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.”

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Does Exercise Help You Sleep Better? has some pretty strong things to say about the link between sleep and exercise. A quick summary: there isn’t a link. This is my favorite part:

There is “absolutely no scientific evidence” that working out in the late evening keeps you from sleeping, Mr. Youngstedt said.

I have found the same thing as the article: evening work-outs do nothing to inhibit sleep. Add this research to the growing pile that says: “the mind is really really powerful if you train it to work in your favor.”

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Family dinners are extremely extremely important. I haven’t always thought this. In fact, I’ve usually considered food to be simply a necessity for living, nothing more. I dislike eating out in a mindless pattern (and I had better start to cook or train the cat to do so, lest we exhaust my wonderful wife, our only cook). On the contrary, I really enjoy eating out and trying new things… when there’s no obligation (perceived or otherwise) to eat the whole thing. My ideal dinner would be sharing a bunch of newfangled dishes at a restaurant… my nightmare is receiving a huge plate of something I feel obliged to consume. I have this problem where I think “all or nothing” re:the food on my plate… it’s easiest for me to eat all of it or none of it. It is supremely difficult for me to eat a little, unless my mono-food voraciousness is held in check by social obligations to my fellow diners. Hence the sharing.

So I’ve come to understand food as something that needn’t be 100% healthy or 100% unhealthy. Sampled in reasonable quantities, food eaten out can be OK. Secondly, there’s a quote that goes like this: “eating together softens people.” I always thought that lunch meetings were a silly thing, and then I started to ponder that quote (whose origin eludes me). But I’ve come to believe that the shared table does have the “civilizing influence” of which so many articles speak.

My attitude towards food has been shaped by the chefs kottke consistently links. Here’s a great article he recently linked called “To Develop Young Tastes, Look Past the Children’s Menu”:

“You know, I’m their parent, I’m not their best friend,” Mr. Marzovilla noted. “I have a duty to mold and teach.”

The idea is: you tell your kids to try new things. They needn’t like them, or always like you, but they at least should understand the breadth of the privilege in which they are brought up. Marzovilla’s quote at the end elegantly sums up that sentiment.

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Sesame Street: Feist sings 1,2,3,4. I think this is really good.

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Today I cleaned all the moldy grout lines in our shower with Soft Scrub® and a toothbrush. Mykala made sure I took off my sweatpants (my only pair) before I bleached them along with the grout. Today I swept the tree pieces off of our deck. We sat outside, soaking in the perfect temperature and filtered sun. Today I saw a woman taking a walk with an IV while smoking. I then worked out for 2½ hours — this means that I am finally getting back into legs, which brings me joy. Today, Mykala and I had a wonderful day.

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Radiolab: Limits (April 16, 2010). WOW. Mykala recommended I listen to this, and it has been far too long since she did so. Last night, I finally listened to the episode and it was amazing. I loved the part about the “central governor” theory — that there is a part of our minds that works all the time to tell us that we’re tired. You go running: central governor says “you’re tired”. And it’s not like a little itch you have to scratch — this is convincing, all-encompassing, total-body exhaustion. When you feel this, you apparently have between 25 and 50% of your reserve left.

You can just keep going: you train your mind right alongside your body. The second part: on the limits of the mind, specifically memory, is fascinating to hear, too. It’s important for us to forget as well as remember: our minds want to extract meaning, not retain random bits of information.

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Harmful Drinks in America, 2010. Rockstar Energy Drink sugar equivalent: 6 Krispy Kreme originals.

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Lightweight lifestyle, or, what hiking teaches you about life:

This principle is not easy to see in our modern culture, where success is generally viewed as proportional to the value and quantity of one’s possessions. Society percieves the owner of a big house which can hold more possessions as more successful, when in fact he may be held in bondage by high house payments, taxes, utilities, repair costs, and a general lack of freedom. In an ever-increasing need for protection he acquires security lights, burglar alarms, double locks, fences, and moves into a subdivision with a locked gate. He pays large insurance premiums so he can afford to replace everything in case all his protection doesn’t work.

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The Irony of Satire: Political Ideology and the Motivation to See What You Want to See in The Colbert Report

… there was no significant difference between the groups in thinking Colbert was funny, but conservatives were more likely to report that Colbert only pretends to be joking and genuinely meant what he said while liberals were more likely to report that Colbert used satire and was not serious when offering political statements.

Science shows we’re all wearing blinders — I think the genius lies in Colbert’s fabricated persona: open to many interpretations.

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I really really love my wife. When she pulls up the dashboard on her computer, there is a fruitcake widget. 3 years ago, she downloaded it in honor of her computer’s first Christmas. We had been interacting with the dashboard widgets, including the whoopee cushion one, and we sat there for a few minutes trying to click the right part of this fruitcake-in-profile. Then, we realized that the fruitcake doesn’t do anything. It just sits there. Like a fruitcake. A big, heavy, dense fruitcake… that never expires. So that’s sitting there, and every time I see it, I’m happy.

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