I had the pleasure of attending a Pathology grand rounds given by Dr. Gawande at Brigham and Women’s Hospital a year or so ago. He certainly captivated the audience. It was pretty much a summation of many of the anecdotes you mention in this book.
I don’t know how he does find any time to write; I wonder what his academic schedule is like and how many weeks he is on service in a year (she writes, realizing this sounds petty and like she is comparing her hectic schedule with his hectic schedule and, anyway, the reality is, some people are just better than other people and I guess he is better than me at writing. That’s for sure Oh, the sour grapes of it all : ) )
On a side note, one of the issues in academic medicine is the heavy service responsibility given to many junior faculty and the push, of course, to still publish. The publish part, of course, is what is often the most rewarded. Frustrating, because if you really care about your patients and make sure you dot your i’s and cross your t’s, well, you won’t always get rewarded for it academically. Which isn’t important compared to doing your duty by the patient. But it’s annoying…..
Oh, and I’ve also found that if you expect a high standard from your students/residents, you are more likely to get a higher level of effort. Seems like a no brainer, but medicine is not the only field where this concept seems to be haphazardly applied.