Sunday, July 15, 2007

Atul Gawande's Better

My review of Atul Gawande's latest medical book appeared in Lounge on May 14.

An inexact science

The one science we expect certainty from, in which doubt would ideally have no place, is as likely to be applied with solid judgment as with a feeling, a guess, or an ordinary whim. This is medicine, practiced by people whose failings include arrogance, insecurity, and not washing their hands clean. And it is to this flawed, inconsistent, and yet often amazing world that people hand their bodies over in Atul Gawande’s books.

Gawande’s first book, Complications, arose from true incidents during his training in general surgery. It explained why students operated on patients, why doctors switched off suddenly and, in a famous chapter, why one man’s enormous hunger refused to subside. The idea that medicine had layers rich with complications was brought alive in these stories, where narrative storytelling was buttressed by facts and clinical observations. People want progress in clearly defined terms, Gawande wrote then, “but of course it rarely is. Every new treatment has gaping unknowns – for both patients and society – and it can be hard to decide what to do about them.” Medicine’s usual state was uncertainty, and this is what made being a patient or a doctor so difficult.

In the five years since his last book, Gawande has, in his job as a general surgeon at Brigham and Women’s Hospital in Boston, focused on reducing surgical injuries and improving the quality of care. It is the dominant theme of his latest book, Better, which begins with a chapter on why few medical staff wash their hands, and concludes with an essay on doing things better.

Gawande highlights the simple, yet astonishing, fact that while there are big budgets and incessant demands for new innovations in medicine, doing existing things well, which saves more lives sooner, is an underutilized concept. But it is possible to be better, he says, and it does not take genius. “It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.”

Gawande takes up diligence in a chapter based in India, where he watches a collection of doctors and volunteers attempt to limit a poliovirus (one word, Sanjukta) outbreak. He describes it as an unambitious, relentless, and somewhat limited goal, but transforms its very meaning by setting it against the outbreak. Only by being relentless can an impossible task be achieved. And yet he remains wary of the impressive declarations by global do-gooders. “International organizations are fond of grand-sounding pledges to rid the planet of this or that menace. They nearly always fail, however. The world is too vast and too various to submit to dictates from on high.”

The grand announcements overlook what Gawande is all too familiar with: the complexities that arise from individual choices at the ground level. So varied are their choices and the effects that follow. In one episode in Complications, Gawande draws a ‘decision tree’ with possible outcomes to a surgical procedure. Like in any other profession, he writes, decisions in medical science compound themselves. When he accounts for all possible outcomes, “my tree looked more like a bush”.

Given the complications involved, how much should a surgeon make? The question is put to Gawande after his training is complete, and he quickly understands that his salary is not connected with his abilities. It involves frequent run-ins with insurance agents, doing very un-doctorlike things. He calls for an overhaul of the American healthcare system. (For the record, though, the average salary for general surgeons is $264,375.) In India, where the problems are systemic, he instead focuses on individual drive and dedication, and describes how physicians and surgeons have adapted to the lack of proper medical equipment, and have invented, in some cases, surgical operations thought impossible.

Gawande’s writings have appeared in The New Yorker and on Slate, as well as in medical journals. By his own account, his writings are more important to him, and it is remarkable to note that he began writing relatively late. His language is direct, often delicately balanced, and pretty persuasive. The episodes read as thrillers would, with periods of action interrupted by interludes of data and context. They conclude mostly with the problem resolved, a life saved, and therefore, a happy ending. This is a surgeon writing, but the words could just as well have been from a writer who explores the medical profession as a new world filled with flawed but frequently dazzling things.

I'll leave you with a few pieces I've enjoyed. This one's on how we age now. I particularly enjoyed the one on how much medical practitioners should earn, and there's always more fun stuff to read at Slate.


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Sd said...

Thanks for the lucid review. Gawande writes wonderfully about the medical profession. A year ago,he wrote in the 'New Yorker' about doctors and how they get sued which was an eye opener.

Rahul Bhatia said...


I must have missed that one. Thank you for pointing that out. I think he, and Oliver Sacks, both tend to write beautifully.