Sunday, May 11, 2008

better: A Surgeon’s Notes on Performance by Atul Gawande

I, personally, have had a few issues with those in the medical profession. For example, about 6 years ago I asked my pediatrician if the vaccines she had contained Thimerosal, a preservative that used to be commonly added to vaccines. This was exactly what the CDC suggested I ask. She said they did not, but began lecturing me; stridently insisting that if I was concerned with mercury I should be more concerned about the fish I ate. She also told me that Thimerosal did not contain mercury. At that point, my husband and I – both of us Ph. D. chemists – looked at each other, made a few under-the-breath comments, and walking out of her office decided to never see her again. Thimerosal contains mercury; her comment was like insisting that chocolate chip cookies contain no chocolate. Why would a doctor make up something like that? If she doesn’t know any chemistry, why pretend she does? I don’t expect doctors to know everything, but I do expect them to be honest about what they don’t know.

That was only my most egregious incident. I have had other minor incidents with doctors that just simply did not feel right. This may be why I appreciate the writings of Atul Gawande so much. He does not sugarcoat what goes on in medicine. He also obviously cares for his patients and cares about the state of medicine as a whole. He gives an insider view into why certain decision or practices are so prevalent. For example, in better he spends a chapter looking at the increase in cesarean section rates in this country. I was surprised to learn that a forceps delivery, in the hands of an experienced doctor at a large hospital, actually has “fabulous results”. However, it turns out that it is much easier to teach someone how to do a c-section and that is why it has become the standard of care in difficult deliveries. Gawande expresses his concerns eloquently, “Some hospitals across the country are doing Cesarean sections in more than half of child deliveries. It is not merely nostalgic to find this disturbing. We are losing our connection to yet another natural process of life. And we are seeing the waning of the art of childbirth, too. The skill to bring a child in trouble safely through a vaginal delivery, however inconsistent and unevenly distributed, has been nurtured over the centuries. In the obstetrical mainstream, it won’t be long before it is lost.” (pg 198)

Gawande also examines the care of children and adults with cystic fibrosis. The data collected on the treatment of children with cystic fibrosis has been compiled by the Cystic Fibrosis Foundation and for many years they reported back to the responding hospitals on how well they were doing in comparison with other hospitals. A hospital, Cincinnati Children’s Hospital, wanted to do better. They asked to know what the top hospitals were so they could learn from them. The Foundation did not want to give this data out because then hospitals may be less likely to report their data, if they knew it was not going to be anonymous. It is a fascinating look into the system. The data was finally released and it is now available online. Now, when will this ever happen for other specialties?

I found the other chapters in better interesting as well, but the afterword where Gawande gives suggestions for becoming a positive deviant is worthwhile reading for anyone in any profession. A positive deviant is someone who gets much better results than anyone else. For example, in 1964 the average age of death for someone with CF was twenty-one years at the best center, which was seven times the age of patients at other centers. A patient could live 7× longer if they happened to be at that one center and it was mainly due to the efforts of one doctor. Gawande suggestions for being the positive deviant, with my quick summations, are as follows:
1. Ask an unscripted question – find out something new about a patient or colleague.
2. Don’t complain – it’s just discouraging.
3. Count something – you may find out something new.
4. Write something – you may find out something new or just feel better.
5. Change – don’t get stuck doing the same thing if it is not working.
I think his main point is to be mindful and pay attention. “Regardless of what one ultimately does in medicine—or outside medicine, for that matter—one should be a scientist in the world.” (pg 254)

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