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.