Articles — Atul Gawande
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The Checklist
Better
In Conversation with Atul Gawande
Guest Columnist – New York Times
A healthy dose of American belligerence
Medical Failures, and Successes Too: A Q&A with Atul Gawande
Do No Harm
The Malpractice Mess
Perspective
Five Rules
The Bell Curve
Piecework
Left Behind
Casualties of War
THE CHECKLIST
By Atul Gawande
If a new drug were as effective at saving lives as Peter Pronovost’s checklist, there would be a nationwide marketing campaign urging doctors to use it.The damage that the human body can survive these days is as awesome as it is horrible: crushing, burning, bombing, a burst blood vessel in the brain, a ruptured colon, a massive heart attack, rampaging infection. These conditions had once been uniformly fatal. Now survival is commonplace, and a large part of the credit goes to the irreplaceable component of medicine known as intensive care.
It’s an opaque term. Specialists in the field prefer to call what they do "critical care," but that doesn’t exactly clarify matters. The non-medical term "life support" gets us closer. Intensive-care units take artificial control of failing bodies. Typically, this involves a panoply of technology—a mechanical ventilator and perhaps a tracheostomy tube if the lungs have failed, an aortic balloon pump if the heart has given out, a dialysis machine if the kidneys don’t work. When you are unconscious and can’t eat, silicone tubing can be surgically inserted into the stomach or intestines for formula feeding. If the intestines are too damaged, solutions of amino acids, fatty acids, and glucose can be infused directly into the bloodstream.
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Guest Columnist - New York Times
Atul Gawande was a guest columnist at the New York Times in May 2007. Here’s a link to his first column, on why it’s important to look for failures to improve performance. Note that this link requires a TimesSelect subscription. www.select.nytimes.com.Back to list
In Conversation with...Atul Gawande, MD, MA, MPH
Dr. Robert Wachter, Editor, AHRQ WebM&M: You started Better with a story about the "eyeball test"—a resident correctly perceives that something is amiss in a patient whose objective signs were fine. How do you reconcile the importance of "eyeball tests" in an era that's increasingly about measurement?Dr. Atul Gawande: Well, if we're not even asking at the end of the day whether we've won or lost, then we have no shot at getting better at what we're doing. We just have a random intuition about the direction to go. Surgery is a good case in point. I just finished an operation today, and I'm going to go out and talk to the family and the family is going to ask me how it went. And what we ordinarily say is, "It went fine," because I just had a gut feeling that it went fine. Yet some patients crash and have major complications within the next 30 days and some don't. If we don't have any way to measure whether eyeball tests worked out a month later, then we're not going to do well. Very few of us in surgery actually take a look to see what happened at 30 days to monitor whether we're getting better or getting worse. So I think there has to be more than just the eyeball test.
In the story you mentioned from the book, the resident thought there was something wrong with this elderly lady who wasn't breathing well. All the numbers were right. We were all going off to our morning conferences, and he circled back to see her again, instead of waiting all day to see what happened. Well, part of what intrigued me about that case was not only did he try to think whether something more was going on than the numbers implied, but he recognized that the people around him weren't good enough to do that for themselves. Then he made the decision to act on it. Part of what that reflects is also the fact that we now talk endlessly about systems and the need to make them work right, but around us the systems break down constantly. You must have good, conscientious people who are willing to say that sometimes the system doesn't work and then take responsibility for it.
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A healthy dose of American belligerence
We do not think about medicine as a daily battle against the forces of sickness and decay
By Jeremy Laurance
All parents want the best for their children, none more so than when they are sick. Fraser Brown, son of Gordon Brown, the Prime Minister, celebrated his first birthday last month.While Fraser's dad wonders how to save the NHS, his mother, Sarah, is in charge of looking after Fraser. To help her, she could do no better than glance at Chapter 10 of a newly published book, Better, by Atul Gawande.
Gawande is - uniquely - a top American surgeon at the Brigham and Women's hospital in Boston and a columnist on the New Yorker. His theme is how to improve performance in health care and, unlike most medical tomes, this one is beautifully written. It could help to save Fraser's life. When she has finished the book, Mrs Brown may want to press it on her husband, for it contains a devastating critique of how 21st-century health care has lost its way. It could help save the NHS, too.
Fraser has cystic fibrosis, the commonest inherited condition in the West, affecting 250 babies a year in the UK, which damages the lungs, liver and pancreas.
The gene defect that causes the condition thickens secretions throughout the body making them dry and gluey. The effect in the pancreas is to block the ducts carrying digestive enzymes, making a child less able to absorb food and hence grow. But the lethal effect is on the lungs, whose airways fill with sticky mucus and become shrunken until there is no lung capacity.
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Medical Failures, and Successes Too: A Q&A With Atul Gawande
by Stephen J. Dubner
As I’ve written before, I am a big fan of the writing of Atul Gawande, a surgeon who also happens to be a wonderful writer. His current book is called Better: A Surgeon’s Notes on Performance. Between his operating and his writing, he also found time to answer this Q&A we sent him. After you read this, go read his book.Q: What do you think are the most intractable problems in medicine today?
A: Intractable problems come in two flavors. There are failures due to scientific ignorance (lack of knowledge), and failures to use the knowledge we have (ineptitude). Two of the most intractable failures of ignorance are how to deal effectively with chronic pain — one of the most common complaints people come to doctors with — and how to treat diseases of the immune system (not just HIV but also conditions like multiple sclerosis, some types of diabetes, and rheumatoid arthritis). Still, to me the most depressing are the failures to consistently use discoveries we’ve already made — and leading my list are our failures to wash our hands consistently and prevent the rampant spread of hospital infections (which kill an estimated 90,000 Americans each year), to reliably getting patients hospitalized with pneumonia (the country’s No. 1 killer) the correct antibiotic and in a timely way. We’re only now beginning to realize that reliable performance doesn’t just happen in medicine. It is extremely difficult. And success requires work and innovation.
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Better
By Atul Gawande
"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.
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Do No Harm
The New York Times Sunday Book Review
By Pauline W. Chen
Ask people who have spent any time there and they will tell you this: The hospital can be a dangerous place. Families in waiting rooms will fill you in on the long list of delayed procedures. Patients will reel off complications suffered because of medical care. Doctors will warn of drug-resistant infections contracted only on the wards. And nurses, especially the seasoned ones, will urge you to do everything in your power not to land in the hospital in July, when the newest crop of interns are let loose on medical centers everywhere.It’s a wonder anyone ever gets better.
To read more of this review visit The New York Times Sunday Book Review webpage.
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The Malpractice Mess
Who pays the price when patients sue doctors?
by Atul Gawande
It was an ordinary Monday at the Middlesex County Superior Court in Cambridge, Massachusetts. Fifty-two criminal cases and a hundred and forty-seven civil cases were in session. In Courtroom 6A, Daniel Kachoul was on trial for three counts of rape and three counts of assault. In Courtroom 10B, David Santiago was on trial for cocaine trafficking and illegal possession of a deadly weapon. In Courtroom 7B, a scheduling conference was being held for Minihan v. Wallinger, a civil claim of motor-vehicle negligence. And next door, in Courtroom 7A, Dr. Kenneth Reed faced charges of medical malpractice.Reed was a Harvard-trained dermatologist with twenty-one years of experience, and he had never been sued for malpractice before. That day, he was being questioned about two office visits and a phone call that had taken place almost nine years earlier. Barbara Stanley, a fifty-eight-year-old woman, had come to see him in the summer of 1996 about a dark warty nodule a quarterinch wide on her left thigh. In the office, under local anesthesia, Reed shaved off the top for a biopsy. The pathologist’s report came back a few days later, with a near-certain diagnosis of skin cancer—a malignant melanoma. At a follow-up appointment, Reed told Stanley that the growth would have to be completely removed. This would require taking a two-centimetre margin—almost an inch—of healthy skin beyond the lesion. He was worried about metastasis, and recommended that the procedure be done immediately, but she balked. The excision that he outlined on her leg would have been three inches across, and she couldn’t believe that a procedure so disfiguring was necessary. She said that she had a friend who had been given a diagnosis of cancer erroneously, and underwent unnecessary surgery. Reed pressed, though, and by the end of their discussion she allowed him to remove the visible tumor that remained on her thigh, only a half-inch excision, for a second biopsy. He, in turn, agreed to have another pathologist look at all the tissue and provide a second opinion.
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Perspective
Naked
by Atul Gawande
There is an exquisite and fascinating scene in Kandahar, a movie set in Afghanistan under the Taliban regime, in which a male physician is asked to examine a female patient. They are separated by an opaque screen. Behind it, the woman is covered from head to toe by her burka. The two do not talk directly to each other. The patient’s young son serves as the go-between. She has a stomachache, he says."Does she throw up her food?" the doctor asks.
"Do you throw up your food?" the boy asks.
"No," the woman says, perfectly audibly, but the doctor waits as if he has not heard.
"No," the boy tells him.
For the exam, the doctor has cut a two-inch circle in the screen. "Tell her to come closer," he says. The boy does. She brings her mouth to the opening, and through it he looks inside. "Have her bring her eye to the hole," he says. And so the exam goes. Such, apparently, can be the demands of decency.
When I started my surgical practice two years ago, I was not at all clear about what my own etiquette of examination should be. Expectations are murky; we have no clear standards in the United States; and the topic can be fraught with hazards. Physical examination is deeply intimate, and the way a doctor deals with the naked body — particularly when the doctor is male and the patient female — inevitably raises questions of propriety and trust.
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Five Rules
Harvard Medical School Commencement address
by Atul Gawande
Ladies and gentlemen, Dean Martin, Dean Donoff, faculty, alumni, and most of all, graduates of the Harvard Medical School and Harvard School of Dental Medicine Class of 2005, thank you for the unbelievable honor of getting to speak to you on this day. I was stunned to receive the call requesting my presence here. Then they explained that, actually, Bono was your first choice, but he was unavailable. After that, they tried to get either a Nobel Laureate or one of the plastic surgeons on Extreme Makeover, but everyone was pretty busy. So really I was all they had left.Still, it is a privilege and a surprise to be before you today. Only ten years ago I was sitting just where you are—in fact, right there, six rows in, a bit to the side—a graduate-to-be largely unaware of what I was getting myself into.
Looking back, I think it was the numbers that I was most unprepared for. We are a nation of 296,320,780 people (as of this morning). For this population—never mind the six billion people around the world—you today become but one of 819,000 U.S. physicians and surgeons trying to help them lead long, healthy lives. Also taking part in that effort will be some 2.4 million nurses, 388,000 medical assistants, 232,000 pharmacists, 294,000 lab technicians, 121,000 paramedics, 94,000 respiratory therapists, 85,000 nutritionists…. The numbers are incomprehensible.
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The Bell Curve
What happens when patients find out how good their doctors really are?
by Atul Gawande
Every illness is a story, and Annie Page’s began with the kinds of small, unexceptional details that mean nothing until seen in hindsight. Like the fact that, when she was a baby, her father sometimes called her Little Potato Chip, because her skin tasted salty when he kissed her. Or that Annie’s mother noticed that her breathing was sometimes a little wheezy, though the pediatrician heard nothing through his stethoscope.Back to list
Piecework
by Atul Gawande
To become a doctor, you spend so much time in the tunnels of preparation—head down, trying not to screw up, trying to make it from one day to the next—that it is a shock to find yourself at the other end, with someone shaking your hand and asking how much money you want to make. But the day comes. Two years ago, I was finishing my eighth and final year as a resident in surgery. I had got a second interview for a surgical staff position at the Brigham and Women’s Hospital, in Boston, where I had trained. It was a great job—I’d get to specialize in surgery for certain tumors that interested me, but I’d also be able to do some general surgery. On the appointed day, I put on my fancy suit and took a seat in the wood-panelled office of the chairman of surgery. He sat down opposite me and then he told me the job was mine. "Do you want it?" Yes, I said, a little startled. The job, he explained, came with a guaranteed salary for three years. After that, I would be on my own: I'd make what I brought in from my patients and would pay my own expenses. So, he went on, how much should we pay you?Back to list
Left Behind
by Douglas Starr
DR. ATUL GAWANDE IS conducting a simulated thyroid removal at Brigham and Women’s Hospital. The operation is a bloody procedure. It involves about 100 instruments and dozens of surgical sponges, small gauzelike pads used for sopping up blood. Each time Gawande asks for more sponges, the nurses count them aloud before handing them over – the standard way of keeping track of equipment to make sure nothing gets left inside the patient. Later, as he’s getting ready to close, an exchange takes place that no surgeon wants to hear.Back to list
Casualties of War
Military Care for the Wounded from Iraq
by Atul Gawande
Each Tuesday, the U.S. Department of Defense provides an online update of American military casualties (the number of wounded or dead) from Operation Iraqi Freedom and Operation Enduring Freedom.¹ According to this update, as of November 16, 2004, a total of 10,726 service members had suffered war injuries. Of these, 1361 died, 1004 of them killed in action; 5174 were wounded in action and could not return to duty; and 4191 were less severely wounded and returned to duty within 72 hours. No reliable estimates of the number of Iraqis, Afghanis, or American civilians injured are available. Nonetheless, these figures represent, by a considerable margin, the largest burden of casualties our military medical personnel have had to cope with since the Vietnam War.Back to list