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.

Errors, Knowledge, and Quality Assurance

In his book The Checklist Manifesto, which is an expansion of “The Checklist” published in The New Yorker, Gawande marvelously describes how simple, well-designed checklists can help prevent and solve extraordinarily complex problems and thereby improve patient outcomes in medicine. Gawande begins by distinguishing between “necessary fallibility,” the idea that, even when enhanced by technology, we (physicians) fail because what we set out to do is beyond our physical and mental capacities, failure due to ignorance, the idea that we “err because science has given us only a partial understanding of the world and how it works” (i.e. lack of knowledge), and failure due to ineptitude, the idea that we err because even though “the knowledge exists, …we fail to apply it correctly” (7-8). Up until the last several decades, many of the errors we made in medicine were due to sheer ignorance; however, since then, we have gained enough scientific knowledge such that errors due to ineptitude are becoming as much our struggle as errors due to ignorance. While error due to ignorance may be easily forgivable, error due to ineptitude is not and Gawande presents a simple manner – checklists – that have the power to improve the safety and quality of patient care. These checklists are based around regimentation in the sense that they ensure that a multitude of steps are carried out in a specific sequence and manner. Gawande writes of how such simple measures - checklists, regimentation, and ensuring that gaps are filled – utilize the medical knowledge we do have effectively. These measures have resulted in greater hand hygiene thus lowering the spread of infections in hospitals, the widespread deliverance of the polio vaccine in polio-stricken areas, reduction of infection resulting from central line insertion, and reduction of major surgical complications as Gawande details in Better and “The Checklist.” When the knowledge now exists to improve the safety and quality of medical care, it seems marvelous that it is resulting in better patient outcomes, but also ridiculous that rates of hand hygiene, infection, surgical complication, etc are still nowhere near 0%. There is thus always room for improvement. 

Medical Self-help

I believe that Atul Gawande's Better had both a phenomenal strength and weakness. Gawande is an enticing story-teller, and provides the reader with captivating and fantastic anecdotes. His experiences and interviews truly portray his interest and commitment to medicine. At the same time I found the book to be weakened by a lack of theme and destination, which reflects its somewhat vague title. Given this sensationalist recipe, I finished the book in an afternoon, and it left me with a lot to think about. His stories gave the impression of a physician really dedicated to hone his art; something I believe is becoming increasingly important in today's healthcare climate. Gawande explores topics which are somewhat shunned to discuss openly; namely the sexuality and salary of physicians. I believe such candid discussion within the field will become a cornerstone of future medicine. Many of the subtleties of medical practice are seen as things you learn outside of medical school, through experience. Doctors are expected to lift themselves out of their struggles, to endure through arduous internships etc. This self-coaching approach towards the profession is risky and can lead to discrepancy in practice across the field. The more doctors are candid among their peers, the more they will be able to open up towards their patients, and deliver more personal and effective care. This could be an additional argument to search for students that are less introverted and more well-rounded.

In addition to this perspective, Gawande explores the work of physicians from the battlefields of Iraq to overcrowded Indian hospitals, and this provides a compelling landscape of how healthcare is delivered in a variety of conditions. Gawande's efforts to compare his Western practice against these different approaches indicates what I believe is a wonderful devotion towards self-development. In class today we discussed how modern medicine is fundamentally about manipulating within very narrow margins, and I believe that having such self-critical skills is absolutely essential to being an effective physician. This reiterates one of the broad themes of the book - the importance of diligence across the board - not only in order to be a competent health delivering machine, but to evolve communication skills, and to be able to navigate the uncertainty that is inherent in the practice. And in the end, that is how I believe Gawande frames his book; it is a testament to his self-development as a doctor. In his conclusion he puts forth five open-ended steps which are really geared towards critical self-development: (1) to ask unscripted, genuine questions to patients, (2) to avoid complaining, (3) to count something, critically study your practice, (4) to write your thoughts, and (5) to change and evolve the way you work. As such, Gwande's book reads more like a self-help book rather than a tangible to treatise to improve the system.

Achieving Diligence

In Atul Gawande's book Better, Gawande stresses the importance of diligence in medicine. In order to illustrate this point, he profiles a recent campaign to "mop-up" polio from southern India through a large scale vaccination. I found this extreme case of diligence to be very provoking because of the great lengths these doctors had to go through to administer vaccines to a large number of children in the area. Among other logistical problems, doctors had to overcome illiteracy and compliance issues in order to execute the vaccination. For example, vocal announcements had to be made in order to spread news of the program to those locals who were illiterate.

The issue which I found the most interesting was compliance. I found it surprising that circulating rumors implying immoral intentions of the physicians were a signficicant obstacle. In this particular case, there was a rumor that the vaccine was going to cause infertility. Of course, parents were not going to allow vaccinations of their children if they believed such a rumor. How could a problem as widespread and intangible as a rumor be solved?

I thought the particular WHO doctor in this situation, Pankaj Bhatnagar, had an extremely reasonable approach towards such compliance issues. When Pankaj was confronted with a woman who did not consent to the vaccination of her children, he was not persistent or violent. In fact, when Pankaj's colleague started yelling at the woman, Pankaj instantly stopped him and explained that such an attitude would only enforce any negative rumors about the vaccine that were already circulating.

I thought this was a good way to approach diligence in this situation. Pankaj demonstrated that the achievement of diligence is not about obsessing over small tasks, but rather being persistent in trying to achieve a larger goal.

Clinical Standards and The Law

The section that really interested me in the book The Gold Standard by Stefan Timmermans and Marc Berg was about the relation between clinical practice guidelines and the law. This was particularly outstanding to me because of all the legal implications there are behind medicine. I knew there were things like malpractice for doctors but I did not realize how complex it was. Referencing another comment by a student, the extent of my medical knowledge is probably Grey's Anatomy, which is not even real life. The medical and legal world can have two completely different interpretations on what happened in a particular case that is being brought into question. In my opinion, I feel like it is hard to judges and people in court to determine the outcomes of cases like these because they do not understand all the practicalities of medicine and the patient that is being dealt with, and they won't bee sure if the evidence was not completely accurate. There is a quote stating "Indeed, the different interpretation of 'evidence' in the legal and medical realm points to the risk of equating evidence-based medicine with the legal standard of care," (Timmermans, Berg 109). There is much debate over the way courts interpret the medical information they are given, and the way they set the legal standards for the hospital being accounted for. I find this a little odd because they set a certain standard of judgment which a particular practice is held to and that although it is beneficial to a point seems a little bit limiting in the types of treatments that the doctors can give on certain patients. This results in a lowering of the creativity that the doctors can use in their treatments because if they go against these guidelines they can be penalized and brought to court for it.

He also states that "physicians might not want to develop or adopt guidelines out of fear of liability consequences," (111). This statement is reasonable to me because it would be damaging to any physicians career if they agree to these guidelines and then come across a case where they can't follow them as strictly as they are set and the patient makes a complaint. Even if it is not directly the doctors fault, they were just working out of experience or trying to think out of the box, the can be severely punished. There are so many rules and regulations that these doctors have to follow it is like they are being held back by a certain "red tape," because a lot of things are already determined for them like how they allocate their resources to which department, rules to limit the clientele, etc. According to the book, some people view all of these third party external reinforcements of the hospitals and practices as unprofessional and an autonomous way to run a profession.

Standardization and Creativity

There are several significant points that Timmermans and Berg make in The Gold Standard.  First of all, it is important to realize and understand the implications of standardization.  They show how standardization leads to a more unified field thus creating a profession.  This was discussed in chapter one in regards to the standardizing of patient records.  Doctors used to simply jot down notes about their patients in their own personal notebooks.  Over time, standards were implemented that required patient records to be kept at their bedside.  Along with these changes came specialized doctors, so patients would sometimes see multiple doctors.  These records were important so all the doctors attending to an individual were one the same page and knew the same information.  Today, this is seems so logical and hard to imagine a time without a detailed medical record.  In regards to medical records, standardization seems like a good thing.   We should hope that our doctors know our past medical history when taking care of us.  However, they mention some arguments against standardization that state it stifles doctors’ work practices, and drains their creativity.  Doctors should follow certain guidelines and standards when diagnosing patients and determining what treatment they should receive.  This supports the practice of evidence-based medicine.  Doctors should advise patients on the best available methods, which is determined through studies and tests.  However, the doctor must always remember to take into consideration the wishes of the patient.  In regards to the claim that standardization drains the doctor’s creativity, I believe the doctor still needs to be creative in his diagnosis.  This argument relates to the other discussions we have had in class as to what makes a good doctor, and especially to How Doctors Think.  Doctors still need to take creativity into account when diagnosing a patient, since every case is individual.  

Instinct, Reasoning, and Guidelines

An important aspect of The Gold Standard is that Timmermans and Berg attempt to explore the reasoning and psychological factors of the individuals when attempting to understand why standardization in the medical field is met with either acceptance or resistance.  I believe that this is important because it is different that simply analyzing group dynamics within the profession.  My interpretation of why compliance with clinical practice guidelines is relatively low is that on the individual level, physicians are instinctively not receptive to these guidelines.  As illustrated in this work, evidence based medicine is based on probability and statistical constructs.  As a result, such guidelines function to treat the “average patient,” a constructed through such statistical analysis.  Physicians, however, live in a different reality than the construct of the average patient, one where probability cannot always be trusted.  While physicians may accept the principle of the idea of evidence based medicine and guidelines, their instinct may overtake their reasoning in actual practice.  On the individual level, physicians may agree that the evidence based guidelines are generally valid, but decline to follow such guidelines after analyzing specific cases and determining that they are not appropriate for the situation.  As a result, a dichotomy is created between what physicians say they believe and what they do in while practicing. 

I believe that the problem with standardization is the threat it poses to professional autonomy.  The professionalization of the medical field was based upon the concept of autonomy as it allows patients to put more trust in their doctors and ultimately gives doctors moral and scientific authority.  If we allow standards to intervene in medical decision making, physicians will no longer be able to exercise their own professional discretion, harming the credibility of the entire field.  This is why, I believe, that while evidence based medicine is an important part of clinical medicine, analyzing patients and treatments on a case by case basis should not be completely overshadowed by standardization.

The gold standard

One thing i found interesting in The Gold Standard was the transition of the way doctors keep records of their patients. Before we had our modern technologies doctors used to keep journals or diaries of their patients medical histories, they would also make quick scribbles of their visits an records. It was unorganized and propably easily lost and it was har to put together someones medical hostory if they saw many dofferent doctors. Now we have computers and data bases which makes everything more organized an easier to acess. I also found it disturbing that certain illnesses or disorders are made up just so drug companies can keep functioning and making money. By reading this book as well as the previous ones it makes me question what is the goals of many doctors because from these readings it shows doctors are more about making money an politics rather then helping people. The authors also state that it is inevitable to keep everyone alive so they save mainly the people who are in a better state an they just leave the ones who are worse off to die.

Evidence-Based Medicine

I thought The Gold Standard’s discussion of the role of evidence-based medicine in doctoring to be one worthy of further investigation. One well-written article found online said, “Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” It later reads: “evidence based medicine is not “cookbook” medicine. Because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patient’s choice, it cannot result in slavish, cookbook approaches to individual patient care.” I suppose I’m bothered by the fact that EBM is something that people feel needs to be implemented; given the nature of medicine, it seems, to me at least, logical to use the “current best evidence” in making decisions. Perhaps I’m unclear as to what the alternative is...pulling a diagnosis out of a hat...? I wouldn’t be one to assume that EMB yields “cookbook” medicine because, though individuality in patient care is important, evidence and statistics can provide valuable information. It seems to me that it would be awfully difficult to practice medicine without some sort of evidentiary backing. Then again, I’m not a doctor, so I really don’t know.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2349778/pdf/bmj00524-0009.pdf

Guns, Germs, and Steel

Upon first reading this book, I honestly did not realize what the point that Diamond was trying to make in going through a progression of all these different societies dating back to the pre-Clovis people. I did not understand how it related to science or medicine really. After a few discussions and reading some posts, I realized that a lot of it had to do with nature and how humans in the pre-colonial eras made a living for themselves off of the land they had. Diamond intertwines a mixture of history and sociology but in my opinion he does not discuss science or medicinal techniques as a dominant part of his book.

Diamond goes extensively into the different cultures and societies that were building at different points in time. One of the early societies he starts to analyze are tte Native Americans in the Fertile Crescent and people of New Guinea. These people were extremely important to us today because they helped domesticate animals and were the first ones to hunt and gather which helped the human population survive in times where there was little technology. On page 160 there is a outline of the domesticated animals at the time on different countries. He goes on to state that "This very unequal distribution of wild ancestral species among the continents became an important reason why Eurasians, rather than peoples of other continents, were the ones to end up with guns, germs, and steel," (Diamond 161, 162). I feel that this quote, besides having the title in it, encompasses a lot of what Diamond is trying to achieve in this book. He wants to find out why certain countries and continents ended up like they did. Why some of them had advanced supplies and advanced crops while others lagged behind. He also wants to know what  fueled these differences and why some places did not ever catch up.

Some countries learned to domesticate and use nature to their advantages, like Europe, much quicker than other countries did. In his chapter called "Necessity's Mother" Diamond starts to talk about the first developments of human technologies and he also states that Europe and Russian countries were the first to succeed in these areas, such as ceramics, printing, and anatomy. In fact, Europe was the country in the lead in all aspects, including science and population in general, according to the chart on page 263 even into the 1990s. One of the reasons Diamond states for disparities between the Native Americans and the European societies was the food production differences. While Europe had protein- rich cereals and advanced tools to farm the Native Americans and some other countries did not. Ultimately, Diamond is examining why human societies such as these , that were all in communication with each other, developed completely and utterly differently.

In his afterword, Diamond states "My main conclusion was that societies developed differently on different continents because of differences in continental environments, not in human biology. Advanced technology, centralized political organization,...could emerge only in dense sedentary populations capable of accumulating food surpluses," (Diamond 426). Diamond wants the take away of this book to be that societies develop accordingly depending on the resources at hand, and these can make or break a society as a whole. He might not have used the most concise and precise way to do this. however he provided an extreme amount of details that are beneficial in understanding how societies came to be today.

"Ultimate Conclusions"

Jared Diamond's Guns, Germs, and Steel was an interesting read to me because he focuses on societies that were not successful in order to understand how the powerful ones were able to come about. He is also continuously challenging the reader by stating that we should try to come to the conclusion of ultimate explanations. However, when in comes to these conclusions, I don’t think Diamond is able to provide insightful answers. For example, in the food power chapter Diamond explains how hunter-gatherers were less advantaged than those that domesticated animals and plants. I thought I would find out some innovative reason as to why they came about but his “ultimate explanations” were reasons that were very much straightforward. I mean it’s pretty obvious that with more food, you can feed more people so there will be denser populations. On top of that I would assume he would provide some kind of evidence to these conclusions but he doesn’t. Furthermore, in the next chapter, “History’s Haves and Have-Nots” Diamond asks so many thought-provoking questions as to why food production began at different times in different regions. And ultimately his conclusion is a list of regions and its primary domesticates.  I think many times throughout the book, he is able to pump the reader up of curiosity and then when it comes to the reasoning, it just doesn’t get interesting anymore because of the bland answers.

Guns, Germs and Steel

I found that several of the points in Jared Diamond’s Guns, Germs and Steel were either given substantial evidence or minimal. For example, his description of how plants and animals were domesticated was very thorough. However, I found his argument about why certain societies are innovative versus those that are conservative insufficient. For one thing, I wish his list of factors for what leads to different degrees of receptivity across societies were more universal norms rather than descriptions of time periods. For example, for economic factors, I wish he would have made a stronger institutional case such as emphasizing the importance of liberal institutions for innovation. While he certainly makes the point that patent protection exists in the Modern West and that its lack of discourages innovation in China, I think he could have made a stronger case from a broader historical standpoint rather than using such narrow evidence. But my biggest issue was his lack of describing what led certain societies to be conservative and shy away from embracing new technology versus those that are innovative and readily adapt new technology. I found his explanation left something to be desired. I don’t believe his anecdotal evidence can necessarily be applied to all of human history. He uses the example of two tribes in New Guinea: one, the Chimbu who he indicates is innovative and readily embrace its introduction to new technology, and the other the Daribi who he describes as “briefly looked at [the first helicopter] and just went back to what they had been doing” (252). So his evidence provides a good explanation of what they did, but it doesn’t address why. Are their larger social differences between the two? Do the two tribes have essentially the same structure or do they vary greatly? From my understanding, he makes it seem as if it is a random process by which societies are innovative or conservative rather than being the product of their social environment. While I realize this isn't a sociological text, I wish he had provided more social explanations.

Guns, Germs, & Steel

In Guns, Germs, and Steel Jared Diamond theorizes that rather than genetic or intellectual superiority, biogeographical factors have historically been responsible for the rise of certain societies and their dominion over others, making certain successes “inevitable." However, there seem to be some flaws with this argument. In claiming geographical determinism, Diamond neglects inequalities deeply entrenched and not necessarily predestined in various societies such as: slavery, colonialism, and genocide. Furthermore, very few populations in Asia were wiped out as a result of European "germs"--almost negating his whole argument. If Diamond is making a claim about geography equating destiny, are we to assume that racial and ethnic inequalities are a direct factor of certain environments and health conditions within that society? And furthermore, how would Diamond reconcile the immense technological successes and flourishing of countries such as China and India? Diamond almost shakes his head at those "uncivilized" (another issues I have with the book: archaic terms) societies and embraces only those that took on new technology. He never really gives attention to those societies which may not have thrived by Western standards but are perhaps healthier than Westernized societies as a result of their technological lag. I agree entirely that the book could have certainly benefited from a more thorough (and perhaps less eurocentric) sociological analysis of why some societies progressed while others took different routes or declined. Had he delved slightly deeper into these concepts, perhaps he would have been able to fill in some of the voids to his lofty argument.

The Evolution of Societies

In Guns, Germs, and Steel, Jared Diamond explores the factors contributing to the development of human societies. Diamond’s central question asks why some societies developed fundamental advantages (guns, germs and steel), while others did not. Diamond’s approach to this question has very little to do with the intrinsic abilities of the people themselves, but rather the natural consequences of the land they happened to inhabit.

Diamond’s model of the development of civilization begins with the transition from hunter gatherer to food production by farming. I found Diamond’s explanation of this shift to be very elegant. Diamond establishes early on that farming was not an “invention” or a “discovery”, which completely changed the way I thought about the process. Diamond makes an important distinction when he explains that people in early societies did not consciously strive for the farming lifestyle as a “goal”. Instead, the shift to farming was because of natural human tendencies towards efficiency. The inevitable depletion of wild game, new farming technologies, and the ability for farming societies to support growing populations all contributed to this natural transition (110).

The way I see it, the transition to farming was the product of a process analogous to evolution, but on a societal  level. Like genetic evolution, it was natural, gradual, and occurred as series of adaptations to environmental pressures. This process is paralleled throughout the book, with my personal favorite being his discussion on plant domestication. In this section, Diamond explains how the domestication of wild plants was crucial to the transition to farming. Interestingly, wild plants were initially domesticated by selection from humans. People were naturally more likely to pick and take seeds from plant mutants with desirable traits. This way, domesticated crops genetically changed to become tastier, easier to eat, and more manageable than their wild relatives. Through this simple overarching mechanism, plant domestication was achieved.

I think it’s interesting that the societal shift from hunter-gatherer to farmer was driven by an evolutionary mechanism which was mirrored in the wild plant's shift to domestication.  Our past reading Survival of the Sickest came to mind, as Moalem also elaborated on the dynamic nature and incredible influence of evolution. Overall, I find the theme of evolution in the development of societies to be invigorating and extremely eye-opening.

Social Controls on Medical Doctors

After reading the book Forgive and Remember by Charles L. Bosk, I realized that there are a lot of controls and checks on what goes on in a medical hospital and between all the doctors, attendings, residents, and interns. These controls seemed to be odd to me at firs and I did not know quite how to describe them until recitation today, when we talked about how it seemed a little bit like a cult. I completely agree with this statement because every example that Bosk was giving was about how the interns had to follow around the residents or the attendings, abide by their every word, and check their every move against theirs. There seems to be conformity among them, and although they are learning, the interns never seem to really be doing anything solely on their own. There are always checks and error and guidelines that are very strict that they are expected to follow. In the introduction to hte book as well, Bosk was talking about all the different controls that doctors have on them. For example, there is informal -internal controls, which are the ways members of a group remind each other of their responsibilities during their work routines,  formal-internal controls, which are reviewing performance of a doctor periodically, there are formal-external controls, and so on. There seem to be a lot of controls coming from many different directions on doctors. There is a certain track that the new doctors are supposed to keep on that they cannot deviate from. Additionally, there is much more competition among doctors than in other professions. They are always trying to get on the good side of the higher-ups so they look better and gain favor and a good reputation. I feel that this is because out of medical school all the interns are treated the same and that in order to get even a smidge of appraisal the interns have to go out of their way to mak it known that they did something good or worthy of notice.
All in all, I think there needs to be some reform within the medical field of how things are carried out. I feel that they can reduce the amount of errors that students and interns make by having more guided training, and a lot less hierarchy. The need that interns feel to claw their way to the top probably does not help their concentrationo n their patients. Additionally, I think there needs to be a better way of assigning interns in hte first place. I feel that a lot of the errors they make come from the fact that hey are seeing tons of different patients a day and paper work is being filled out everywhere and it is very disorganized because there are time constraints. Since they do not really know what they are doing I think interns should only focus on a few patients at a time but work with them full out, and work on their charts and paperwork and medications as well. I think that not enough credit is given to them having come out of medical school with that hugh encyclopedia in their head and attendings and residents do not give them the chance to fully show their knowledge. These reforms would most definitely increase the quality of patient care and that is the ultimate goal of health care professionals.

Doctors and Errors

Today in class, we discussed why doctors are held to such high standards especially in regards to when they make mistakes.  For me, this comes down to the fact that we trust doctors with our health and life.  We believe that after all their rigorous years of schooling, they will know what to do, and not make a careless mistake.  While I realize that doctors are humans and they do make mistakes, sometimes these mistakes are not that minor.   Like the examples from class, there are the horror stories of the wrong limb being amputated or receiving the wrong dosage of a painkiller.  These are major errors since they leave significant and visible repercussions, sometimes even death.  Furthermore, it seems that it is much easier to pinpoint a medical error to a specific time and person.  If my healthy foot was amputated, I would be able to track it and blame the doctor in charge of the surgery.  Professor Jennings asked us to briefly think how medical errors compare and contrast to other fields.   I find this comparison to other fields, especially education, to be extremely interesting.  Our education has a very big impact on our lives.  If a person graduates from high school, he or she has spent at least 12 years of formalized schooling.  Let’s say that while this person was in kindergarten, his teacher labeled him as a trouble, hyper child.  Because of his antsy behavior, he couldn’t focus and learn.  However, the teacher did not try other methods or to accommodate his learning style or see what other issues may be affecting his behavior.  The teacher talks to the other teachers and word spreads that this student is a troublemaker.  The student will most likely start to think he is in fact a troublemaker and won’t make an effort to change, if none of his teachers give him the care and attention he needs.  Now the child carries this label with him, which will affect the education he receives.  Now, it might seem easy to pinpoint this error in teaching back to his kindergarten teacher, but none of his other teachers tried to work with him and change this label.  As a result, it is more difficult to pinpoint this error, which has long-term consequences.  When doctors make mistakes, it seems so detrimental since the errors are easier to pinpoint and the effects are more visible.   

Omissions and Social Constructs

In the amended appendix of the second edition of Forgive and Remember, Bosk includes two stories that he had purposefully omitted from the previous edition. Both omissions relate back to the idea of the social construction of medical errors, as he states, “Each blunted the interpretation, analysis, and critique of surgical training and professional socialization, shop-floor ethics, and professional social control embedded in the ethnographic account” (217). These are all very important concepts and the two omitted stories add a great amount of depth to their understanding. The first omission occurs in Chapter 5, where Bosk illustrated the influence attending surgeon’s judgments of the residents’ performance on their careers, exploring the differences between the four types of errors. An entirely new context is added to this chapter because the resident he describes, Dr. Jones, is a woman and not a man as originally stated. Not only was Jones a woman, but she was the sole woman out of all of the residents Bosk observed. Bosk claims that he made this change in order to protect the subjects’ confidentiality and anonymity, but the analysis of the observation changes completely when the gender changes. Jones’ experience as the only woman in a hostile, patriarchal environment may have very well played a huge role in determining her behavior and her subsequent dismissal. The influence that sexism may have had on what others deemed to be her errors is a narrative that encourages a very important discussion regarding male domination, gender identity, and its influence on the medical profession.

The second omission that Bosk made involved the attending surgeon, Dr. Arthur. What Bosk did not mention in the earlier edition was that Dr. Arthur, who believed that residency was a “stress test” and that recreating “battlefield conditions” were critical for developing excellence, would rountinely make incredibly demeaning and racist remarks. This relates to his analysis of the resident Dr. John Carter, who Bosk now believes was baited and ended up leaving the program due to his resistance to the hostile environment created by Dr. Arthur rather than due to his own personal attributes. Both of these omissions are important to Bosk’s work because they add important perspectives to the analysis of medical errors. They add to the discourse as they clearly illustrate how the application of quasi-normative standards can undermine the fairness of the normative standards of medical training. As Bosk states, “We need to ask ourselves: how many voices have we allowed to speak and how many hidden presumptions have we questioned.”

How Doctors Reflect

First, I did some digging and found this article which states that "WebMD has become 'synonymous with Big Pharma Shilling' in certain circles:"

http://www.nytimes.com/2011/02/06/magazine/06FOB-Medium-t.html?_r=3&adxnnl=1&emc=eta1&adxnnlx=1297188225-sw5Vl/lB7WQPSUmOBBKY6Q

Apparently WebMD has admitted connections to pharmaceuticals and other health related companies. The website has biases towards certain medication and advertises various medications openly throughout their site. Kinda interesting no?

This is my second reading of Jerome Groopman's How Doctors Think and I believe the book serves its purpose well, demonstrating the difficult decisions and bioethical issues faced by physicians. On a slight negative note, I have always thought that while Dr. Groopman does a fair job identifying problems, he offers few concrete suggestions for reform. For example, while he does make a number of suggestions on how physicians can think more clearly (think outside the box, questions gut instinct, etc), he does not offer a concrete program for improving the diagnostic skills and thought processes of physicians in the US. His only idea for improving training seems to be to push clinicians to ask themselves the above questions more frequently. Given the success of the book, you would have thought the guy would come up with some original solutions to ethical and professional issues.

But while this shortcoming does provide a certain degree of post-reading dissatisfaction, Groopman manages to demonstrate how some physicians fail while others succeed, and raises some important questions around the profession. Americans have a various ideas on what they expect from their physicians, as demonstrated in class discussions. It is impossible to expect any sort of perfect competence from doctors, but I believe it is essential for all physicians to exhibit a strong inclination for self-development. The field of medicine will always be messy and complicated, both in terms of ethics and practicing effective medicine. It is pinnacle for physicians to be able to develop a personal philosophy around delivering effective and efficient care, alongside a permanent grasp of medical knowledge. Without constantly developing a strong, positive moral agreement and maintaining clear communication with patients, it becomes very easy for physicians to become unsatisfying with the challenges of their job. There is no silver bullet for the issues of medicine, and this is the reason for Groopman’s omission. Most of the changes that would positively contribute to patient care need to happen among the psyches of individual physicians, constantly reevaluating the care they provide and not being stuck with their egos.

Medical Ethics

Despite my extreme distaste for Forgive and Remember: Managing Medical Failure, I thought Bosk’s discussion about the “Varieties of Normal Action” and the accompanying grid of expectations and outcomes (pg. 116-120) to be were interesting and worth more detail, particularly Cell 4, expected failure. Here, doctors face the difficult situation of knowing that medical intervention will most likely be unsuccessful, but needing to care for their patients in the most ethical and humane way possible. I stumbled across this New York Times article from 1990 that touches on the same idea: http://www.nytimes.com/1990/05/15/science/the-doctor-s-world-despite-many-shifts-oath-as-old-as-apollo-endures-in-medicine.html?src=pm. In a nutshell, the Hippocratic oath, a list of axioms repeated by new doctors that essentially mean they will do no harm, has been phased out in the medical school setting and there’s a question of the validity of its origins. According to the article, it’s quite possible the Hippocratic oath (and accordingly, medical ethics) are not studied in medical school at all, which is detrimental to patients, and that the oath has paternalistic roots that don’t honor a patient’s wishes and hold the doctor above all others. It’s an interesting read, and encompasses bits of our discussions about How Doctors Think, medical ethics and our current reading.

Surprising Medical Insights

After reading the book How Doctors Think, by Jerome Goodall, I gained a lot of new, shocking insights about what goes on behind-the-scenes in the medical world. And although some of it seemed a little upsetting, I gained an entirely new respect for the work that doctors, especially pediatricians do everyday.  I definitely underestimated what it took to be an experienced, well-rounded doctor.

However, I do feel as if there are problems with the ways in which medical schools are teaching their students. He explained that in medical school when they saw patients during rounds, they would be "led through a calm, deliberate, and linear analysis of the clinical information," (Groopman 34). Even on the first night of being out of the medical school and into the hospital on his own, Groopman learned that "thinking was inseparable from acting," (Groopman 35). Nobody can truly be prepared to what can happen to a patient when they are not working under an instructor. Groopman was dealing with a patient, William Morgan, just having a normal conversation with him when his blood pressure started falling and his breathing turned abnormal and he had to idea what to do. He was getting flustered and frenzied, because obviously he had never dealt with an experience like this. This is one thing that medical schools will teach you in textbooks and writings but how do you know how to really deal with it when you face it in real life? This is definitely a flawed system because all the medical students have to rely on is that encyclopedia in their heads or index cards that they carry around with them. However, textbook definitions of diagnoses and procedures is not always how it goes with patients.

Despite the flaws of medical schools, I never realized all the different problems and things that doctors had to go through when evaluating patients. I mean, obviously I knew that being a doctor would be no cake walk, which is why only the smartest people can become one, but I never realized the extent of it until this book. For example, even when a doctor thinks they have the right answer, all the right symptoms pointing to one disease and everything, they should create a list in the back of their minds of other possibilities that it could be. The doctor cannot ask patients questions in certain ways, and there can always be misunderstandings between patients and doctors. For example, he described the pediatrician that had a regular patient that left because she thought she was being racially profiled as having dirty blood, when in fact it was just a diagnosis that her blood had been contaminated while being tested and she completely misunderstood, but left to find a new doctor anyway. Doctors have to do their best, most complete job under heavy time constraints, Groopman described it as spinning plates with people distracting you and always asking you for something at the same time. In that sense, doctors have to be able to have very good divided attention. As we discussed in lecture, there are tons of qualities that people look for in doctors, and knowledge is not even one of the top ones,, and great doctors have to encompass all of these, even after going through a flawed medical school system!