To Join Us      For Clients Cases News & Comment Books

 

   Book Review

     Autumn 2007

  
   
   Better
    A Surgeon's Notes on Performance
    By Atul Gawande
    Metropolitan Books, New York, pp. 273, 2007

    Dr Gawande, Harvard affiliated and working surgeon at Brigham and Women's Hospital in Boston,
   sometime staffer for the New Yorker  magazine, has written a fairly short book about how to improve 
   medical practice with a view towards making patients (now called healthcare recipients) better. Part
   philosophy, part practical guide, part history and physical examination of the American medical system,
   the work concentrates on how doctors and others can make the system work by improving their own
   practices.  Much is wrong with our current system of healthcare as so aptly and humorously
   pointed out by Michael Moore in his film Sicko. We certainly could use a few more Dr. Gawandes
   but whether improving one's medical performance will override the stranglehold of the insurance
   and pharmaceutical companies is doubtful.

   Still it's a start. Foremost in the book is the author's paean to diligence or what we used to call
   compulsive behavior learned in medical school. Or so we thought. Taking simple hand washing
   as the most important procedure in preventing in-hospital infections, one is amazed how
   often this simple procedure is skipped or done perfunctorily. It has quite a low cost benefit
   ratio: soap and water or more recently the even more accessible alcohol gel in bedside dispensers.
   While sterile technique and strict adherence to antisepsis is the rule in the operating room, it seems
   to disappear in the ICU or medical-surgical units. Every doctor knows the profound impact Drs.
   Semmelweis and Lister had on medicine in recommending sterile technique in the 19th century, even
   before the germ theory was established. The problem, according to Gewande, is not lack of knowledge
   but the failure to be diligent.

   But the book is more than a recital of due diligence. The author takes on most of the chronic diseases
   affecting American medicine today: medical malpractice and our flawed system for sorting out the
   real victims of medical negligence and offering them adequate compensation; the strange methods
   of physician compensation delivered by the government and private insurance, unless they can avoid
   payment entirely by excluding the patient's coverage for errors on the application or having a "pre-
   existing condition;"
  
   Gawande spends a chapter on how doctors are paid, including his own "name your own salary" offer
   (within reason) for the first three years he began work as a general surgeon at a major Boston medical
   center. Hard to figure your own worth? Maybe so but not for the doctors who are constantly battling,
   occasionally suing, insurance companies for underpayment. The latest trend among some physicians
   and surgeons is to establish so-called boutique practices: accept no insurance, cash only. If you're
   really good, you can make a pretty satisfactory living such as the surgeon specialist in endoscopic
   procedures that the author interviews: $1.2 million per year (net). Not in the same league with
   high-priced lawyers or Wall Street moguls but not too shabby either.

   There is a fascinating section on physician participation in executions, a practice that has been deemed
   not ethical by the AMA and other major medical organizations. Most doctors who participate do so
   on a limited basis: declaring death of the inmate, signing a death certificate but occasionally more
   technical and professional knowledge is required: advising on drug dose or starting an intravenous line.
   Most of these, usually anonymous, doctors were friends of the warden or other prison staff and practice
   in the town where the state prison is located.

   Another chapter chronicles a brief history of obstetrics, and how this specialty has improved both
   infant and maternal mortality dramatically. And without a lot of placebo-controlled, double-blinded
   studies. It comprises the author's larger point that sometimes common sense and a little ingenuity
   trumps careful research and so-called evidence based medicine. An example: the Apgar score for
   evaluation of the newborn, the product of the fertile mind of a lady anesthesiologist (not even an
   obstetrician or pediatrician) from New Jersey that has saved countless infants. Also the much
   disputed c-section, often accused of being "unnecessary surgery," but in reality has saved many a
   mother and her newborn from the potentially lethal complications of delivery.

   Dr. Gawande can write and tells a good story. Perhaps that is why his work is at once enjoyable and
   thought-provoking, even if he is a surgeon. An interesting notion is his take on excellence, why some
   doctors or medical centers are at the right-hand end of the bell-shaped curve and why most are
   depressingly in the middle. He cites public exposure of medical and surgical results as the way forward,
   citing the dramatic experience of the war on cystic fibrosis that has dramatically improved the quality
   and quantity of life for those poor individuals afflicted with this common genetic disorder. Even when
   techniques and procedures from the best programs are shared, they still remain at the top: a
   combination of ingenuity and constant refinement, never accepting even good results in the quest for
   the perfect.
  
   More Book Reviews