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.