Books : reviews

Atul Gawande.
Complications: a surgeon's notes on an imperfect science.
Profile. 2002

rating : 2.5 : great stuff
review : 26 May 2009

After reading this, my respect for doctors has soared, and I hope I never have to be a patient.

Gawande is a surgeon, and he tells stories of what it's really like: stories of miraculous successes, and heart-rending failures, some due to the skill of the doctors combined with good luck, some due to bad luck. He poses the paradoxical point: we all want to be treated by the best doctors; doctors have to be trained; they get their training by treating people. So, if we want to be treated by well-trained doctors, we have to be treated by trainee doctors too.

His stories of actual patient cases, and how success or failure can rest on the smallest of details, are hair-raising. His stories of how massive improvements could be made with systematic attention to procedure and process (example range from hernias to anaesthesia) are enraging, because these relatively simple ideas could have massive returns if they were applied uniformly, but they aren't. But overall, his stories about people coping with their illnesses are amazing.

A real eye-opener. Even before writing this review, I went off and bought his next book.

Atul Gawande.
Better: a surgeon's notes on performance.
Profile. 2007

rating : 3 : worth reading
review : 2 July 2009

Gawande's first book was about why and how things can go wrong in medicine, essentially because it is incredibly complicated and uncertain. His second book brings some hope: here he concentrates on how things can be made better. Essentially the theme is one of process, process, process: a "science of performance". When it is implemented, the results can be spectacular. Gawande gives details as diverse as casualty rates in the Iraq war, polio vaccination in India, the prevalence of Caesarean deliveries, and the treatment of Cystic Fibrosis. However, this barely scratches the surface of what could be done.

pp232. we have not effectively used the abilities science has given us. ... the scientific effort to improve performance in medicine ... can arguably save more lives in the next decade than bench science

He is not arguing against scientific research, just for the extremely cost effective process improvement. But why is this so rarely done? (It's not just in medicine. Take software development, for example. There are (some) companies developing business critical software who don't use even use source code control systems.) Gawande gives an example of why this might be. Take hand washing. After all, the germ theory of disease is well-known, the horrifying death rates from puerperal fever being slashed by hand washing in the mid 1800s is common knowledge, and yet medical staff still don't wash their hands between examining patients. Why on earth not? Well, things are not as simple as they seem. I was surprised to read:

pp17-18. proper hand washing requires a strict procedure. First, you must remove your watch, rings, and other jewelry (which are notorious for trapping bacteria). Next, you wet your hands in warm tap water. Dispense the soap and lather all surfaces, including the lower one-third of the arms, for the full duration recommended by the manufacturer (usually fifteen to thirty seconds). Rinse off for thirty full seconds. Dry completely with a clean, disposable towel. Then use the towel to turn the tap off. Repeat after any new contact with a patient.
   Almost no one adheres to this procedure. ... Even if you get the whole cleansing process down to a minute per patient, that's still a third of staff time spent just washing hands.

Okay, so "washing hands" in a hospital is a little more involved than I had thought. But inconvenience is not the only problem. There is inertia, too:

pp18. alcohol rinses and gels have been in use in Europe for almost two decades but for some reason only recently caught on in the United States. They take far less time to use---only about fifteen seconds or so to rub a gel over the hands and fingers and let it air-dry. ... they are more effective at killing organisms, too.

So what is to be done? Bringing in changes to procedure requires a culture change: as Gawande points out, no-one could get away without "scrubbing up" for an operation. But culture change is hard. Gawande investigates some examples where things have been successfully changed, and discovers the entirely unsurprising answer: it has been a bottom-up rather than a top-down process. When the front-line practitioners are consulted and asked for suggestions, are involved, things can improve dramatically; when control is imposed top-down, resistance is the common response.

There are other essays in here too, covering things as diverse as the ethics of medical staff attending executions, how much a doctor should be paid, and malpractice suits. In all cases the arguments are thought-provoking, and show how the situation is actually much more complicated and nuanced than the usual sound-bite stories.

Atul Gawande.
The Checklist Manifesto: how to get things right.
Profile. 2010

rating : 2.5 : great stuff
review : 25 August 2011

In Better, Gawande noted how a focus on process, on doing what we know how to do, and doing it well and consistently, could have enormous benefits. Here he focusses a whole book on how to do this, based around the well-known aviation model of a checklist. He gives some historical background: checklists were invented when aeroplanes become to difficult to fly from pure memory and training. He also describes how large construction projects rely on checklists. Other tasks -- surgery and other medical procedures in particular -- have a similar degree of complexity, with people often missing critical steps, particularly when distracted. Could checklists help?

Unsurprisingly (otherwise there would be no book!) the answer is "yes". Much more surprising is how big a difference adherence to a very simple checklist can make, in some cases resulting in double-digit percentage improvements, and hundreds of millions of dollars savings, in a single procedure. (I was amazed to learn that some large hospitals have an annual budget exceeding that of some entire third world countries.)

He gives a great example of a surgery checklist he helped introduce as part of a WHO committee. Use of this checklist (once properly debugged) had a significant impact no matter whether it was used in a major hospital in an industrialised country, or in a poverty stricken third world clinic. One important point on the checklist is simply for the surgical team to introduce themselves by name before the operation. (I hadn't realised that it is common in large hospitals for a given team never to have worked together before: I blame small cast-list TV dramas for this misperception.) He then gives a self-deprecating anecdote of how he also introduced it into his own surgery (despite not needing it, of course, but not wanting to look like a hypocrite), only to discover that its use averted several major problems, and saved at least one life.

One of the things he talks about is the difficult of getting some surgeons to adopt it. They seem to feel that it demeans their expertise. He makes the telling point that use of a checklist is part of the transition to a disciplined approach to team working, rather than the traditional doctor-as-lone-hero. One might almost use the word "professionalism" for this new model. Aircrew have made the transition. (An earlier example might be the transition from warrior to soldier.) So doctors should shape up and make the transition too.


Atul Gawande.
Being Mortal: illness, medicine, and what matters in the end.
Profile. 2014

rating : 2 : great stuff
review : 27 January 2016

For most of human history, death was a common, ever-present possibility. But now, as medical advances push the boundaries of survival further each year, we have become increasingly detached from the reality of being mortal.

So here is a book about the modern experience of mortality – about what it’s like to get old and die, how medicine has changed this and how it hasn’t, where our ideas about death have gone wrong. In a story that crosses the globe, Atut Gawande examines his experiences as a surgeon and those of his patients and family, and learns to accept the limits of what he can do.

Never before has ageing been such an important topic. The systems that we have put in place to manage our mortality are manifestly failing; but, as Gawande reveals, it doesn’t have to be this way. The ultimate goal, after all, is not a good death, but a good life – all the way to the very end.

We are all going to die. Hopefully, we will live a long and healthy life first. But the fear is always of a slow, lingering, undignified death. In this deeply moving and thought-provoking book, physician Gawande demonstrates why modern medicine is not set up to cope with the inevitability of death.

Much medicine is about heroic acts that, through strict treatment regimes, violent surgery and toxic drugs, make us better, after we have suffered through the warfare between illness and cure. Death is failure. But people who are nevertheless dying will not get better: medicine offers only the debilitating warfare, with no peaceful recovery after. All pain, no gain. Only failure.

Is there an alternative to the standard end-of-life route of incarceration in a nursing home, made subject to loss of independence and an infantalising regime of “doctor knows best”, accompanied by ever more violent interventions, culminating in dying in a sterile hospital bed while attached to tubes and beeping machines?

Gawande describes his discovery of this alternative: patient-centric palliative care, carefully discovering what the patient wants from their remaining time, and ensuring they get that: time at home, time with family, time to enjoy what time is left, medical care appropriate to that, and, if it is what is wanted, further interventions.

And the consequences of this approach, of providing the patients what they want, of not insisting on providing the fullest medical interventions possible, are possibly counter-intuitive:

[pp177-8] A landmark 2010 study from the Massachusetts General Hospital had even more startling findings. The researchers randomly assigned 151 patients with stage IV lung cancer ... to one of two possible approaches to treatment. Half received usual oncology care. The other half received usual oncology care plus parallel visits with a palliative care specialist. .... The ones in the study discussed with the patients their goals and priorities for if and when their condition worsened. The result: those who saw a palliative care specialist stopped chemotherapy sooner, entered hospice far earlier, experienced less suffering at the end of their lives—and they lived 25 percent longer. In other words, our decision making in medicine has failed so spectacularly that we have reached the point of actively inflicting harm on patients rather than confronting the subject of mortality.

So end-of-life medicine needs to change to incorporate quality of current life, not just quality of later (here, non-existent) life. And quality of life nearly always means independent living, and dying, at home. We need to move from second stage medicine to third stage:

[p192] Scholars have posited three stages of medical development that countries go through, paralleling their economic development. In the first stage, when a country is in extreme poverty, most deaths occur in the home because people don’t have access to professional diagnosis and treatment. In the second stage, when a country’s economy develops and its people transition to higher income levels, the greater resources make medical capabilities more widely available. People turn to health care systems when they are ill. At the end of life, they often die in the hospital instead of the home. In the third stage, as a country’s income climbs to the highest levels, people have the means to become concerned about the quality of their lives, even in sickness, and deaths at home actually rise again.

Gawande, with a combination of heart-rending, and heart-warming, case studies, and hard medical data, argues convincingly for this change, and for an extension of the palliative care approach. It is more humane, it improves quality of life and lifespan, and, if more argument is needed, it is cheaper.

Some may be concerned that allowing people to choose not to undergo medical procedures might lead to people feeling they have to choose this route so as “not to be a burden”. But many of the people Gawande spoke to who had chosen to go the route of more interventions, had done so not because they wanted to, but because of pressure from their families who, understandably, didn’t want them to die.

This is an important book that should be read by all people involved in delivering medical care, all involved in medical policy, and all who will one day be at the end of their own lives.