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Better, by Atule Gawande

I just finished the second of Gawande’s two books, titled Better. I found his first, Complications, very eye-opening, and this one is just as captivating, though in a different way.

Much like his first book, Better is also made up of three parts, each with several interesting medical cases to illustrate his point: that medicine is not a static field, but one where the individuals that make up the profession should be constantly seeking to improve themselves, their skills, and the health of society at large.

The first part is titled Diligence, in which he gives us compelling examples where it was a doctor’s attention to detail and drive to give 110% that led to extremely positive outcomes in dire situations. Part two, Doing Right, features several stories where doctors’ decisions are more than just designations of a prescription or a treatment plan; examples included doctors deciding what to charge for their services, doctors in the administration of lethal injection to death row inmates, and doctors in malpractice lawsuits. The final part, Ingenuity, is a call for doctors to be critical of their own practices and be constantly in seek of improvement, greater efficiency, and better care management for their patients.

I will do the same thing as I did in my post about Complications – give a few excerpts of the book that I found extremely powerful. This book had more passages that I took note of, and in order not to violate any copyright laws, I’ll stick to the really good ones.

This first passage is actually at the very end, as part of the afterword, which itself is titled “Suggestions for Becoming a Positive Deviant.”

“No doctor wants to believe that he or she is a bit player, though. After all, doctors are given the power to prescribe more than 6,600 potentially dangerous drugs. We are permitted to open human beings up like melons. Soon we will even be allowed to manipulate their DNA. People depend on us personally for their lives. And yet, as a doctor each of us is just one of 819,000 physicians and surgeons in this country tasked with helping people live lives as long and healthy as possible…

…It can be hard not to feel that one is just a white-coated cog in a machine—an extraordinarily successful machine, but a machine nonetheless. How could it be otherwise? The average American can expect to live at least seventy-eight years. But reaching, and surpassing, that age deepens more on this system of millions of people than on any one individual within it. None of us is irreplaceable. So not surprisingly, in this work one begins to wonder: How do I really matter?

I get to lecture to the students at our medical school on occasion. For one lecture, I decided to try to figure out an answer to this question, both for them and for myself. I came up with five—five suggestions for how one might make a worthy difference, for how one might become, in other words, a positive deviant. This is what I told them. —

— My first suggestion came from a favorite essay by Paul Auster: Ask an unscripted question. Ours is a job of talking to strangers. Why not learn something about them?

On the surface, this seems easy enough. Then your new patient arrives. You still have three others to see and two pages to return, and the hour is getting late. In that instant, all you want is to proceed with the matter at hand. Where’s the pain, the lump, whatever the trouble is? How long has it been there? Does anything make it better or worse? What are the person’s past medical problems? Everyone knows the drill.

But consider, at an appropriate point, taking a moment with your patient. Make yourself ask an unscripted question: “Where did you grow up?” or: “What made you move to Boston?” Even: “Did you watch last night’s Red Sox game?: You don’t have to come up with a deep or important question, just one that lets you make a human connection. Some people won’t be interested in making that connection. They’ll just want you to look at the lump. That’s OK. In that case, look at the lump. Do your job.

You will find, however, that many respond—because they’re polite, or friendly, or perhaps in need of human contact. When this happens, try seeing if you can keep the conversation going for more than two sentences. Listen. Make note of what you learn…

…One can of course do this with people other than patients. So ask a random question of the medical assistant who checks their vitals, a nurse you run into on rounds. It’s not that making this connection necessarily helps anyone. But you start to remember the people you see, instead of letting them all blur together. And sometimes you discover  the unexpected…

…If you ask a question, the machine beings to feel less like a machine.

My second suggestion was: Don’t complain. To be sure, a doctor has plenty to carp about: predawn pages, pointless paperwork, computer system crashes, a new problem popping up at six o’clock on a Friday night. We all know what it feels like to be tired and beaten down. Yet nothing in medicine is more dispiriting than hearing doctors complain.

…Medicine is a trying profession, but less because of the difficulties of disease than because of the difficulties of having to work with other human beings under circumstances only partly in one’s control. Ours is a team sport, but with two key differences from the kinds with lighted scoreboards: the stakes are people’s lives and we have no coaches. The latter is no minor matter. Doctors are expected to coach themselves. We have no one but ourselves to life us through the struggles. But we’re not good at it. Wherever doctors gather—in meeting rooms, in conference halls, in hospital cafeterias—the natural pull of conversational gravity is toward the litany of woes all around us.

But resist it. It’s boring, it doesn’t solve anything, and it will get you down. You don’t have to be sunny about everything. Just be prepared with something else to discuss: an idea you read about, an interesting problem you came across—even the weather if that’s all you’ve got. See if you can keep the conversation going.

My third answer for becoming a positive deviant: count something. Regardless of what one ultimately does in medicine—or outside medicine, for that matter—one should be a scientist in this world. In the simplest term, this means one should count something. The laboratory researcher may count the number of tumor cells in a petri dish that have a particular gene defect. Likewise, the clinician might count the number of patients who develop a particular complication from treatment—or just how many are actually seen on time and how many are made to wait. It doesn’t really matter what you count. You don’t need a research grant. The only requirement is that what you count should be interesting to you…

…My fourth suggestion was: Write something. I do not mean this to be an intimidating suggestion. It makes no difference whether you write five paragraphs for a blog, a paper for a professional journal, or a poem for a reading group. Just write. What you write need not achieve perfection. It need only add some small observation about your world.

You should not underestimate the effect of your contribution, however modest. As Lewis Thomas once pointed out, quoting the physicist John Ziman “The invention of a mechanism for the systematic publication of ‘fragments’ of scientific work may well have been the key event in the history of modern science.” By soliciting modest contributions from the many, we have produced a store of collective know-how with far greater power than any individual could have achieved. And this is as true outside science as inside.

You should also not underestimate the power of the act of writing itself. I did not write until I became a doctor. But once I became a doctor, I found I needed to write. For all its complexity, medicine is more physically than intellectually taxing. Because medicine is a retail enterprise, because doctors provide their serves to one person after another, it can be a grind. You can lose your larger sense of purpose. But writing lets you step back and think through a problem. Even the angriest rant forces the writer to achieve a degree of thoughtfulness.

Most of all, by offering your reflections to an audience, even a small one, you make yourself part of a larger world. Put a few thoughts on a topic in just a newsletter, and you find yourself wondering nervously: Will people notice it? What will they think? Did I say something dumb? An audience is a community. The published word is a declaration of membership in that community and also of a willingness to contribute something meaningful to it.

So choose your audience. Write something.

My suggestion number five, my final suggestion for a life in medicine, was: change. In medicine, just as in anything else people do, individuals respond to new ideas in one of three ways. A few become early adopters, as the business types call them. Most become late adopters. And some remain persistent skeptics who never stop resisting. A doctor may have good reasons to take any of these stances…

…Nonetheless, make yourself an early adopter. Look for the opportunity to change. I am not saying you should embrace every new trend that comes along. But be willing to recognize the inadequacies in what you do and to seek out solutions. As successful as medicine is, it remains replete with uncertainties and failure. This is what makes it human, at times painful, and also so worthwhile.

The choices a doctor makes are necessarily imperfect but they alter people’s lives. Because of that reality, it often seems safest to do what everyone else is doing—to be just another white-coated cog in the machine. But a doctor must not let that happen—nor should anyone who takes on risk and responsibility in society.

So 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.”

Atule Gawande, I think you and I are meant to be. I know that premed/med students are so busy caught up in learning what it is they need to know, and perfecting their knowledge and skills – all of which are undoubtedly, extremely important. But if it comes at the expense of caring for patients, or actually wanting to take the time to make those connections with them, is it worth it? I’m not saying the two are mutually exclusive at all, but it must be a difficult balance to strike.

As I’ve learned in the last few weeks, there are a lot of things wrong with the health care system, and so much of the talk of how to fix it has been focused on creating “incentives” for different agents – doctors, insurance companies, etc. It’s unfortunate to think that there’s so much getting in the way of people wanting to provide the highest quality care just because it’s what people deserve.

This next blurb is from the middle of the book, where there Gawande presents some cases where patients are seemingly beyond help, but situations when doctors choose to push further. That, of course, brings up issues of when we decide to honor patients’ peace of mind and body (it’s all so complicated) but these words are striking: “The seemingly easiest and most sensible rule for a doctor to follow is: Always Fight. Always look for what more you could do. I am sympathetic to this rule. It gives us our best chance of avoiding the worst error of all—giving up on someone we could have helped.”

In this book, Gawande draws a lot from his cultural background, and an experience he had visiting medical facilities in India, where he learned a lot about their system, but also a lot about the health care doctors provide in America.

“… There was much the surgeons had no control over: the overwhelming flow of patients, the poverty, the lack of supplies. But where they had control—their skills, for example—these doctors sought betterment. They understood themselves to be part of a larger world of medical knowledge and accomplishment. Moreover, they believed they could measure up in it. This was partly, I think, a function of the Nanded surgeon’s camaraderie as a group. Each day I was there, the surgeons found time between cases to take a brief late-afternoon break at a café across the street from the hospital. For fifteen or thirty minutes, they drank chai and swapped stories about their cases of the day—what they had done and how. Just this interaction seemed to prod them to aim higher than merely getting through the day. They came to feel they could do anything they set their minds to. Indeed, they believed not only that they were part of the larger world but also that they could contribute to it.”

I think the main message of his book is (and it’s aimed mainly at those in the field, now and in the future) this: that going through the motions of learning and mastering the physical, technical skills only scratches the surface of becoming a doctor. As in other professions, and in succeeding in whatever it is you do in life, we all need to give more than just what’s expected.

“True success in medicine is not easy. It requires will, attention to detail, and creativity. But the lesson I took from India was that it is possible anywhere and by anyone. I can imagine few places with more difficult conditions. Yet astonishing successes could be found. And each one began, I noticed, remarkably simply: with a readiness to recognize problems and a determination to remedy them.

Arriving at meaningful solutions is an inevitably slow and difficult process Nonetheless, what I saw was: better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.”

Being a good doctor is not a formula or a checklist. We shouldn’t treat it like a race or a competition, though we will no doubt need to prove ourselves along the way. Going the extra mile or taking the extra care is sometimes not measurable in countable terms. True tests of being a good doctor are just as much tests of character and the person you are as a whole.