Book Review “Better” by Atul Gawande

First time I came across a non fiction book that too by a doctor which I found was hard to put down , I am really touched by each and every chapter of the book beginning from hand wash till how doctors perform under pressure in each part of world.

Book is written by Dr Atul Gawande , as the title suggests “Better” , book talks about improvement in performance. 3 things Gawande mentioned in his book which can make good at something ,they are Diligence, ingenuity and “Doing Right”. Gawande tried to illustrate all these qualities and did it beautifully with stories from his own experience in India and in USA and also with conversation and experience of other physicians

Diligence- Sometimes small things matter most , and there is a need to give sufficient attention to these small but important things to avoid mistakes, in his story he demonstrated that simple act of hand washing can dramatically decrease infections rate in hospital. Story on “Washing Hands” most simple yet most ignored infection control rule in hospitals. Ignac Semmelweis who was very forthright about views on hand washing in hospitals, as per him Hand washing was single most common reason for maternal deaths from puerperal fever in 19th century .But it took around another 150 years for others to realize this . But condition is no better even today, still doctors and nurses do not adhere to this simple policy . Yokoe and marino did every possible thing to make staff nurses and physicians aware about Hand washing , but still compliance was not more than 50- 60%.

Being Diligent is not an easy job , there are tons of things which oppose you from the diligent efforts that you wish to do, Many things or tasks we wished to do but could not do , then you realize that Diligence which seems very simple is actually Very difficult . Another story about polio eradication from India brings out outstanding achievement by Staff and doctors whose diligent efforts can do things which seemed to be impossible .

The story of US army is most inspiring to me, through diligence, surgeons could drastically enhanced the survival rate among causalities in Iraq .Surgeons realized and found that bottleneck in whole process was delay in care and treatment , Early and improved trauma care could drastically decrease causalities, they used knowledge and technology already in hand, Surgeons realized that wounded soldiers have Golden five minutes not Golden Hour , so Forward surgical teams were made, this is a great example of diligent effort by doctors in war zone. I work in emergency department, while reading this part of book, similar picture was striking in my mind ,that can i also do something like that for trauma patients coming to me in their Golden hour , can i also Make protocol of Golden five minutes rather than an hour, seems simple but soon i realized that i need to put diligent effort to make it happen as there are so many resistance on the way.

Doing Right- Chances to go wrong in medical profession are pretty high, as medicine is not only vast but very complex profession , it is therefore , always troubled with human errors, medicine failures, procedure failures, some failings may be due to human greed, ego, misinterpretations, misunderstandings and insecurity. So solutions and problem are going side by side in human traits.

First section of book focuses on need of another medico person in examination room normally called chaperone, this person is usually a female nurse which stays in examination room while medical examination of another female is going on, in most countries like UK they have standard protocols about Chaperone, about 4 % of disciplinary orders that state medical boards issue against physicians are of sex related offenses, I personally have seen many cases while in Practice in India where some of my fellow doctors are facing sexual harassment cases, so it is very important to have some standard protocols when male physician is examining a female patient.

Now a days, most feared thing in medical profession is Malpractice suit, problem is so severe that now each and every doctor in hospital need an insurance to save himself ,called indemnity. In US problem is more severe where 55000 patients sue the doctors , only few get compensation ( 1 in 100). Lawyers also charge a hefty money. In story lawyer Berry Lang, a independent malpractice lawer earns about $200k in a year, he gets about 5 cases in a year , and out of these , 4 gets the money

One doctor gets sued once in 6 years on an average and also pay around 1 million dollar as premium of insurance. In every profession there is a chance of error, doctors are also human beings , so they also do mistakes, doctors work under pressure and uncertainty, one odd mistake in doctors life can claim his licence , author gave example of Dr Kenneth Reed who faced charges of medical malpractice even though he tried everything from his side to give right advice to the patient. Doctors would never know when things will turn out differently, we as a doctors always try to do best for the patient , but still chances of making mistakes are always there. After mentioning number of stories where system failed , author also told about system that worked “Vaccines”

No matter how safe vaccines are but some children will develop side effects say 1 in 10000 or so, this led to law suits against manufacturers, this followed by manufacturers to go out the business , this caused shortage of vaccine , price hikes etc. To deal with the situation , American vaccine association came with an idea where vaccine will carry 75% surcharge, this additional money will cover all cases where vaccine caused side effects, compensation given usually satisfied the affected parties. One such example gives a hope that system still can be improved .

In next section author mainly writing things about how doctors are compensated, insurance companies had made doctors more like businessmen , to be successful doctors must take most of the insurance trouble themselves , Most doctors are dissatisfied with profession only because they are unable to sort to sort through the insurance morass. So where is the solution , some doctors did remarkably well , like Dr Harris Berman in 1971 , he did a radical experiment , where group of doctors offered patients on fixed annual fee without any bills to insurance company and they paid themselves a fixed salry, idea worked very well By the mid-1980s, sixty thousand patients had joined the Matthew Thornton Health Plan.

Next section of doing Right touch some troublesome and moral issues as if doctors should take participation in legal executions or not, if yes then what is the extent till which doctors can take part. I personally think that taking part in execution is not right for working healthcare professionals as on one side we want doctors to be empathetic with patients , on other side we want them to take part in executions , at the end doctors are also human being, it is not ethically and morally right for doctors to participate in such activities

Doctors are considered next to God as they are the only hope and stand between patients and their illnesses, they fight and fight for patients diseases. But for few successful doctors , element of fighting with illness is different , it is very easy bring ego on table, and when ego is there , patients are on huge risk. Doctors should learn when to stop, and let go of the egos, it is always better to get out rather than holding on egos. When to fight and when to stop and take help is crucial decision that every doctor should learn. All decisions are taken for patients, not for themselves . it is always about patients , not about doctors and his credentials and experience. Many good doctors understand that now it is not worth trying and let the patient die. It is same like doing a business, when business goes well, good for you, when business go wrong, it is time to do cost cutting.

Ingenuity – Childbirth was considered one of most dangerous event in any woman’s life till late 19 30 s, as mortality rate was very high, with the development of new antibiotics , new technology woman’s mortality rate came down significantly, but newborn death rate was still very high, most of the limp babies were considered non viable and left to die. Then there was Ms Virginia Apgar anaesthesiologist came up with score which could measure the child’s health status at birth. Apgar Score included some health variables and scores given to each variable , score 10 means child health status is perfect whereas less than 5 means child requires immediate attention. This metric soon became the instrument in looking at the whole delivery process and soon whole world recognised and used this tool for better outcome of deliveries. Improvements in perinatal care, postnatalcare, Post op care occurred using example of Apgar score

There is another story of Don Berwick, Dr Berwick used quantitative and diligent care to fight against deadly disease “ Cystic fibrosis” . message from bell curve story is we all have bell curve in our work , sometimes we do average work, and there will be times when you do extraordinary work. One should look into himself and see what kind of work brings best out of him and then keep at it.

Finally Author shared his experience of visit in India. He witnessed how doctors managed to work in difficult conditions , scarcity of resources and overwhelming patient load., He also witnessed that procedures and some operations are done based on shared and textbook knowledge , A general surgeon saved life of a boy with almost no resources in Hand.

He concluded “Arriving at meaningful solutions is an inevitably slow and difficult process.Nonetheless, what I saw was: better is possible. It does not take genius. It takesdiligence. It takes moral clarity. It takes ingenuity. And above all, it takes awillingness to try”.

Suggestions for Becoming a Positive Deviant:

1. Ask an Unscipted question- ask patients ‘randomly , machine begins to feel less like machine

2. Don’t complain- Nothing in medicine is more dispiriting than hearing doctors complain

3. Count something- regardless what ever you do – you should be a scientist in this world , in simplest terms one should count something.

4. Write something- write anything , does not matter it achieves perfection or not, it need only add small observation about the worl

5. Change- Look for the opportunity to change .So find something new to try, something to change. Count how often you succeed and how often you fail. Write about it. Ask people what they think. Seeif you can keep the conversation going.

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