November 12th, 2023
“BETTER” IS EXCELLENT a book review by Jim W. Vogele
Better, a Surgeon’s Notes on Performance, by Atul Gawande, MD, MPH (Publisher: Picador) 2007, ISBN-13: 978-0-312-42765-8
Introduction
Reading a book about medicine while you’re on a hiking vacation in northern Italy?
I wasn’t sure if this was a good idea. If I’m not reading a couple books, however, then I’m not really on vacation, regardless of how much hiking, biking, skiing or walking along a beach I may do.
Thus it was that on this recent hiking (and reading) adventure, among the books I brought along was Atul Gawande’s 2007 work, BETTER, subtitled, A Surgeon’s Notes on Performance. Lest you think I am an insufferable boor (which may be true of course), please note that I did bring several books that had nothing to do with practicing medicine or law. For example, THE SUNNY SIDE OF THE ALPS includes fascinating history of the Dolomites, including explanations of the historical naming practices in Northern Italy which have resulted in multilingual place names in this stunningly beautiful part of the world (e.g. names in Italian, Austrian – German and Ladin . . . but I digress).
As Gawande proposes in his Introduction, “In medicine, as in any profession, we must grapple with systems, resources, circumstances, people – and our own shortcomings, as well.” That proposition, as Gawande says, is applicable to all professions. My field, the law, is no exception, but medicine presents a context in which all of life and death is on the line. And this is probably why Atul Gawande believes in healthcare practitioners striving to be “better.”
Diligence, doing right, and ingenuity
Dr. Gawande is an author, surgeon and public health researcher. And as known by anyone who has read his essays in the New Yorker or his book BEING MORTAL, the doctor-author-researcher Gawande is all about critical self-analysis in furtherance of improving the practice of medicine individually and systemically on a national (and international) basis.
Gawande structures his book in three parts:
- Diligence.
- Doing Right.
- Ingenuity.
The book starts with the topic of hand-washing. BETTER was published nearly 15 years before the Covid pandemic of 2020 – 2022, when hand-washing had a long and important 15 minutes of fame. But not surprisingly, hand-washing has always been absolutely critical to infection control. In 1847, for childbirths occurring in a hospital the maternal death rate was 20% due to “childbed fever” or puerperal fever, a bacterial infection. At the same time, when births occurred at home the maternal death rate was just 1%. Ignaz Semmelweis, a Viennese obstetrician, discovered that doctors themselves were to blame for the abysmal morbidity statistics at hospitals. Semmelweis concluded that physicians’ inadequate handwashing practices were leading to the rampant transmission of bacteria. Semmelweis was a 19th century disrupter, and his findings were not readily accepted in the medical community until after his death. Later in the 19th century, Louis Pasteur’s work ensured our recognition of the role that transmission of bacteria plays in healthy and unhealthy living (and dying).
It is also worth noting here that Gawande emphasizes the vast superiority of antibacterial soaps over mere warm water and hand soap. His detailed description of proper handwashing procedure is enlightening:
“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 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 person.”
Unfortunately, the next sentence reads: “Almost no one adheres to this procedure.”
The things we learn by reading!
Physician compensation
Given that I am a physician contract attorney, I watch for opportunities to read thought-provoking books about the practice of medicine that provide perspective and insight to inform my legal work. Invariably, a good book on healthcare practitioners will include material that does just that.
In BETTER, in a chapter entitled, “Piecework,” Gawande addresses everyone’s favorite topic: getting paid. Yes, indeed, BETTER devotes a chapter to a topic squarely relevant to the best physician contract reviews.
In the “Piecework” chapter, Dr. Gawande refers to “the insurance morass,” a potentially discouraging phrase familiar to all of us. But the good news for my clients – who are primarily looking for Oregon, Washington, Montana, or California physician contract reviews – is that employees are generally working for an employer that will shoulder the burden of billing and collections. Yes, employed physicians need to conscientiously work with third party payers and need to diligently complete their coding, charting, documentation and so forth, but employed healthcare practitioners are not personally wrangling with insurers to obtain fair payment.
Without veering entirely off-topic, note that attorneys are in a similar boat when it comes to the relative advantages of working as an employed versus self-employed professional. In my opinion and experience, one distinct advantage of “employed” status is the relatively lighter administrative duties and marketing responsibilities an employee has in comparison to an individual operating their own business. Not that any of us escape entirely the demands of administration (including staff meetings, supervisory responsibilities and so forth), but employees are not solely responsible for the financial end of the picture in contrast to self-employed professionals.
Back to the “insurance morass” situation – how bad is it? One consultant quoted by Gawande explains that adequate in-office systems help immensely. These include computerized billing systems, careful review and comparison of billing records going out and payment records coming in, and hiring office personnel to deal with insurance companies. According to this consultant, “A well-run office can get the insurer rejection down from 30 percent to, say, 15 percent.” While this may be encouraging, the consultant tells Gawande: “That’s how a doctor earns money . . . It’s a war with insurance every step of the way.”
Indeed, few things are more complicated than the financial aspects of healthcare in America. Some parts of the story are disheartening and others encouraging. For example, Gawande shares with readers an anecdote about the heart surgery that saved his son’s life. The total cost of the surgical process was nearly a quarter million dollars. Gawande’s portion of the bill? Five dollars. This was the cost of the co-pay for the initial visit to the emergency room.
Gawande is keenly attuned to the fact that far too many people are less fortunate than his family – whether because they have no insurance or because the results of their loved-one’s surgery are not so good. But one can readily see, as Gawande suggests, the effect financial imprimaturs have upon the quality of healthcare. For example, consider the diligent, thorough hand-washing procedure mentioned above. How does a physician required to see 25 patients a day find the time to engage in such scrupulous handwashing with the frequency recommended to meet the strictest of sanitary standards? I will let Dr. Gawande’s book elaborate upon that question; which of course it does, with the author’s typical blend of aspirational pragmatism.
Dr. Gawande uses a frame narrative for his “Piecework” chapter, with the larger framework being: How much would our author be paid in his initial staff surgeon position in a Boston hospital? While Gawande doesn’t provide the answer, he does recite many of the relevant considerations he explored, including somewhat awkward conversations with colleagues or future colleagues on the topic of income.
Gawande also reveals his final question to the Chairman of Surgery after the young doctor-author has already accepted the offer: “‘What are the health insurance benefits like?’ I asked.”
That’s an important question, even though in most physician employment contracts the benefits will be more or less established. And you may need to ask questions regarding specifics, and request benefits summaries in order to see the full picture (the most common approach to benefits in physician employment contracts is along the lines of ‘the employed Physician will receive the same benefits package as other providers who work for us’).
Bottom-line here is that nearly every physician encountering an employment contract will have to address the question: Am I being compensated adequately and fairly? Part of my job as a physician contract review attorney is to help you answer that question.
Difficult subjects
Author Gawande does not shy away from difficult topics. For example, his chapter entitled, “The Doctors of the Death Chamber,” examines the issue of lethal injections for convicts with death sentences; and specifically considers the physicians and nurses who have in some capacity participated in that process. Dr. Gawande lets us know that few healthcare practitioners involved in lethal injections are willing to talk on the record about this difficult topic.
Likewise, Gawande’s chapter on military medicine explores the similarly difficult topic of treating the unfortunate souls wounded in war. These days, the percentage of wounded combatants who are ultimately saved is phenomenally high – up to 90% — which is amazing given how serious that war injuries tend to be, and, as Gawande explains, what they used to be, for example, in WW II.
In short, Gawande’s discussion of lethal injections and war casualties are just as well-conceived and thought-provoking as the balance of his book.
And one of the most difficult subjects . . .
The issue Gawande offers as the most difficult issue doctors will face exemplifies how far modern healthcare has advanced:
“I used to think that the hardest struggle of doctoring is learning the skills. But it is not, although just when you begin to feel confident that you know what you are doing, a failure knocks you down. It is not the strain of the work, either, though sometimes you are worn to your ragged edge. No, the hardest part of being a doctor, I have found, is to know what you have power over and what you don’t.
. . .
We have at our disposal today the remarkable abilities of modern medicine. Learning to use them is difficult enough. But understanding their limits is the most difficult task of all.
. . .
In the end, no guidelines can tell us what we have power over and what we don’t. in the face of uncertainty, wisdom is to err on the side of pushing, to not give up. But you have to be ready to recognize when pushing is only ego, only weakness. You have to be ready to recognize when the pushing can turn to harm.”
Sage advice.
As an attorney, you are faced with countless instances of an injustice done, yet there may be no viable remedy to repair the damage (the reasons there is no viable remedy are as varied as you might imagine – sometimes it’s the facts, sometimes the law). In such cases, while you might yearn to give a potential client some hope, you are doing no favor by giving false hope. Sometimes the best advice you can give is not to push onward at all costs. The best advice may be to relinquish the matter, to accept things as they are, and to make the best of the present and whatever the future holds. As I write these words, I realize again the critical distinction between legal issues and medical issues. With legal issues, one is most often dealing with money and not with life and death (examples abound of legal issues in the criminal justice system that equate figuratively or literally to life and death, but, by and large, the civil legal system is about recovering money to redress a wrong, however incomplete the remedy may seem, and to incentivize bad actors to behave differently in the future so as to avoid injuring others, i.e. deterrence). In short, the relief for injustice available by means of the civil system is most often largely financial.
On the topic of dollars and cents, Gawande draws our attention to a rather remarkable statistic on allocation of healthcare spending: “Analysts often note how ridiculous it is that we spend more than a quarter of public health care dollars on the last six months of life. Perhaps we could spare this fruitless spending – if only we knew when people’s last six months would be.”
Indeed.
This “last six months” topic is certainly one of interest to Gawande. His book, BEING MORTAL, which Gawande published in 2014, is all about the end-of-life issues in healthcare. As with BETTER, I highly recommend BEING MORTAL.
The final section of BETTER is “Ingenuity,” with chapters on delivering babies and cystic fibrosis. Again, Gawande’s writing, his research, and his ability to craft an engrossing narrative are on full display.
To circle back to Italy for a second, BETTER was not only a suitable book for a vacation read, I looked forward to the reading regardless of the beauty of the northern Italian mountains (and did enough hiking that I deserved my quiet moments of reading with a glass of wine).
Conclusion
To conclude this little paean to BETTER, I want to mention Gawande’s observations garnered in India, his “ancestral home.”
Early in the book, the author talks about the polio vaccination effort he witnessed in 2003. The coordination of mass vaccination efforts to eradicate disease is awe-inspiring and, if you haven’t read about the scope of such efforts, you will appreciate Gawande’s description. Later in the book, BETTER tells us a little about Dr. Gawande’s experiences when, having “just finished my surgical training, and before starting my practice in earnest” in Boston, Gawande decided to travel to India as a “visiting surgeon . . . .”
One of the physicians Gawande accompanied in his India ‘rotation’ was Dr. Ashish Motewar, “a general surgeon in his late thirties on duty that day. He had a black Tom Selleck mustache, khaki pants, a blue oxford shirt open at the neck. He did not wear a white coat. His only equipment was a pen, his thin, almost belligerent fingers, and his wits.”
What Gawande witnessed was a dedication that is nothing short of remarkable. For example: “In total, Motewar saw thirty-six patients in three hours that morning. But he was calm despite the chaos. He would smooth down his mustache with his thumb and forefinger and peer silently over his nose at the papers people thrust before him. Then he would speak in a slow and quiet way that made one listen carefully to hear him. He could be brusque at times. But he did what he could to give everyone at least a few moments of individual attention.”
For context, Gawande explains the working conditions of Dr. Motewar and his colleagues: “The Naded hospital, however, is the lone public hospital serving a district of 1,400 villages like Uti, a population of 2.3 million people. It has five hundred beds, three main operating rooms, and I found when I visited, just nine general surgeons (Imagine Kansas with just nine surgeons.).” Despite this, countless successful surgeries are conducted; diagnoses and prescriptions are made; and pathways to better health are mapped out.
A few pages later Gawande observes: “Using just textbooks and advice from one another, the surgeons at this ordinary district hospital in India had developed an astonishing range of expertise . . . . In that remote, dust-covered town in Maharashtra, Motewar and his colleagues had become among the most proficient ulcer surgeons in the world.”
One cannot help but be inspired by Dr. Motewar and by Dr. Gawande’s book, BETTER. As Gawande sums up: “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 takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.”
All of us are better off as a result of the thoughtful, compassionate, and humane analysis and story-telling of Atul Gawande.
