Deep in the innards of Dr Atul Gawande’s essay collection, BETTER: A SURGEON’S NOTES ON PERFORMANCE (Holt, April 3rd, 2007) hides “Piecework,” which deals with “retailing” medical care and paying doctors, a Gawandan thesis. But BETTER, with its non-cohesive surgical notes, is itself piecework. Sometimes, Gawandan physicians don’t perform “better,” while patients want best. Distinctions often blur among average, better, best medical care.
Early on, Gawande asks rhetorically, “What does it take to be good at something where failure is so easy, so effortless?” For the non-conoscenti, “something” means patient care, which “requires understanding the fine details behind success and willingness to act on that understanding.” The second part is essential. Physicians, argues Gawande, should exercise “positive deviance,” from ‘‘easy effortless”—sometimes fruitless-- care.
For example, physicians should always wash their hands. Every year, 90,000 Americans die of hospital-acquired infections. If doctors washed their hands between patients, touching instruments, shaking hands, reading electrocardiograms, they could “consistently halt the spread of infections.” Yet less than 50% of doctors wash their hands even perfunctorily when they should.
Doctors protest that patients don’t “comply.” Patients forget their pills, don’t fill prescriptions, cheat on diets, don’t get tests, forget follow-up. But when it comes to hand-washing, physicians don’t comply. Despite hospitals’ carrots and sticks, “operating room meticulousness remains behind double doors.” Rampant infections ensue.
BETTER's leitmotif is medicine’s crying need for diligence, “the prerequisite of great accomplishment.” Diligence “sets high, seemingly impossible, expectations for performance and human behavior.” Only a few of Gawande’s physicians meet these expectations. Indian doctors fight polio in a remote village. Military surgeons, far from TV’s MASH, fight death, amputate limbs, patch brains in Iraq. Brave stories, yes, but connected only anecdotally in this surgeon’s journal.
Repeatedly, Gawande loses focus. In “Doing Right,” he wastes pages on patients’ proper dress for an examination. The medical encounter’s essentials receive short shrift: eliciting details; finding hidden agendas; asking specific questions; helping patients understand; giving bad news compassionately; taking time, listening.
Although Gawande cannibalized “Bell Curve,” from his New Yorker article, it’s BETTER’s best. “Bell Curve,” reveals what patients should know: all doctors and medical centers are not alike, not equally capable, not better than faraway places. Gawande graphs medical centers’ performances “with a handful of teams showing disturbingly poor outcomes for their patient, a handful obtaining remarkably good results, a great undistinguished middle.” Neither advertising nor popularity guarantees top medical performances.
Occupational grading is endemic to modern life, yet doctors hate acknowledging bell curves. Corporations file earnings reports, teams vie for pennants. Still, only New York, Pennsylvania, and California report cardiac surgical outcomes per surgeon/ per hospital. Even these states report no other medical data for patients who need to know.
Donald Berwick, a Gawande hero, crusades against medical secrets. Berwick believes complication rates, drug misdeliveries, less optimum outcomes require annual publishing, available to everyone. But doctors fight data publication at every step.
The Cystic Fibrosis Foundation (CFF) leads assessments of care and outcome variations. Average CF patients may live 40 years, but a Minnesota center promises 64 years. Despite this, CFF fights medical transparency about good, better, best, that euphemism for letting patients know the score on crucial care decisions.
Although Gawande’s ruminations seem like internists’ diagnoses, they lack surgical recommendations for extirpating American medical culture’s authoritarianism. Yet believing doctors shouldn’t be defensive, he decries bulletproof jackets over professional egos. The problems are there, need recognizing, and admitting. And, he asserts, they’re soluble. The problems aren’t cost--they’re value-laden, increasing the value of care delivered for money spent.
For his part, nowhere does Gawande say how to solve problems except with generalizations: “The subtleties of high performance medical practice can be identified and learned. But the lessons are hidden because no one knows who the high performers really are…if we are genuinely curious how the best achieve their results.” Much depends on who cares. And how much.
Questions eat at the reader. What does a doctor—or a patient do—if the doctor turns out to be a B-? Not a C or a D—or heaven forfend, an F, but an ordinary B-? “If the bell curve is fact,” warns Gawande, “…then most doctors are going to be average….What is troublesome is not 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.”
True. But what about average doctors? Ones who settle for less or, more disconcerting, ones who strive to be better but can’t make the grade? BETTER’s afterword sludgily offers “Suggestions for becoming a positive deviant,” trying to rise above the crowd of 819,000 American physicians. These are amazingly oversimplified. Like the simple task of washing your hands, not many doctors will follow BETTER's advice.
“Write something,” urges Gawande to achieve “positive deviance.” Yet who would tell him to perform an operation to halt his own missteps? “Writing,” asserts Gawande, “lets you step back and think through a problem.” Maybe. With BETTER, writing flunked its test. Author of COMPLICATIONS, nominated for a National Book Award, Gawande can do better. His next book probably will--if he gives it more time and relies less on bits and pieces from his previous essays.