Wednesday, March 26, 2008

Better, by Atul Gawande

In this book Gawande focuses on performance: how well doctors do what they do.

He finds a few who step out from the rest, who are in effect "rogues" because they won't settle for "standard practice". Especially representing this group is a doctor who works on patients with cystic fibrosis. He invented a special jacket these patients can wear that pounds their chests (using air) to loosen mucus inside (previously patients had to depend on family and friends to pound their chests for them). He also insists on higher levels of performance from his patients and asks them directly what they have noticed about their illness, as a way to developing more specific care for them. The proof is in the result: his patients live far longer than average cystic fibrosis patients.

Through each of the little stories in this book Gawande looks at results. Instead of peering into a microscope to look at causes of illnesses he looks at how doctors get results. And he concludes that medical miracles are not the answer; rather, doctors using what they have at their disposal and using it well will get better results.

I had some quarrels with some of his conclusions but I could not fault his reasoning. For example, he compares the use of forceps in difficult deliveries to the use of ceasarean section. A C-section is easier to learn and perform for all doctors and therefore can more reliably be used than forceps, which require special skill to use correctly. He hints at the overuse of C-sections but does not challenge current medical practice enough for my satisfaction. But I can't argue with his conclusion that if our goal is to achieve more healthy live babies the increased use of C-section may be the correct route (personally I think less interference is better, that proper vaginal deliveries are preferable and especially without drugs, but this route requires greater understanding of the process and a willingness to let nature lead). He does note that nobody is keeping track of the condition of the mother, however, and that this is a focus that needs to be changed.

I also wondered about his conclusion that increased use of mammography is where it's at in breast cancer - many studies have concluded that mammography is only helpful in specific older age groups and that in others it is a waste of resources. However, his real emphasis is on a bigger question: how do you change a population's habits for the better? (In the case of mammograms the massive public information blitz changed women's habits and led to greater numbers of mammograms being done.) It's a question that needs answers.

The book provides great insight into the medical profession and where it is headed. It's thoughtfully and compassionately written by a surgeon who pays attention and takes notes. The afterword offers five actions a doctor can take to become a "positive deviant" - a doctor who achieves better results. It may be surprising to discover that Gawande, as much as he admires the stand-out rogues, is trying instead to reach the majority of doctors, to encourage them to use what they have better rather than to reach for unattainable stars.

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