Better

  Contents

  TITLE

  COPYRIGHT

  INTRODUCTION

  PART I Diligence

  ON WASHING HANDS

  THE MOP-UP

  CASUALTIES OF WAR

  PART II Doing Right

  NAKED

  WHAT DOCTORS OWE

  PIECEWORK

  THE DOCTORS OF THE DEATH CHAMBER

  ON FIGHTING

  PART III Ingenuity

  THE SCORE

  THE BELL CURVE

  FOR PERFORMANCE

  AFTERWORD: SUGGESTIONS FOR BECOMING A POSITIVE DEVIANT

  NOTES ON SOURCES

  ACKNOWLEDGMENTS

  ABOUT THE AUTHOR

  ALSO BY ATUL GAWANDE

  Complications:

  A Surgeon's Notes on an Imperfect Science

  Better

  Better

  * * *

  A SURGEON'S NOTES

  ON PERFORMANCE

  * * *

  Atul Gawande

  Metropolitan Books

  Henry Holt and Company

  New York

  Metropolitan Books

  Henry Holt and Company, LLC

  Publishers since 1866

  175 Fifth Avenue

  New York, New York 10010

  www.henryholt.com

  Metropolitan Books(r) and (r) are registered

  trademarks of Henry Holt and Company, LLC.

  Copyright (c) 2007 by Atul Gawande

  All rights reserved.

  Distributed in Canada by H. B. Fenn and Company Ltd.

  Several of these chapters have appeared, in different form, in

  The New Yorker and The New England Journal of Medicine

  Library of Congress Cataloging-in-Publication Data

  Gawande, Atul.

  Better : a surgeon's notes on performance / Atul Gawande.--1st ed.

  p. cm.

  ISBN-13: 978-0-8050-8211-1

  ISBN-10: 0-8050-8211-5

  1. Gawande, Atul. 2. Internal medicine--Case studies. 3. Medicine-- Miscellanea. I. Title.

  RC66.G392007

  616--dc22

  2006046962

  Henry Holt books are available for special promotions and

  premiums. For details contact: Director, Special Markets.

  First Edition 2007

  Designed by Meryl Sussman Levavi

  Printed in the United States of America

  1 2 3 4 5 6 7 8 9 10

  For my parents and sister

  Better

  Introduction

  Several years ago, in my final year of medical school, I took care of a patient who has stuck in my mind. I was on an internal medicine rotation, my last rotation before graduating. The senior resident had assigned me primary responsibility for three or four patients. One was a wrinkled, seventy-something-year-old Portuguese woman who had been admitted because--I'll use the technical term here--she didn't feel too good. Her body ached. She had become tired all the time. She had a cough. She had no fever. Her pulse and blood pressure were fine. But some laboratory tests revealed her white blood cell count was abnormally high. A chest X-ray showed a possible pneumonia--maybe it was, maybe it wasn't. So her internist admitted her to the hospital, and now she was under my care. I took sputum and blood cultures and, following the internist's instructions, started her on an antibiotic for this possible pneumonia. I went to see her twice each day for the next several days. I checked her vital signs, listened to her lungs, looked up her labs. Each day, she stayed more or less the same. She had a cough. She had no fever. She just didn't feel good. We'd give her antibiotics and wait her out, I figured. She'd be fine.

  One morning on seven o'clock rounds, she complained of insomnia and having sweats overnight. We checked the vitals sheets. She still had no fever. Her blood pressure was normal. Her heart rate was running maybe slightly faster than before. But that was all. Keep a close eye on her, the senior resident told me. Of course, I said, though nothing we'd seen seemed remarkably different from previous mornings. I made a silent plan to see her at midday, around lunchtime. The senior resident, however, went back to check on her himself twice that morning.

  It is this little act that I have often thought about since. It was a small thing, a tiny act of conscientiousness. He had seen something about her that worried him. He had also taken the measure of me on morning rounds. And what he saw was a fourth-year student, with a residency spot already lined up in general surgery, on his last rotation of medical school. Did he trust me? No, he did not. So he checked on her himself.

  That was not a two-second matter, either. She was up on the fourteenth floor of the hospital. Our morning teaching conferences, the cafeteria, all the other places we had to be that day were on the bottom two floors. The elevators were notoriously slow. The senior resident was supposed to run one of those teaching conferences. He could have waited for a nurse to let him know if a problem arose, as most doctors would. He could have told a junior resident to see the patient. But he didn't. He made himself go up.

  The first time he did, he found she had a fever of 102 degrees and needed the oxygen flow through her nasal prongs increased. The second time, he found her blood pressure had dropped and the nurses had switched her oxygen to a face mask, and he transferred her to the intensive care unit. By the time I had a clue about what was going on, he already had her under treatment--with new antibiotics, intravenous fluids, medications to support her blood pressure--for what was developing into septic shock from a resistant, fulminant pneumonia. Because he checked on her, she survived. Indeed, because he did, her course was beautiful. She never needed to be put on a ventilator. The fevers stopped in twenty-four hours. She got home in three days.

  WHAT DOES IT take to be good at something in which failure is so easy, so effortless? When I was a student and then a resident, my deepest concern was to become competent. But what that senior resident had displayed that day was more than competence--he grasped not just how a pneumonia generally evolves and is properly treated but also the particulars of how to catch and fight one in that specific patient, in that specific moment, with the specific resources and people he had at hand.

  People often look to great athletes for lessons about performance. And for a surgeon like me, athletes do indeed have lessons to teach--about the value of perseverance, of hard work and practice, of precision. But success in medicine has dimensions that cannot be found on a playing field. For one, lives are on the line. Our decisions and omissions are therefore moral in nature. We also face daunting expectations. In medicine, our task is to cope with illness and to enable every human being to lead a life as long and free of frailty as science will allow. The steps are often uncertain. The knowledge to be mastered is both vast and incomplete. Yet we are expected to act with swiftness and consistency, even when the task requires marshaling hundreds of people--from laboratory technicians to the nurses on each change of shift to the engineers who keep the oxygen supply system working--for the care of a single person. We are also expected to do our work humanely, with gentleness and concern. It's not only the stakes but also the complexity of performance in medicine that makes it so interesting and, at the same time, so unsettling.

  Recently, I took care of a patient with breast cancer. Virginia Magboo was sixty-four years old, an English teacher, and she'd noticed a pebblelike lump in her breast. A needle biopsy revealed the diagnosis. The cancer was small--three-quarters of an inch in diameter. She considered her options and decided on breast-conserving treatment--I'd do a wide excision of the lump as well as what's called a sentinel lymph node biopsy to make sure the cancer hadn't spread to the lymph nodes. Radiation would follow.

  The operation was not going to be difficult or especially hazardous, but the team had to be meticulous about every st
ep. On the day of surgery, before bringing her to the operating room, the anesthesiologist double-checked that it was safe to proceed. She reviewed Magboo's medical history and medications, looked at her labs in the computer and at her EKG. She made sure that the patient had not had anything to eat for at least six hours and had her open her mouth to note any loose teeth that could fall out or dentures that should be removed. A nurse checked the patient's name band to make sure we had the right person; verified her drug allergies with her, confirmed that the procedure listed on her consent form was the one she expected. The nurse also looked for contact lenses that shouldn't be left in and for jewelry that could constrict a finger or snag on something. I made a mark with a felt-tip pen over the precise spot where Magboo felt the lump, so there would be no mistaking the correct location. Early in the morning before her surgery, she had also had a small amount of radioactive tracer injected near her breast lump, in preparation for the sentinel lymph node biopsy. I now used a handheld Geiger counter to locate where the tracer had flowed, and confirmed that the counts were strong enough to indicate which lymph node was the "hot" one that needed to be excised. Meanwhile, in the operating room, two nurses made sure the room had been thoroughly cleaned after the previous procedure and that we had all the equipment we needed. There is a sticker on the surgical instrument kit that turns brown if the kit has been heat-sterilized and they confirmed that the sticker had turned. A technician removed the electrocautery machine and replaced it with another one after a question was raised about how it was functioning. Everything was checked and cross-checked. Magboo and the team were ready.

  By two o'clock I had finished with the procedures for my patients before her and I was ready too. Then I got a phone call.

  Her case was being delayed, a woman from the OR control desk told me.

  Why? I asked.

  The recovery room was full. So three operating rooms were unable to bring their patients out, and all further procedures were halted until the recovery room opened up.

  OK. No problem. This happens once in a while. We'll wait. By four o'clock, however, Magboo still had not been taken in. I called down to the OR desk to find out what was going on.

  The recovery room had opened up, I was told, but Magboo was getting bumped for a patient with a ruptured aortic aneurysm coming down from the emergency room. The staff would work on getting us another OR.

  I explained the situation to Magboo, lying on her stretcher in the preoperative holding area, and apologized. Shouldn't be too much longer, I told her. She was philosophical. What will be will be, she said. She tried to sleep to make the time pass more quickly but kept waking up. Each time she awoke, nothing had changed.

  At six o'clock I called again and spoke to the OR desk manager. They had a room for me, he said, but no nurses. After five o'clock, there are only enough nurses available to cover seventeen of our forty-two operating rooms. And twenty-three cases were going at that moment--he'd already made nurses in four rooms do mandatory overtime and could not make any more. There was no way to fit another patient in.

  Well, when did he see Magboo going?

  "She may not be going at all," he said. After seven, he pointed out, he'd have nurses for only nine rooms; after eleven, he could run at most five. And Magboo was not the only patient waiting. "She will likely have to be canceled," he said. Cancel her? How could we cancel her?

  I went down to the control desk in person. One surgeon was already there ahead of me lobbying the anesthesiologist in charge. A second was yelling into the OR manager's ear on the phone. Each of us wanted an operating room and there would not be enough to go around. A patient had a lung cancer that needed to be removed. Another patient had a mass in his neck that needed to be biopsied. "My case is quick," one surgeon argued. "My patient cannot wait," said another. Operating rooms were offered for the next day and none of us wanted to take one. We each had other patients already scheduled who would themselves have to be canceled to make room. And what was to keep this mess from happening all over again tomorrow, anyway?

  I tried to make my case for Magboo. She had a breast cancer. It needed to be taken out. This had to happen sooner rather than later. The radioactive tracer, injected more than eight hours ago, was dissipating by the hour. Postponing her operation would mean she would have to undergo a second injection of a radioactive tracer--a doubling of her radiation exposure--just because an OR could not be found for her. That would be unconscionable, I said.

  No one, however, would make any promises.

  THIS IS A book about performance in medicine. As a doctor, you go into this work thinking it is all a matter of canny diagnosis, technical prowess, and some ability to empathize with people. But it is not, you soon find out. In medicine, as in any profession, we must grapple with systems, resources, circumstances, people--and our own shortcomings, as well. We face obstacles of seemingly unending variety. Yet somehow we must advance, we must refine, we must improve. How we have and how we do is my subject here.

  The sections of this book examine three core requirements for success in medicine--or in any endeavor that involves risk and responsibility. The first is diligence, the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles. Diligence seems an easy and minor virtue. (You just pay attention, right?) But it is neither. Diligence is both central to performance and fiendishly hard, as I show through three stories: one about the effort to ensure doctors and nurses simply wash their hands; one about the care of the wounded soldiers in Iraq and Afghanistan; and one about the Herculean effort to eradicate polio from the globe.

  The second challenge is to do right. Medicine is a fundamentally human profession. It is therefore forever troubled by human failings, failings like avarice, arrogance, insecurity, misunderstanding. In this section I consider some of our most uncomfortable questions--such as how much doctors should be paid, and what we owe patients when we make mistakes. I tell the stories of four doctors and a nurse who have gone against medical ethics codes and participated in executions of prisoners. I puzzle over how we know when we should keep fighting for a sick patient and when we should stop.

  The third requirement for success is ingenuity--thinking anew. Ingenuity is often misunderstood. It is not a matter of superior intelligence but of character. It demands more than anything a willingness to recognize failure, to not paper over the cracks, and to change. It arises from deliberate, even obsessive, reflection on failure and a constant searching for new solutions. These are difficult traits to foster--but they are far from impossible ones. Here I tell the stories of people in everyday medicine who have, through ingenuity, transformed medical care--for example, the way babies are delivered and the way an incurable disease like cystic fibrosis is fought--and I examine how more of us can do the same.

  Betterment is a perpetual labor. The world is chaotic, disorganized, and vexing, and medicine is nowhere spared that reality. To complicate matters, we in medicine are also only humans ourselves. We are distractible, weak, and given to our own concerns. Yet still, to live as a doctor is to live so that one's life is bound up in others' and in science and in the messy, complicated connection between the two. It is to live a life of responsibility. The question, then, is not whether one accepts the responsibility. Just by doing this work, one has. The question is, having accepted the responsibility, how one does such work well.

  VIRGINIA MAGBOO LAY waiting, anxious and hungry, in a windowless, silent, white-lit holding area for still two hours more. The minutes ticked, ticked, ticked. At times, in medicine, you feel you are inside a colossal and impossibly complex machine whose gears will turn for you only according to their own arbitrary rhythm. The notion that human caring, the effort to do better for people, might make a difference can seem hopelessly naive. But it isn't.

  Magboo asked me if there was any real prospect of her having her operation that night. The likelihood, I said, had become exceedingly small. But I couldn't bring myself to send her home, and I asked her t
o hang on with me. Then, just before eight o'clock, I got a text message on my pager. "We can bring your patient back to room 29," the display read. Two nurses, it turned out, had seen how backed up the ORs had gotten and, although they could easily have gone home, they volunteered to stay late. "I didn't really have anything else going on anyway," one demurred when I spoke to her. When you make an effort, you find sometimes you are not the only one willing to do so.

  Eleven minutes after I got the page, Magboo was on the operating table, a sedative going into her arm. Her skin was cleansed. Her body was draped. The breast cancer came out without difficulty. Her lymph nodes proved to be free of metastasis. And she was done. She woke up calmly as we put on the dressing. I saw her gazing upward at the operating light above her.

  "The light looks like seashells," she said.

  PART I

  Diligence

  On Washing Hands

  One ordinary December day, I took a tour of my hospital with Deborah Yokoe, an infectious disease specialist, and Susan Marino, a microbiologist. They work in our hospital's infection-control unit. Their full-time job, and that of three others in the unit, is to stop the spread of infection in the hospital. This is not flashy work, and they are not flashy people. Yokoe is forty-five years old, gentle voiced, and dimpled. She wears sneakers at work. Marino is in her fifties and reserved by nature. But they have coped with influenza epidemics, Legionnaires' disease, fatal bacterial meningitis, and, just a few months before, a case that, according to the patient's brain-biopsy results, might have been Creutzfeld-Jakob disease--a nightmare, not only because it is incurable and fatal but also because the infectious agent that causes it, known as a prion, cannot be killed by usual heat-sterilization procedures. By the time the results came back, the neurosurgeon's brain-biopsy instruments might have transferred the disease to other patients, but infection-control team members tracked the instruments down in time and had them chemically sterilized. Yokoe and Marino have seen measles, the plague, and rabbit fever (which is caused by a bacterium that is extraordinarily contagious in hospital laboratories and feared as a bioterrorist weapon). They once instigated a nationwide recall of frozen strawberries, having traced a hepatitis A outbreak to a batch served at an ice cream social. Recently at large in the hospital, they told me, have been a rotavirus, a Norwalk virus, several strains of Pseudomonas bacteria, a superresistant Klebsiella, and the ubiquitous scourges of modern hospitals--resistant Staphylococcus aureus and Enterococcus faecalis, which are a frequent cause of pneumonias, wound infections, and bloodstream infections.