Wednesday, May 2, 2012

Becoming "Better"

Something that prominently stuck out to me in Gawande's book was his relation of failure in the medical field to making error in baseball as a third baseman. If a baseball player were to miss a throw or overshoot a throw the fans would boo him and make fun of him and the press would be all over him for the next few days. Errors like these could hurt a baseball players career, no matter how experienced in the field he is. This is the same for medicine but worse. When doctors make errors, like performing the wrong surgery, or leaving an instrument inside the person, or giving a wrong treatment or prescription, it could cost the person's life. "Nobody would see him in quite the same light,"(Gawande 107). In medicine, Gawande notes that families who do get hurt by faulty medicinal practices, do not even end up suing for what they should rightfully get. These families usually do not even receive an apology or any additional help. The doctor may be too ashamed to face what happened or the situation he or she caused.

Additionally, I feel as if the checklist that Gawande talks about is also something that should be taken up by the majority of hospitals in the coming 10 years or more. This is because the checklist, if done right, is perfect at making surgeries run much more smoothly. When all the people on the team know each other an they know for sure that they have done certain procedures, and what job each will be doing, there is not as much of a window for error. According to a quick survey in class today it is clear that most people getting operated on would prefer if doctors use this checklist because it makes the procedure much more safe. Gawande points out that some doctors can be vey careless because they just want to get in, get out, and make their money. In his "Piecework" chapter, Gawande mentions that some doctors who seem way too interested in just collecting money are questionable because the care they give cannot be reliable when all they care about is how much money they're receiving. All in all, I agree with what was said in class today, that although the medical field tries to be a system, it cannot be because there are so many problems that need to be fixed and not enough togetherness among practitioners.

Tuesday, May 1, 2012

Ethical Dilemmas

“In this work against sickness, we begin not with genetic or cellular interactions, but with human ones (82).”  

Better, by Atul Gawande is an easy and enjoyable read. His anecdotes really made me think about certain aspects of medicine that I haven’t thought of before, such as the chapter on medical malpractice and on salaries and medical insurance. His point of view is very much the same as Groopman’s in How Doctors Think, in that he stresses that doctors must make meaningful connections with patients and look at cases individually and creatively.

The section that stuck out to me that most was when Gawande gets his first job and is asked how much he wanted as his salary. He goes through many ethical and moral questions about how much doctors should be paid. His discussions with the surgeon from an East Coast hospital, with a net income of 1.2 million, struck me the most. This surgeon looks at his profession and the health care system as a business, and doesn’t see the harm in charging large sums of money for his services that only attract those who can afford it.  Gawande says, “in this view, doctors need to understand that we are businessmen – nothing less, nothing more – and the sooner we accept this the better (123).” While, of course, we know that the health care system is a business, I find his point of view unsettling. This kind of attitude makes it seem like he’s isn’t concerned with his patients’ well being. This attitude is looked down upon in the medical world, as Gawande discovers as he asks fellow staff about their salary compensation. Many of the doctors he speaks don’t want to discuss salary, as it makes it seems as if they are in the field for money rather than to do “meaningful and respected work for people and society.” However, I also understand the surgeon’s point of view in that doctors go through extensive schooling compared to other profession. Where do we draw the line? The surgeon’s point of view on eliminating insurance companies is a complex one, in which I don’t think it is necessary to charge such large sums for his services, but like that he eliminates the middleman.

Also, as a side note, I watched his recent TED talk, where Gawande speaks about reducing errors in surgery using a simple check list system:

Knowing Yourself

Atul Gawande's "Better: A Surgeon's Notes on Performance" was a smooth and delightful read. Just like many of the books we have read before, this story has countless personal experiences that allows the readers to understand the author well. Gawande's stories are so descriptive that sometimes I really do feel like I'm watching the scene before my eyes. Although it may seem that Gawande jumps from various topics, I realized in the end that he gives us many accounts in order to really grasp the difficulties doctors may go through. These difficulties can come from simple hand-washing habits to making life or death decisions for others.
Gawande's statement that the hardest part of being a doctor is to know what you have power over and what you don't. This statement reminded me of the Confucian teaching that you really got to know yourself. And in order for you to do that, you need the opinions of others around you. Overall, it's a matter of knowing your weaknesses and strengths. Sometimes it may be hard to do this because people can be so obsessed with their successes only that they start to identify themselves only through those times. They can also be blinded by their successes that they don't even take into consideration their weaknesses. That's why accountability is so important so that others can shine light on what you can't see. I feel like this may be due to many cultures pushing people to live for success. Therefore, from such a young age we become so money-driven, and identify ourselves with credentials.
We don't take the time to acknowledge our weaknesses and failures. Instead we try to cover up our failures as fast as we can and don't work on them. I'm really glad Gawande makes this point because I believe, weaknesses are what really develops a person in many ways. And having those weaknesses really compels people to become genuine to others and honest with themselves. It just got me thinking that it must be really hard for doctors to constantly go through the process of bettering themselves through their failures since it must take a lot of inner strength to do so. And sometimes they have to go against what society thinks just as Semmelweis did in order to stand up for what they believe in.

The Importance of the Individual in Reducing System Errors

I found Atul Gawande's Better to be an extremely fascinating examination into failures and triumphs of the medical profession.  In particular, I was interested in Gawande's Afterward, in which he proposes five "suggestions for becoming a positive deviant." His first suggestion is for doctors to ask their patients unscripted questions, meaning, questions about their lives outside of the ailments that they came to the hospital for.  Gawande rationalizes that when a doctor is able to learn a memorable fact about a patient's personal life, it allows the doctor to see that patient as more of an individual, rather than an anonymous patient as a part of a routine checkup.  I think that this is an intriguing idea, but I also can't help but wonder about the bias factor when doctors engage in friendly relationships with their patients, as we explored in Groopman's book. Gawande's next suggestion is to avoid complaining, which seems like a reasonable and universal piece of advice.  He then notes that "counting something" is helpful in reducing errors such as leaving sponges in a patient during surgery.  This seems logical, and I would fully support the counting of sponges before a doctor decides to close up a patient. Next, he urges doctors to "write something," as writing can allow them to think through a problem and reflect in an alternative way.   Gawande's final piece of advice is "Change," and he urges doctors to stand up for what they believe in and not just be "another white-coated cog in the machine." These suggestions seem to stem from Gawande's personal experience, and I find it interesting that his final word in Better is how to become a more effective doctor, and not how the medical system should implement sweeping changes. He emphasizes the importance of individual people working to improve themselves as the optimal way to change the medical profession as a whole.

Monday, April 30, 2012

Ask New Questions

I had actually read Better before this class, way back during my Junior year of high school when it first came out. One of my neighbors, who is a malpractice lawyer, gave it to me and told me that  reading it would be a good start in making sure he wouldn't have to sue me when I eventually (hopefully) become a doctor. I found all of the anectodes in the book really interesting when I first read it, but some of the larger concepts kind of went over my head given that I didn't know much about the health care system and didn't really have a well developed idea of what being a doctor would actually involve since no one in my immediate family was a doctor and I didn't have much guidance. Reading the book opened my eyes to a lot of issues in the field of medicine that I hadn't thought about, and rereading it now in the context of everything we've learned in this class I think it's a great tool for aspiring doctors to get a peek inside the complicated world that doctors face every day. 

Particularly, what stood out to me the most in Gawande's Better was his suggestion to ask patients new and genuine questions, which was one of his 5 concluding suggestions to physicians at the end of the book. I think this is a really helpful and valuable suggestion that can be utilized in a variety of different realms when practicing medicine and can lead to better diagnoses and better treatments. In one sense it sort of echoes back to How Doctors Think in that in complicated cases it's helpful to set aside old records and look at a case with a clean slate in order to avoid making the same wrong diagnosis over and over again. It can also help doctors to get to know a patient better in a short amount of time by asking questions that really give a sense of what the person is going through, instead of skimming the surface of a patient's records and not getting any valuable information out of them. In addition, asking new questions can put a research-like spin on new cases in that a doctor can treat each new case like a puzzle that they are trying to solve instead of slipping into a routine which can become mundane and cause doctors to miss important clues that would lead them to the right diagnosis. 

The Issue of Time and Professionalism

Gawande, like of the authors we've read from this semester, is also concerned with time and asserts how many doctors simply do not have the time in between patients to properly employ good hospital hygiene up to standards. In a particularly disturbing chapter on hand washing Gawande illuminates not the laissez-faire attitude of hospitals and hygiene but the issue of time in both remembering and having the almost commodity moment to sanitize before interacting with a patient. Gawande admits that he, like many, can be careless with this and forget to squirt some Purel on his hands before touching a patient (eek!) There is a crucial flaw, however, with Gawande's argument in this chapter. He mentions that sometimes "the patient puts his hand out in greeting and I think it too strange not to go ahead and take it (23). While this is an honest statement, and one most can empathize with, Gawande (and presumably many doctors) sometimes seem more attuned to the social interaction of medicine and less so with the technical aspect of it. I'm not trying to nitpick at this one sentence that seems more or less of little significance, but it got me thinking about earlier discussions about technical and personal aspects of medicine--is it social or scientific? And how many doctors are worried about appearing rude at the cost of the patients health (not to mention the crazy bills for extended hospital stays as a result of infection.) I understand that doctors and surgeon juggle a complex balancing act of likability and professionalism, but at what cost? Perhaps Gawande was just anecdotally adding to his theories and meant nothing by the statement but it seems it human nature to respond to social circumstances the way he describes. When should a doctor draw the line, look like kind of a douche bag, and ignore the patients hand? (So to speak...)

Pushing Standards

Overall, I found Better one of the, well, better assigned books of this class. What really stood out to me was the chapter on The Bell Curve. Gawande’s concluding remarks on accepting that there is a bell curve that describes all aspects of human behavior were somewhat disheartening. My impression is he accepts the bell curve as a given and there being nothing an individual can really do to improve his performance. He even questions what individuals should do given their realization that they are average, or, gasp, below average. He states:

             “What if I turn out to be average? If we took all the surgeons at my level of experience, compared our results, and discovered that I am one of the worst, the answer would be easy: I’d turn in my scalpel. But what if I were / a B-? Working as I do in a city that’s mobbed with surgeons, how could I justify putting patients under the knife? I could tell myself, Someone’s got to be average. 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? . . . What is troubling is not just being average but settling for it. . . . When the stakes are our lives and the lives of our children, we want no one to settle for average” (Gawande, 229-230).

He, of course, has a point, we do not want our physicians to settle for average. But to me, realizing where a physician is along the bell curve has important implications for improving the standard of care. What’s important is not settling per se, but constantly trying to improve. It’s raising the bar for what average is. Of course there will always be a handful of physicians that will be top notch, but what matters is the variance among them. He says that he would turn in his scalpel if he realized he was the worst, but what if he could improve? What if he could study the behavior of individuals with the best performance and become average? More importantly, what if it were possible to apply the behavior of the top performers to the entire curve and improve those who are average or worst? If the difference between the top and average is negligible, then settling is not really settling, it’s merely improving the definition of what average is.

I can certainly understand the uncertainty in grading physicians not only from a patients’ perspective but also from the graded individuals’ perspective. People typically do not want to be thought of as average. Patients do not want to go to an average doctor, they want to go the best doctor. This of course can only be created if individuals and patients are aware of the grades. But if the grades aren’t available, is it possible to improve? The article  Grading Docs With Electronic Medical Records seems to agree with this point by describing doctors who were able to improve their care once they were aware of what areas they needed to improve.