Better: A Surgeon's Notes on Performance by Atul Gawande

From Barnes & Noble

In one of the most readable science titles of recent years, surgeon and MacArthur fellow Atul Gawande applies his gift for limpid prose to medical and ethical dilemmas in this collection of essays, some of them adapted from articles in the New England Journal of Medicine and The New Yorker. From battlefield surgical tents in Iraq to delivery rooms in Boston, the bestselling author of Complications uses riveting accounts of medical failure and triumph to show how doctors can and must better their rate of success while confronting daunting obstacles and grappling with what are often literally life-and-death issues.

From the Publisher

National Bestseller

The struggle to perform well is universal: each of us faces fatigue, limited resources, and imperfect abilities in whatever we do. But nowhere is this drive to do better more important than in medicine, where lives may be on the line with any decision.

Atul Gawande, the New York Times bestselling author of Complications, examines, in riveting accounts of medical failure and triumph, how success is achieved in this complex and risk-filled profession. At once unflinching and compassionate, Better is an exhilarating journey, narrated by "arguably the best nonfiction doctor-writer around" (Salon.com).

The Washington Post - Perri Klass

Better makes a compelling case for medical self-awareness in the operating room, on the hospital ward and even on the battlefield. Gawande succeeds in looking at medical achievement -- and lapses -- from a new perspective. His stories evoke the profound desire that doctors feel to cure, along with our besetting anxieties about poor performance and its consequences. He makes his case that failure is "so easy, so effortless," but also that "positive deviance" -- deliberate and determined individual improvement -- is possible. His own self-consciousness, his ability to ask questions about the nuts and bolts of medical practice, and his storytelling skills make this a book about the complex grandeur of the human endeavor that is medicine.

The New York Times - Pauline W. Chen

As with his first book, Complications, Gawande provides a cleareyed view of the medical profession that both resonates and gives pause. Once again, he spares no one, himself included. Gawande, a surgeon, manages to capture medicine in all of its complex and chaotic glory, and to put it, still squirming with life, down on the page. While fans of his work may be disappointed to find they've already read half of the chapters in The New Yorker (where Gawande is a staff writer) or elsewhere, Gawande's meditation on performance is not only an absorbing collection of essays on how some doctors manage to do better but also an exhilarating call for the rest of us to do the same.

Publishers Weekly

Veteran character actor Lloyd does a commendable job in narrating Gawande's arresting exposé of the razor-thin margin that separates top doctors from the rest. While the book has its share of sensational and bloodcurdling tales of virulent infections and medicine gone wrong, Lloyd resists the urge to sensationalize his reading. He rightly senses that these tales do not constitute the heart of this book. Some parts are necessarily slow-moving and methodical, including a lecture on the proper way to scrub hands or a complex rundown of India's health care system. Lloyd's quietly authoritative reading lends an unhurried air that is appropriate for a book fundamentally about taking the time to care, and care diligently, about the things that matter most. Gawande's writing works well on audio as several chapters appeared as discrete essays in the New Yorkerand the New England Journal of Medicine, and still bear the stamp of stand-alone material. It's perfect for listeners who prefer thoughtful, short essays for a ride in the car or a walk on the treadmill. Simultaneous release with the Metropolitan hardcover (Reviews, Feb. 12). (May)

Publishers Weekly

Surgeon and MacArthur fellow Gawande applies his gift for dulcet prose to medical and ethical dilemmas in this collection of 12 original and previously published essays adapted from the New England Journal of Medicine and the New Yorker. If his 2002 collection, Complications, addressed the unfathomable intractability of the body, this is largely about how we erect barriers to seamless and thorough care. Doctors know they should wash their hands more often to avoid bacterial transfer in the ward, but once a minute does seem extreme. Using chaperones for breast exams seems a fine idea, but it does make situations awkward. "The social dimension turns out to be as essential as the scientific," Gawande writes-a conclusion that could serve as a thumbnail summary of his entire output. The heart of the book are the chapters "What Doctors Owe," about the U.S.'s blinkered malpractice system, and "Piecework," about what doctors earn. Cheerier, paradoxically, are the chapters involving polio and cystic fibrosis, featuring Dr. Pankaj Bhatnagar and Dr. Warren Warwick, two remarkable men who have been able to catapult their humanity into their work rather than constantly stumble over it. Indeed, one suspects that once we cure the ills of the health care system, we'll look back and see that Gawande's writings were part of the story. (Apr.) Copyright 2007 Reed Business Information.

James Swanton - Library Journal

Gawande, a Harvard-trained endocrine surgeon, contributor to The New Yorker, best-selling author (Complications: A Surgeon's Notes on an Imperfect Science), and 2006 MacArthur fellow, examines the nature of how success and excellence are achieved in medicine and how diligence, doing right, and ingenuity can combine to do better—in not only medicine but also all other human endeavors. In a narrative style reminiscent of Oliver Sacks, Sherwin B. Nuland, and Abraham Verghese, Gawande candidly weaves a tapestry of essays on topics as varied as hospital hand washing, polio in India, surgical tents in the Iraq war, physicians' salaries, malpractice insurance, and doctors' roles in lethal injections. The essays are united, as they highlight opportunities for improvement within the medical community, which serves as a successful framework for Gawande's study of a profession predicated on betterment. These revealing, humanistic essays are highly recommended for all libraries. Gawande's varied accomplishments have been publicized, and this book is certain to be a best seller [For a Q&A with Gawande, see LJ3/15/07.--Ed.]

Kirkus Reviews

"What does it take to be good at something, when failure is so easy?" asks writer/physician Gawande in his follow-up to Complications (2002). Diligence, ingenuity and "doing right," he answers. Gawande illustrates each of these qualities with stories from his own experience, as well as his observations of and conversations with other physicians. Being diligent about the simple act of hand-washing dramatically reduces hospital infections, he demonstrates, and through diligence, army surgeons in Baghdad have greatly enhanced the survival rate among casualties in Iraq. The section on doing right tackles such troublesome moral issues as whether doctors should participate in executions and at what point treatment of a patient becomes mistreatment and should be stopped. Discussing ingenuity, Gawande shows how the rating scale devised by Virginia Apgar, neither an obstetrician nor a mother, transformed the practice of obstetrics. A similar rating scale for every medical encounter, he believes, would inform patients and improve the performance of doctors and hospitals. He lauds the innovative thinking of Don Berwick, head of the Institute for Health Care Improvement, who is challenging the medical profession to measure and compare the performance of doctors and hospitals and to give patients total access to that information. When such information is available, medical professionals can identify the best performance and learn from it, as Gawande illustrates with an account of exceptional results in treating cystic fibrosis at Babies and Children's Hospital in Cleveland. Monitoring and improving clinical performance would do more to save lives than advances in laboratory knowledge, he contends. Foryoung doctors wondering how they can make an individual difference, Gawande suggests five strategies: Ask unscripted questions, don't complain, "count something" (be a scientist as well as a doctor), write something (to make yourself part of a larger world) and change in response to new ideas. A must-read for medical professionals-and a discerning, humanizing portrait of doctors at work for the rest of us.

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Product Details

• ISBN: 0312427654
  
• ISBN-13: 9780312427658
• Format: Paperback, 288pp
• Publisher: Picador
• Pub. Date: January 2008
• Edition Description: Reprint
• Sales Rank: 1,281

• Table of Contents
• Read an Excerpt
• Read a Sample Chapter

Table of Contents

Read an Excerpt

Read a Sample Chapter

Better

Henry Holt and Company

Chapter One

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, theplague, 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.

Each year, according to the U.S. Centers for Disease Control, two million Americans acquire an infection while they are in the hospital. Ninety thousand die of that infection. The hardest part of the infection-control team's job, Yokoe says, is not coping with the variety of contagions they encounter or the panic that sometimes occurs among patients and staff. Instead, their greatest difficulty is getting clinicians like me to do the one thing that consistently halts the spread of infections: wash our hands.

There isn't much they haven't tried. Walking about the surgical floors where I admit my patients, Yokoe and Marino showed me the admonishing signs they have posted, the sinks they have repositioned, the new ones they have installed. They have made some sinks automated. They have bought special five-thousand-dollar "precaution carts" that store everything for washing up, gloving, and gowning in one ergonomic, portable, and aesthetically pleasing package. They have given away free movie tickets to the hospital units with the best compliance. They have issued hygiene report cards. Yet still, we have not mended our ways. Our hospital's statistics show what studies everywhere else have shown-that we doctors and nurses wash our hands one-third to one-half as often as we are supposed to. Having shaken hands with a sniffling patient, pulled a sticky dressing off someone's wound, pressed a stethoscope against a sweating chest, most of us do little more than wipe our hands on our white coats and move on-to see the next patient, to scribble a note in the chart, to grab some lunch.

This is, embarassingly, nothing new. In 1847, at the age of twenty-eight, the Viennese obstetrician Ignac Semmelweis famously deduced that, by not washing their hands consistently or well enough, doctors were themselves to blame for childbed fever. Childbed fever, also known as puerperal fever, was the leading cause of maternal death in childbirth in the era before antibiotics (and before the recognition that germs are the agents of infectious disease). It is a bacterial infection-most commonly caused by Streptococcus, the same bacteria that causes strep throat-that ascends through the vagina to the uterus after childbirth. Out of three thousand mothers who delivered babies at the hospital where Semmelweis worked, six hundred or more died of the disease each year-a horrifying 20 percent maternal death rate. Of mothers delivering at home, only 1 percent died. Semmelweis concluded that doctors themselves were carrying the disease between patients, and he mandated that every doctor and nurse on his ward scrub with a nail brush and chlorine between patients. The puerperal death rate immediately fell to 1 percent-incontrovertible proof, it would seem, that he was right. Yet elsewhere, doctors' practices did not change. Some colleagues were even offended by his claims; it was impossible to them that doctors could be killing their patients. Far from being hailed, Semmelweis was ultimately dismissed from his job.

Semmelweis's story has come down to us as Exhibit A in the case for the obstinacy and blindness of physicians. But the story was more complicated. The trouble was partly that nineteenth-century physicians faced multiple, seemingly equally powerful explanations for puerperal fever. There was, for example, a strong belief that miasmas of the air in hospitals were the cause. And Semmelweis strangely refused to either publish an explanation of the logic behind his theory or prove it with a convincing experiment in animals. Instead, he took the calls for proof as a personal insult and attacked his detractors viciously.

"You, Herr Professor, have been a partner in this massacre," he wrote to one University of Vienna obstetrician who questioned his theory. To a colleague in Wurzburg he wrote, "Should you, Herr Hofrath, without having disproved my doctrine, continue to teach your pupils [against it], I declare before God and the world that you are a murderer and the 'History of Childbed Fever' would not be unjust to you if it memorialized you as a medical Nero." His own staff turned against him. In Pest, where he relocated after losing his post in Vienna, he would stand next to the sink and berate anyone who forgot to scrub his or her hands. People began to purposely evade, sometimes even sabotage, his hand-washing regimen. Semmelweis was a genius, but he was also a lunatic, and that made him a failed genius. It was another twenty years before Joseph Lister offered his clearer, more persuasive, and more respectful plea for antisepsis in surgery in the British medical journal Lancet.

One hundred and forty years of doctors' plagues later, however, you have to wonder whether what's needed to stop them is precisely a lunatic. Consider what Yokoe and Marino are up against. No part of human skin is spared from bacteria. Bacterial counts on the hands range from five thousand to five million colony-forming units per square centimeter. The hair, underarms, and groin harbor greater concentrations. On the hands, deep skin crevices trap 10 to 20 percent of the flora, making removal difficult, even with scrubbing, and sterilization impossible. The worst place is under the fingernails. Hence the recent CDC guidelines requiring hospital personnel to keep their nails trimmed to less than a quarter of an inch and to remove artificial nails.

Plain soaps do, at best, a middling job of disinfecting. Their detergents remove loose dirt and grime, but fifteen seconds of washing reduces bacterial counts by only about an order of magnitude. Semmelweis recognized that ordinary soap was not enough and used a chlorine solution to achieve disinfection. Today's antibacterial soaps contain chemicals such as chlorhexidine to disrupt microbial membranes and proteins. Even with the right soap, however, 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. It seems impossible. On morning rounds, our residents check in on twenty patients in an hour. The nurses in our intensive care units typically have a similar number of contacts with patients requiring hand washing in between. 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. Such frequent hand washing can also irritate the skin, which can produce a dermatitis, which itself increases bacterial counts.

Less irritating than soap, 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. Dispensers can be put at the bedside more easily than a sink. And at alcohol concentrations of 50 to 95 percent, they are more effective at killing organisms, too. (Interestingly, pure alcohol is not as effective-at least some water is required to denature microbial proteins.)

Still, it took Yokoe over a year to get our staff to accept the 60 percent alcohol gel we have recently adopted. Its introduction was first blocked because of the staff's fears that it would produce noxious building air. (It didn't.) Next came worries that, despite evidence to the contrary, it would be more irritating to the skin. So a product with aloe was brought in. People complained about the smell. So the aloe was taken out. Then some of the nursing staff refused to use the gel after rumors spread that it would reduce fertility. The rumors died only after the infection-control unit circulated evidence that the alcohol is not systemically absorbed and a hospital fertility specialist endorsed the use of the gel.

With the gel finally in wide use, the compliance rates for proper hand hygiene improved substantially: from around 40 percent to 70 percent. But-and this is the troubling finding-hospital infection rates did not drop one iota. Our 70 percent compliance just wasn't good enough. If 30 percent of the time people didn't wash their hands, that still left plenty of opportunity to keep transmitting infections, indeed, the rates of resistant Staphylococcus and Enterococcus infections continued to rise. Yokoe receives the daily tabulations. I checked with her one day not long ago, and sixty-three of our seven hundred hospital patients were colonized or infected with MRSA (the shorthand for methicillin-resistant Staphylococcus aureus) and another twenty-two had acquired VRE (vancomycin-resistant Enterococcus)-unfortunately, typical rates of infection for American hospitals.

Rising infection rates from superresistant bacteria have become the norm around the world. The first outbreak of VRE did not occur until 1988, when a renal dialysis unit in England became infested. By 1990, the bacteria had been carried abroad, and four in one thousand American ICU patients had become infected. By 1997, a stunning 23 percent of ICU patients were infected. When the virus for SARS-severe acute respiratory syndrome-appeared in China in 2003 and spread within weeks to almost ten thousand people in two dozen countries across the world (10 percent of whom were killed), the primary vector for transmission was the hands of health care workers. What will happen if (or rather, when) an even more dangerous organism appears-avian flu, say, or a new, more virulent bacteria? "It will be a disaster," Yokoe says.

Anything short of a Semmelweis-like obsession with hand washing has begun to seem inadequate. Yokoe, Marino, and their colleagues have now resorted to doing random spot checks on the floors. On a surgical intensive care unit, they showed me what they do. They walk in unannounced. They go directly into patients' rooms. They check for unattended spills, toilets that have not been cleaned, faucets that drip, empty gel dispensers, overflowing needle boxes, inadequate supplies of gloves and gowns. They check whether the nurses are wearing gloves when they handle patients' wound dressings and catheters, which are ready portals for infection. And of course, they watch to see whether everyone is washing up before patient contact. Neither hesitates to confront people, though they try to be gentle about it. ("Did you forget to gel your hands?" is a favored line.) Staff members have come to recognize them. I watched a gloved and gowned nurse come out of a patient's room, pick up the patient's chart (which is not supposed to be touched by dirty hands), see Marino, and immediately stop short. "I didn't touch anything in the room! I'm clean!" she blurted out.

Yokoe and Marino hate this aspect of the job. They don't want to be infection cops. It's no fun, and it's not necessarily effective, either. With twelve patient floors and four different patient pods per floor, they can't stand watch the way Semmelweis did, scowling over the lone sink on his unit. And they risk having the staff revolt as his staff did against him. But what other options remain? I flipped through back issues of the Journal of Hospital Infection and Infection Control and Hospital Epidemiology, two leading journals in the field, and the articles are a sad litany of failed experiments to change our contaminating ways. The great hoped-for solution has been a soap or a hand rinse that would keep skin disinfected for hours and make it easy for all of us to be good. But none has been found. The situation has prompted one expert to propose-only half jokingly-that the best approach may be to give up on hand washing and get people to stop touching patients altogether.

We always hope for the easy fix: the one simple change that will erase a problem in a stroke. But few things in life work this way. Instead, success requires making a hundred small steps go right-one after the other, no slipups, no goofs, everyone pitching in. We are used to thinking of doctoring as a solitary, intellectual task. But making medicine go right is less often like making a difficult diagnosis than like making sure everyone washes their hands.

It is striking to consider how different the history of the operating room after Lister has been from that of the hospital floor after Semmelweis. In the operating room, no one pretends that even 90 percent compliance with scrubbing is good enough. If a single doctor or nurse fails to wash up before coming to the operating table, we are horrified-and certainly not shocked if the patient develops an infection a few days later. Since Lister we have gone even further in our expectations. We now make sure to use sterile gloves and gowns, masks over our mouths, caps over our hair. We apply antiseptics to the patient's skin and lay down sterile drapes. We put our instruments through steam heat sterilizers or, if any are too delicate to tolerate the autoclave, through chemical sterilizers. We have reinvented almost every detail of the operating room for the sake of antisepsis. We have gone so far as to add an extra person to the team, known as the circulating nurse, whose central job is, essentially, to keep the team antiseptic. Every time an unanticipated instrument is needed for a patient, the team can't stand around waiting for one member to break scrub, pull the thing off a shelf, wash up, and return. So the circulator was invented. Circulators get the extra sponges and instruments, handle the telephone calls, do the paperwork, get help when it's needed. And every time they do, they're not just making the case go more smoothly. They are keeping the patient uninfected. By their very existence, they make sterility a priority in every case.

(Continues...)

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Excerpted from Better by Atul Gawande Copyright © 2007 by Atul Gawande. Excerpted by permission.
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