Better
Just got done reading Atul Gawande’s book Better: A Surgeon’s Notes on Performance. First off, it’s a fantastic title: it reflects the simplicity of Gawande’s language and the complexity he manages to express with those words. The book explains how, through “diligence”, “doing right”, and “ingenuity”, surgeons can improve. The anecdotal essays are fascinating and well-written… and the ideas are inspiring. The idea is, the greatest gains we will see in the delivery and efficacy of healthcare lie not in the raw advances in science, but in the persistent, thoughtful efforts of those “on the ground” fighting the same problems every day. Here’s a bit where Gawande describes the thinking of a surgeon turned malpractice lawyer:
His expenses on a case are typically forty to fifty thousand dollars. So he would almost never take, say, a dental case. “Is a jury going to give me fifty thousand dollars for the loss of a tooth? The answer is no.” The bigger the damages, the better. As another attorney told me, “I’m looking for a phone number”—damages worth seven figures.
Gawande describes his current malpractice insurance situation, and his impression of it:
Cap or no cap, I will pay more than half a million dollars in premiums in the next ten years. I would much rather see that money placed in a fund for my patients who suffer complications from my care, even if the fund cannot be as generous as we’d like it to be. There’s no real chance of this happening right now, though. For the moment, we must make do with what we have.
His views on physicians assisting with the death penalty were particularly enlightening:
The hand of comfort that more gently places the IV, more carefully times the bolus of potassium, is also the hand of death. We cannot escape this truth. This truth is what convinced me that we should stand with the ethics code and legally ban the participation of physicians and nurses in executions. And if it turns out that executions cannot then be performed without, as the courts put it, “unconstitutional pain and cruelty,” the death penalty should be abolished.
End of life issues are ones I can’t even begin to imagine. I’m struggling right now just to care for patient’s mouths. When their lives are at risk of ending, it must be almost impossible to maintain the standard of care, much less maintain composure:
But you have to be ready to recognize when pushing is only ego, only weakness. You have to be ready to recognize when the pushing can turn to harm. In a way, our task is to “Always Fight.” But our fight is not always to do more. It is to do right by our patients, even though what is right is not always clear.
I especially liked Gawande’s quote from Virginia Apgar, the endless champion of her eponymous scoring system for infant health: “Do what is right and do it now.”
Or check this one out, where Gawande talks about the abilities of the average Indian surgeon (emphasis mine):
I had gone [to India] thinking that, as an American-trained surgeon, I might have a thing or two I could teach them. But the abilities of an average Indian surgeon outstripped those of any Western surgeon I know.
…
On rounds in Nanded with a staff surgeon one afternoon, I saw patients he’d successfully treated for prostate obstruction, diverticulitis of the colon, a tubercular abscess of the chest, a groin hernia, a thyroid goiter, gallbladder disease, a liver cyst, appendicitis, a staghorn stone in the kidney, and a cancer of the right hand—as well as an infant boy born without an anus in whom he’d done a perfect reconstruction. Using just textbooks and advice from one another, the surgeons at this ordinary district hospital in India had developed an astonishing range of expertise.
The wonderful part of the book, however, was the end: the call to action. Here, Gawande shows that you can take the steps that these extraordinary people did, and claw your way to, as Conan O’Brien puts it, “the sweet side of the bell curve”. For example, Gawande instructs us to “ask an unscripted question”. This lifts the professional curtain between doctor and patient, opening up a communication channel between two human beings: “This is not a forty-six-year-old male with a right inguinal hernia. This is a forty-six-year-old former mortician who hated the funeral business with a right inguinal hernia.”
I will do my best to attempt the unscripted question. It sounds like a splendid thing to try… and a difficult thing for me, with all this unpracticed dentistry swirling around in my head, to try.
I leave my thoughts on the book with this quote: “Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.”