Better, by Atul Gawande

Atul Gawande is a practicing physician at Brigham and Women’s Hospital in Boston. He is also an Associate Professor of Surgery at Harvard Medical School and Associate Professor in the Department of Health Policy and Management at the Harvard School of Public Health. He also wears many other hats as a writer for New Yorker magazine, researcher on systems innovation for improving patient safety. The Foreign Policy Magazine and TIME magazine has honored Atul Gawande as one of the world’s top 100 influential thinkers. Recently, I read his second book, Better, which was published in 2005.

The book is shaped into ten different chapters with three arching themes of diligence, excellence, and perfection. Because of Gawande’s literature prowess, he writes with such convincing and fascinating details that illuminates the world of medicine practice. Medicine is often untidy, messy at times, but investigative and carefully conscientious.

 My favorite chapter was the one on Cystic Fibrosis (CF). If you haven’t heard of CF before, you are not alone, especially if you grew up in the post baby-boomer era. Cystic Fibrosis is a hereditary disease that is life threatening. Although it is a genetically inherited disease, but it is of the recessive form, meaning that it can skip generations of manifestation and symptoms only surfaces when an individual inherits a copy of the defective gene from each of his / her parents. CF causes the body to produce abnormally thick and sticky fluid, called mucus that builds up in the breathing passages of the lungs and in the pancreas, the organ that helps to break down and absorb food. This collection of sticky mucus results in life-threatening lung infections and serious digestion problems.

 Today, the average life span for people with CF who live to adulthood is approximately 37 years, a dramatic increase over the last three decades which averaged around 6 years ago. The treatment regimen for CF has rigorously improved over the years. Decades ago, manual chest therapy was the traditional airway clearance technique for CF patients. In simple terms, the patient stays in one of few recommended physiotherapy positions while another helper cups his or her hands and thumps on the chest repeatedly. Today there are various less mechanical options like the PEP (Positive Expiratory Pressure) valve which can be used to assist the clearance of excessive mucus from the lungs.

 Gawande took on a quest to understand the reasons behind the differences in performance standards for an average performing facility, Cincinnati Children’s Hospital, and the best in the country, Fairview-University Children’s Hospital. Protocols and technology were largely similar between the two facilities. But what could have resulted in the difference between Fairview at the forefront of the bell curve, and Cincinnati as an average performer? At both facilities, physicians follow the same set of questionnaire to investigate any unexplained decreases in the measurement of lung function, a major indicator of CF prognosis. “Any cough lately? No. Colds? No. Fevers? No. Taking her treatments regularly? Yes, of course. Every day? Yes. Ever miss treatments? Sure. Everyone does once in a while. How often is once in a while?”

 Most physicians would stop right here.

 The distinction lies in the daily pursuance of excellence; the relentless pursuance of the truth behind the numbers. At Fairview, the inquisition goes on until the Fairview physician is able to piece together that this teenager patient has been experimenting with her treatment on a daily basis. Dating a new guy, mixing with new friends would have made her treatment regimen at home difficult to maintain. With this, the Fairview physician doesn’t reprimand, doesn’t blame, and least of all doesn’t get angry. Instead he explains the numbers to his patient, who is still not yet convinced that she is in any peril. “A person’s daily risk of getting a bad lung illness with CF is 0.5 per cent.” He wrote the number down as the patient began welling up. “The daily risk of getting a bad lung illness with CF plus treatment is 0.05 per cent,” he went on, and he wrote that number down. “So when you experiment you’re looking at the difference between a 99.95-per-cent chance of staying well and a 99.5-per- cent chance of staying well. Seems hardly any difference, right? On any given day, you have basically a one-hundred-percent chance of being well. But it is a big difference.” He chalked out the calculations.“ Sum it up over a year, and it is the difference between an eighty-three per-cent chance of making it through 2004 without getting sick and only a sixteen-per-cent chance.”

Of course, many activities monitor statistics like that: catching fly balls, manufacturing microchips, delivering overnight packages. Medicine’s only distinction is that lives are lost in those slim margins. The physician who cares not just about the medical symptoms of the patient, but also understands the temperament, social background, personality of every one of his or her patient, is the physician who keeps at the forefront of the bell curve. Collectively as a society, we seek to shift out the bell curve progressively because that is how to do better over time. The cell curve distribution will always be there, with purported “pioneers” or “average-rs” or “laggards”. But where would you, if you were a physician choose to be? 

Medicine will never be perfect, because it is after all a quasi-social science in continuous experimentation. But to all my newly minted physician friends out there – practice daily excellence in the work that you do. Yes, the hours are long and the benefits may not be commensurate with what you what. But always remember that every decision you make and every patient you see depends on you and only you to do the right thing for them. We always need physicians who lead, experiment, and relentless pursue excellence in their daily practice to illuminate the way.

 For me? This story only serves to affirm my belief that numbers never lie. Always question the numbers and never take I-don’t-know for an answer.

 Memorable quote: Real medicine is “untidy, human and careful conscientious practice”

Website for further reading: http://www.leighbureau.com/speaker_documents.asp?view=article&id=255

Revamping this blog

Hola- I decided to be back after a long hiatus. Several reasons prompted me to revive this fledgling blog. In a recent conversation with a good friend of mine, I had expressed my desire to have a better memory and actually be able to speak or recall with fascinating details. In his usual casual laid-back mannerism, my friend revealed in his computer engineer speech patterns that he just
"learns to upload and download information" because there is too much to remember. In his complex world of computer coding, he often encounters many types of bugs, pardon me for my layman terms. And although he doens't often have the answer immediate on hand, the blog that he keeps to document all the problems he has encountered to date serves as a quick refresher of the approaches and methodologies that he had worked on previously. A small revolution was pulsing within me as I recalled about this abandoned solitude blog. Where were the days when I was so deeply passionate about instituting change in the health care system? Where was the enthusiastic HMP student who was always thinking about whether this could work somewhere else....Perhaps this blog might have a grander purpose for documenting the spontaneous number of ideas that I have about health reform (on a micro scale)!

In recent months I have been reading a couple of social media books, health care books, all of which seemed to be screaming something into my head. In my daily work as a health care consultant, I always ask about the numbers, the metrics, the data and who is accountable for it. For equity's argument, shouldn't I put myself through the same lens which I often judge my clients?
"There are only two mistakes one can make along the way to truth; not going all the way, and not starting," -Buddha
Guess I still have time to recover from my mistake. On pompously starting this blog and then single-handedly throwing it away.

The last reason is perhaps a little more selfish than the others. I can proudly proclaim that I have a memory like a goldfish. I can probably remember things for up to a couple of days and then after that, with the exception of dates and numbers, I often find myself on the tip of my tongue. I had better quit playing that game of taboo with my friends which I am so bad at..

In the spirit of the new year, I wanted to set some metrics to hold me accountable:
1. Blog at least twice every month. In my defense, as you can tell, most of my blog posts can be pretty dense and require some amount of research. Give me a break.
2. Accrue at least 20 followers on this blog. And by that I refer to invested, interested individuals who are actually reading and commenting.
3. Read at least 10 books this year! Obviously book suggestions are very welcome.


Next two posts will be on the two books I recently read. Better by Atul Gawande, a book on Gawande's illuminating experience as a surgeon and what his stories tell us about our world. Next, the Blue Sweater by Jacqueline Novogratz, a International Banker formerly with Chase who followed her heart to better the world through microcredit and her journeys through Ivory Coast, Zaire, Rwanda etc..