Friday, June 15, 2007

Gawande gets even 'Better'

Every now and then, I come across an article or a book that I know is just going to be fantastic course material for our Medical Humanities course at Imperial. Reading Atul Gawande's book, Complications: a surgeon's notes on an imperfect science (reviewed by AJ on this blog here) was one of those 'Ah, brilliant' moments. Here is a book that sits on the interface of science and humanities in showing that the practice of medicine is vulnerable to all sorts of biases and unacknowledged 'human' factors. In a particularly eye-opening first chapter, Gawande explains how the 'learning curve', both for inexperienced junior doctors and for new procedures, exacts a toll. This sometimes adversely affects individuals (costing lives in some instances through initially low success rates) but it's for the greater good as skills develop as 'practice makes perfect'.

Some in the medical profession greeted the exposing of these weaknesses in Complications as a betrayal of the profession. But Gawande doesn't merely flag up weaknesses. In his new book, Better: a surgeon's notes on performance, he gives guidelines on learning from experience, good and bad, to improve the success of individual medical professionals but also medicine as a whole -- after all, as James Bryce said, medicine is 'the only profession that labours incessantly to destroy the reason for its own existence'.

Gawande gave a talk at Imperial College on 4 June in which he highlighted some of the issues he explores in his book. He pointed out the discrepancy that exists in the public imagination about the quality of medical performance: it is generally expected to be more consistently good than the reality of the Bell curve in which only a few people or institutions operate in the 'excellence' range. Gawande is in favour of league tables (shock! horror!), because he believes it identifies the excellent few from whom we can then learn how to be better.

Gawande identified 'diligence' as an attribute of successful doctors: giving attention to detail to avoid errors. This includes surveillance for failure in a profession in which failure is effortless. He also said that doctors need a moral clarity about their mission. Yes, there are financial and time pressures, but professionals need to be innovative about finding ways round these obstacles to deliver good quality care. His third quality was 'bedside ingenuity': protocols only take you so far -- thinking of new solutions and interrogating failure is vital for improvement.

Although I have not yet had a chance to read it thoroughly, Better looks every bit as good as Complications. Gawande has an enviably accessible writing style, and important things to say. I was thrilled to have the opportunity to hear him speak in person. There is a podcast from NPR of Gawande discussing his book and reading from it here.

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