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