Wednesday, June 6, 2007

With great power comes great responsibility - (Book Review - better by Atul Gawande)

Let's play a game. I'm going to say a word and you tell me what your first thought is. Ready? "Surgeon."

Did your mind leap to "makes tons more money than me," or maybe "jerk, usually male, who thinks he's god?" When we give a person permission to cause us great pain, tear us open with sharp objects, administer chemicals, and physically move things inside our bodies, we give them tremendous power. With that power can sometimes emerge from that person the notion that their knowledge is of greater value than all others and they deserve that power. But there is another kind of surgeon, one who accepts that with the great trust we give them comes great responsibility, and that their skills must be used thoughtfully and, sometimes, not at all. Having just finished better by Atul Gawande, it seems that he is that second type of surgeon. His final essay, in fact, is built around the question "How do I really matter?" It exemplifies his approach to his work which values asking questions, facing his own limitations and those of whatever environment he works in with honesty and humility, and it values change. Most of the advice he offers would be applicable in any walk of life and, indeed, after reading I was struck by how much a doctor's life is like anyone else's.

The chapter on hand washing that I mentioned in an earlier post, is informative about the history of that innovation that revolutionized health care. Dr. Ignac Semmelweise, a Viennese obstetrician in the mid 19th century, discovered that the leading cause of maternal death in childbirth was a bacterial infection that could be greatly reduced by washing hands. But really, Gawande's chapter is a cautionary tale about pride and the difficulty of changing human behavior when those who must change have to face that they have been doing something less well than they could. That they've been doing something wrong.

Out of three thousand mothers who delivered babies at the hospital where Semmelweis worked, six hundred or more died of the disease each year - a horrifying 20 percent maternal death rate. Of mothers delivering at home, only 1 percent died. Semmelweis concluded that doctors themselves were carrying the disease between patients, and he mandated that every doctor and nurse on his ward scrub with a nail brush and chlorine between patients. The puerperal death rate immediately fell to 1 percent - incontrovertible proof, it would seem, that he was right. Yet elsewhere, doctors' practices did not change. Some colleagues were even offended by his claims; in was impossible to them that doctors could be killing their patients. Far from being hailed, Semmelweis was ultimately dismissed from his job.

He writes a chapter Naked, on the intimacy involved in a doctor/patient relationship. The doctor is clothed, the patient often naked with examination techniques that requires that the doctor touch them. He speaks of the different ways this relationship manifests itself in patient care in Afghanistan, Venezuela, England, and the United States. Should a chaperone be present? He lays bare his own internal debate and the differences between his father's approach and his own. One of the central themes of this book is success in the performance of medicine, and that makes itself plain in this chapter's conclusion:

It is unsettling to find how little it takes to defeat success in medicine. You come as a professional equipped with expertise and technology. You do not imagine that a mere matter of etiquette could foil you. But the social dimension turns out to be as essential as the scientific...

Gawande's approach to practicing medicine values the humane above the technological and efficient. The book is built on the notion that human connection improves medicine. One chapter ponders the wisdom of our malpractice system as it exists - the inevitability of human error, the suffering of those not served well by the medical system, the arbitrariness of compensation. Another chapter asks why the records of success and failure of doctors and hospitals are not more readily accessible to patients and more frequently confronted by the caregivers themselves. Like every other industry, medicine's performances can be charted on the bell curve, i.e., most performance is average.

It belies the promise that we make to patients: that they can count on the medical system to give them their very best chance. It also contradicts the belief nearly all of us have that we are doing our job as well as it can be done.

Another chapter asks the simple question - how much should a doctor earn? Like each of his chapters, that question is couched in a narrative where a character faces a conflict (the essential need for any drama). In this case a young Gawande fresh from his residency is about to begin practicing medicine. It is the skill of his writing - mixing good story telling and straightforward style, that makes his interesting points compulsively readable.

Gawande writes admiringly of the remarkable Virgnia Apgar, the doctor for whom the Apgar Score is named, whose innovation revolutionized childbirth and the care of newborn, and who seemed a remarkable person to boot:

one of the first women to be admitted to the surgical residency at Columbia University college of Physicians and Surgeons in 1933...She wasn't just a talented violinist; she also made her own instruments. She began flying single-engine planes at the age of fifty-nine...

I could not find any published biography when I Googled her. Perhaps his publisher should ask Gawande if he is up for the challenge.

This book emphasizes the value of building relationships and being open with ourselves and each other as a way to practice better medicine and to live more rewarding lives:

What is more likely to save [a life] - investment in laboratory science or in efforts to improve how existing medical care performs?
The answer most people would come to is investment in laboratory science - the search for a cure....To be sure, we need innovations to expand our knowledge and therapies...but we have not effectively used the abilities science has already given us. And we have not made remotely adequate efforts to change that. When we've made a science of performance, however - as we've seen with hand washing, wounded soldiers, child delivery - thousands of lives have been saved. Indeed, the scientific effort to improve performance in medicine - an effort that at present gets only a miniscule portion of scientific budgets - can arguably save more lives in the next decade than bench science...the stakes could not be higher.

Gawande touches on this theme over and over again, whether writing about the latest technological advances in treatment, about triage on soldiers during war, or treatment in a clinic in Nanded, India. Success in medicine can happen in any context - he insists - and it depends on improving performance

Having a machine is not the cure; understanding the ordinary, mundane details that must go right for each particular problem is.

He sums up by offering suggestions about making a difference in practicing medicine, which are useful advice for making a difference in living your life in any arena. They arose by asking himself a question - something he seems to do often and well. The question is this: "how might one become a positive deviant? " I recommend reading his five suggestions as I did, as the conclusion to this kind and tough-minded book. And I applaud his celebration of the usefulness of deviance. How encouraging.

To play my new Positive Deviant Challenge click here!

1 comment:

soleil said...

thank you for a great and comprehensive review. i am definitely putting this book on my tbr list.