“You press a No 10 blade down through the flesh, along a side-to-side line low
on the bulging abdomen. You divide the skin and golden fat with clean, broad
strokes.” So begins Atul Gawande’s account of delivering a child by
Caesarian section. He cuts deeper – slicing through this, pulling that
apart, stanching the “red blossoms” of blood that spring up – until the
uterus appears, “plum-coloured, thick and muscular”, and he cuts it open, as
if he were splitting “a tough, leathery fruit”. Then comes what still, he
says, seems surreal to him. Reaching inside, you find not a tumour or other
abnormality, as surgeons usually do when they open someone up, but “five
tiny wiggling toes, a knee, a whole leg”. At this point I found I had been
gripping the book so hard that my fingers hurt.
That is the most powerful passage in Gawande’s book, though many others come
close, and its power is that of severe and precise poetry. James Kirkup
wrote a poem about a surgeon titled A Correct Compassion – a perfect phrase
for Gawande’s scrupulous skill. He worked out in his first book,
Complications, that what originally drew him to a career in surgery were the
“fragile but crystalline moments” in which someone’s life is saved. But he
is fascinated, too, by the dilemmas – practical, ethical, financial – that
doctors face. A surgeon in a Boston hospital, he is also a staff writer on
The New Yorker, and in New-Yorker mode he turns abstract issues into human
stories. To clarify the question, for example, of whether doctors should
supervise the execution of criminals by lethal injection in American prisons
(which the American Medical Association forbids), he talks to some who have.
They defend themselves ably. It is a doctor’s duty, one argues, to ensure
that the procedure is painless and not bungled. It is a simple matter of
terminal care. A condemned man “is no different from a patient dying of
cancer – except that his cancer is a court order”. Gawande does not agree,
but he respects the reasoning.
The argument of Better is that great advances in medicine can be brought about
by small, practical changes. Making that extra bit of effort can turn a
situation round, and it works at every level. In hospitals, everyone is
meant to wash their hands before and after touching a patient. But they
don’t, so MRSA rates soar, and 90,000 Americans die annually from
hospital-acquired infections. One Pittsburgh veterans’ hospital decided to
act. They advertised the danger in discussion groups and websites, and
everyone, from janitors to surgeons, cooperated. Hand-washing caught on, and
within a year the MRSA infection rate hit zero. Improved procedure has also
benefited American battle casualties in Iraq. Here, speed is the key. After
exploratory surgery by forward units, the wounded are airlifted to hospital
within the hour, sometimes with their abdomen still open and clear plastic
coverings sewn on. The result is a historic decline in battle deaths, from
30% of the wounded in the second world war to 10% in Iraq.
One of Gawande’s heroines is Virginia Apgar, an obstetrician who started work
in New York in 1933. She was alarmed by the treatment of newborn babies. If
they were malformed, or undersized, or just blue and bad at breathing, they
were listed as stillborn, put out of sight and left to die. So she devised a
score, with a range from 0-10, for objectively classifying a baby’s
condition, and it soon became clear that a baby with a poor Apgar score one
minute after birth could be resuscitated, by oxygen and warming, to a good
score after five minutes. Now the Apgar score is standard worldwide, and the
death rate for newborns in America has dropped from 1 in 30 in the 1950s to
1 in 500 today.
These are heartening stories. But it seems to be a law of nature that if you
make that extra bit of effort, your enemies, human and non-human, will make
an extra effort, too, just to keep up. Gawande never spells this out, but
the evidence for it is everywhere in his book. Hand-washing is desirable in
hospitals, for example, because the bacterial count on our hands ranges from
5,000 to 5m colony-forming units per square centimetre. You can see that
those medieval theologians who believed that the air was populated by
countless demons and hosts of angels who could dance on the head of a pin
were onto something. Like us, these invisible companions can survive only by
improving their performance, and consequently, as Gawande points out, rising
infection rates from super-resistant bacteria have become the global norm.
Then there are the human sharks and jackals. An American surgeon can expect to
be sued every six years for negligence or medical malpractice. The charges
are usually spurious and dismissed by the courts. But trial attorneys have
improved their performance, selecting only cases with a high chance of
success, and if they win, the average jury award is $500,000. So the
parasites fatten, while the surgeons have to find up to $300,000 a year for
malpractice insurance premiums.
The various companies who sell health insurance to Americans have also worked
hard at their performance. They seize on any excuse not to pay up, and
currently reject 30% of the bills they receive. Their success ensures that
their chief executives earn huge sums, far more than doctors or surgeons.
Patients are helpless against the companies’ devious tactics, so doctors are
obliged to hire office staff to fight for claims, which means that, however
charitable they may feel, they will be less able to help the 15% of
Americans who cannot afford health insurance at all.
All this makes improved performance seem less of a panacea, and the suspicion
creeps in that some fundamental social change is needed. When Gawande
travels to India to observe medical conditions in his father’s native
village, the suspicion becomes overwhelming. Indian hospitals, he finds, are
so lacking in basic resources that ramshackle market stalls have sprung up
around them, selling everything from medicines to pace-makers. Doctors
routinely ask patients to buy their own drugs and equipment before coming
for treatment. The Indian government’s total budget for healthcare in 2003
was $4 per person. Widespread illiteracy and ignorance breed distrust of
modern medicine, so help may be refused even when offered. One of Gawande’s
saddest sights is an Indian mother holding her paralysed child, for whom, a
few weeks before, she had refused polio vaccination because other villagers
told her it gave children fever.
Trying to improve performance against such odds might seem futile. But the
abilities of the average Indian surgeon, Gawande reports, outstrip those of
any western surgeon he knows. As he watches them perform intricate,
dangerous operations with basic equipment in filthy conditions, it calls to
mind one of the great classics of medical literature, Mikhail Bulgakov’s A
Country Doctor’s Notebook. Few modern authors could stand that comparison,
but Gawande can. “In the stories of doctors, nurses and patients,” he
writes, “one can find the beauty of human striving.” Bulgakov would have
agreed.
BETTER: A Surgeon’s Notes on Performance by Atul Gawande
Profile £12.99 pp192
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Read on... websites:
http://www.gawande.com/
Biography of Gawande, plus articles and interviews
