Better: A Surgeon's Notes on Performance by Atul Gawande
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Book Reviews of Better: A Surgeon's Notes on Performance
Book Review: Better: Diligence, Doing Right and Ingenuity
Summary: 5 Stars
I have to agree with Stephen Laniel that Gawande's Better is such a thought-provoking and insightful book that I couldn't help but keep reading till the end (however, I am such a slow reader, so I wasn't able to finish it in 4 hours. Though I managed to finish reading it on my road trip back to New York City from Maine this weekend. Of course, I was sitting comfortably in the passenger seat.
I do like "The Doctors of the Death Chambers" a lot. I think it was a tough call for the four physicians to make: whether to abide by the medical ethics codes or to "do it right" according to their conscience. Life is full of these ethical dilemmas that none of us can avoid. Normally we simply follow our gut feelings and if we are wrong likely it won't have any fatal or tragic consequence. But the dilemma these physicians encountered was particularly difficult as human lives were involved. They were being criticized by others as unethical and they could even jeopardize their jobs. Although medical professionals should be dedicated to preserve life, is it wrong to make it a less violent and more peaceful passing when the death is inevitable? Observing the rules blindly meant unnecessary and inhumane suffering during the execution, which is not something the medical society (or anyone of us) should encourage.
"The bell curve" is my favorite. I was particularly impressed by Dr. Warwick's ingenuity. Not only does he constantly push the quality of care he delivers to a higher level and strive for perfection, he also pushes his patient to do better and try harder. During the course of treatment, patients do play a key role in getting the desirable outcome. I couldn't help but keep thinking about a disappointing dialogue I had with my primary care physician when I told her I had been experiencing knee pain lately - mostly after running for over 40 minutes (funny it's as if my knee has a timer). She simply gave me a cold response, "You just have to stop running." I thought to myself that running is what gives me "bliss," so how can I just give up without even "trying" to fix the problem? If I were lucky enough to have Dr. Warwick as my physician, he would have asked the questions to lead to a more proper diagnosis and offered a workable treatment plan that allows me to run a half-marathon, if not a full marathon. Even if I wouldn't get better, at least we wouldn't give up.
Definitely don't miss the Afterword. The suggestions for becoming a positive deviant are not limited to physicians only. They can be applied more broadly to every single individual. Everyone is given the opportunity to be a positive deviant in whatever aspect of life we desire (be it our professional endeavor, our interpersonal relationship, or our social responsibility, etc...). If you do miss the Afterword, here is the essence: As Atul suggested, "Find something new to try, something to change. Count how often you succeed and how often you fail. Write about it. Ask people what they think. See if you can keep the conversation going.
I enjoyed this book so much that I finished his other book titled "Complications" upon returning to NYC and continue to read through the articles posted on Dr. Gawande's website at http://www.gawande.com.
Coincidentally I recently came across an article titled "Where in the body is that sponge?" in the July 2008 issue of Health IT News (Yes, I am a geek in Health IT) which is related to Dr. Gawande's recent published findings in the Annals of Surgery about a computer-assisted method of counting surgical sponges (see http://www.gawande.com/documents/2008AnnSurg--BeyondCountingeditorial.pdf).
Book Review: a captivating peek into medicine
Summary: 5 Stars
Better is an entertaining compilation of writings about different facets of medicine, I picked up this book and finished it during one travel day.
Atul Gawande, a surgeon at Brigham's Hospital in Boston, weaves individual patient's stories with his thoughts about larger issues facing society. The stories remind us that medicine, given all of its dimensions, may be the most "human" of all endeavors.
I am not related to any doctors, I don't have any friends in the medical field, and I see my own doctor as infrequently as possible. Meanwhile, 15% of our economy is based on medicine and health care. This book was a peek into that world for me, showing how engulfing it is, occupied by deeply dedicated professionals who are barraged by emotional, intellectual and physical challenges as part of their commitment to others' health.
Gawande maps out his book in the Introduction. He says that there are three core requirements for success in medicine, around which he organizes his book: diligence, doing right and ingenuity.
In the section on diligence Gawande talks about the effort to encourage doctors and nurses to wash their hands to stop the spread of superbugs, the diligence of doctors on the battlefield in Iraq (many soldiers' lives are saved that would have been lost before,) and lastly, the effort to rid polio from the earth, how complicated and human that effort is in its problems and issues.
In the chapters on doing right Gawande talks about doctors' pay, medical lawsuits, doctors who assist in prisoner executions (when they have sworn to "do no harm") and how to know when to "pull the plug" on a dying patient (hint: you can't know.)
In the chapters on ingenuity Gawande talks about how medical centers can implement systems which improve survival. He describes in detail how a couple medical centers (and, arguably, due to the influence of a couple people in particular) are responsible for the life expectancy of cystic fybrosis patients now being up to age 45+, when in the 1960's the average patient could expect to live to age 3.
For me, reading this book was like meeting a captivating guest at a dinner party who offered me a glance into a deep, engaging, world. I came away thankful for the author and others in medicine for their commitment to a tough field in which they make meaningful differences in people's lives and well-being (and, therefore, happiness.) I know that people in medicine are as human as everyone else, and that there are people in medicine who abuse power, are greedy, etc, just as in every other field. But I think, for the most part, people enter and stay in medicine for noble reasons. This book is about those people, whom I can only admire and appreciate.
Book Review: Improving Performance
Summary: 5 Stars
Dr. Gawande writes very well and this is an important book on what is necessary to improve medical care. However, before considering the book as a whole I want to skip to the section that I found to be the most important and that I'm afraid will be overlooked by most readers.
"What is more likely to save [lives] - investment in laboratory science or in efforts to improve how existing medical care performs?
"The answer most people would come to is investment in laboratory science - the search for a cure... Instead... efforts to monitor and improve and transform clinical performance using know-how already in existence" would save more lives. "[W]e have effectively used the abilities science has already given us. And we have not made remotely adequate efforts to change that. When we've made a science of performance - as we've seen with hand washing, wounded soldier child delivery - thousands of live have been saved. Indeed, the scientific effort to improve performance in medicine - an effort that at present gets only a pitifully miniscule portion of scientific budgets - can arguably save more lives in the next decade than bench science, more lives than research on the genome, stem cell therapy, cancer vaccines, and all the other laboratory work we hear about in the news."
Personally, I have no doubt Dr. Gawande is correct. Improving the provision of medical care will do far more to save lives than research on individual diseases. For that matter, increasing access to medical care for the millions of uninsured Americans will also save tens or hundreds of thousands of lives over the next decade. Unfortunately most Americans seem to believe exactly the opposite: that money spent on research is a better investment than money spent on increasing access and improving care.
Dr. Gawande's other prescriptions for improving care are just as perceptive. He identifies three qualities necessary to advance performance: Diligence, Doing Right, and Ingenuity and provides examples of each either from history or from his own experience. Diligence and Ingenuity seem fairly obvious, Doing Right is less so but deals with the ethics of care. The chapter on Cystic Fibrosis, in the Ingenuity section of the book is a wonderful example of how to improve care by refusing to settle and by being willing to examine one's own behaviors and see how you compare to others in your field. What happens when a hospital finds it is not one of the leaders in care but is only average, or even below average? It takes courage to be willing to examine the question and diligence to pursue the improvements that need to be made.
In sum, this is an excellent book for professionals and lay readers.
Book Review: How A Local Hospital Reduces The Spread of Bacteria
Summary: 5 Stars
From: www.BasilAndSpice.com
Author & Book Views On A Healthy Life!
Book Review: Better by Atul Gawande, MD
Dr. Atul Gawande, General Surgeon at Brigham and Women's Hospital--Boston, Assistant Professor at Harvard Medical School, Staff Writer for The New Yorker, and Best-Selling author of Better writes about the importance of washing hands and how to actually cut the spread of potential lethal disease. He states that approximately two million Americans pick up an infection while in the hospital. Of these, ninety thousand will die from that same infection. Possible attacks come from rotavirus, Norwalk virus, Pseudomonas bacteria, resistant Klebsiella, MRSA-- methicillin-resistant Staphylococcus aureus, and VRE-- vancomycin-resistant Enterococcus--the last two frequently causing pneumonias, wound and bloodstream infections.
Admittedly, Dr. Gawande recognizes that studies show nurses and doctors do not wash their hands frequently enough, up to 50% of the time. Recalling the lesson taught by obstetrician Ignac Semmelweis, he points out the cause of childbed fever (puerperal fever) was the lack of washing hands. In 1847, 600 of 3,000 mothers delivering babies in Semmelweis's Viennese hospital, died from the bacteria Streptococcus, which leads to childbed fever. After instigating a wash up with chlorine and a nail brush for doctors and nurses, between patients, the death rate fell from 20% to 1%. Even though this procedure offered sufficient proof of success, doctors elsewhere declined to institute the hand washing. They simply could not believe that they themselves were making their patients sick.
Recently, a surgeon named Jon Lloyd hit on an idea from the Save the Children program: Positive Defiance, or building upon capabilities people already have, rather than making them change their behaviors. After meeting with small groups (from kitchen worker and janitor to nurses, doctors, and even patients) in a trial Pittsburgh hospital, and instilling the staff's ideas, change was made. For example, they themselves decided where to best place new hand-gel dispensers. By empowering the employees, they worked together toward a common goal. The result at the end of one year, "the entire hospital saw its MRSA wound infection rates drop to zero."
Dr. Gawande continues with news that The Robert Wood Johnson Foundation and the Jewish Healthcare Foundation are beginning to implement this initiative in ten more hospitals across the United States. To this point, no other idea has worked.
This is an excellent book.
5 Stars
Book Review: Fascinating. Must read. Classic.
Summary: 5 Stars
A fascinating and quick read, in each section there are plenty of inspiring stores about doctors making a difference. Dr. Atul Gawande, a general surgeon at Brigham and Women's Hospital and staff writer for the New Yorker has keen observation and insight to make single stories demonstrate not only the failings of our healthcare system but also the solutions to them because of individuals asking questions on how to do better. Ultimately, one of the questions he asks is how can doctors and hospitals be positive deviants? How does one become a positive deviant or an outlier that pushes beyond convention and advances patient care to new levels?
He gives examples of how over four million children need to be vaccinated in Northern/Southern India in three days to prevent a large polio outbreak. An immunization rate of less than 90 percent would be considered a failure.
Dr. Gawande talked about the evolution of obstetrics. After a damaging report in 1933, the specialty consequently committed itself to standardizing childbirth ensuring that with the new medical knowledge that it was applied consistently and routinely throughout the country. As a result maternal death in childbirth fell 90 percent from one in 150 in the 1930s to one in 2000 by 1950s. With continued innovations and the commitment to do better, the chance of a woman dying in childbirth is less than one in 10,000 today.
There are plenty of amazing examples that you don't have to be a doctor to relate on how truly inspirational these individuals are in times when the stakes could not be higher - life or death.
As a practicing family doctor, I believe that our healthcare system can do better in providing all of us the best care consistently and routinely across the country. Although his book is easily a classic and should be required reading for all future doctors, sadly I think true healthcare reform and improvement are years away. I wrote the book Stay Healthy, Live Longer, Spend Wisely: Making Intelligent Choices in America's Healthcare System specifically so everyone has the information they need to get the best care today. Until our healthcare system improves to its full potential as Dr. Gawande challenges us to do, unfortunately will always remain benefiting those who are insiders and harming those who are not. The real question is which one are you?