— I wrote this a couple months ago but I guess I forgot to publish it. Hope you like it and make sure to check out the book!
What does it mean to be a “good” doctor?
Such a question of what is “good” often goes unanswered, in many fields, for a variety of reasons. Chief among them is their subjectivity.
Let’s consider the Presidency. Centuries of rankings still cannot agree who the best President is. No-one really knows what constitutes a “good” President. Is it popularity? If it is popularity, Ronald Reagan, whose economic policy crippled the US economy, should be considered to be one of the best Presidents. Can we confidently draw that conclusion? Can we ever say, with conviction, that someone is truly “good” at what they do?
The dilemma of subjectivity is worse in medicine. At least people try to rank Presidents. To my knowledge, no-one (except for Gawande) has ever reviewed or provided a criterion to evaluate a doctor.
The courts decide what a “bad” doctor is (though sometimes unfairly). We have malpractice lawsuits but we don’t have “benepractice” inquiries. Compounding the problem is the ever-changing face of the medical profession throughout history. In the 18th century, a baby had a 50-50 shot of surviving. Losing 40% of your patients was exemplary. Today, miscarriages are relatively rare due to better technology. A doctor would be sued for losing that many patients. Our standards change as time progresses. “Good” is perpetually unstable.
Dr. Atul Gawande answers my question with astounding depth. He also answers questions that I hadn’t yet asked. Through a wholly engaging text, accurately named “Better,” Gawande explores the challenges that those of the medical profession face and qualities that allow them to surmount those challenges. He begins with the deceivingly simple quality of “Diligence,” then explores what it means for a Doctor to do “right,” and finally explores ingenuity and creativity in what is generally perceived to be a rigid science.
Most people wash their hands. I hope you wash your hands (don’t be that person). But, and I’m reluctant to say it, as average people we can probably get away with skipping the soap and water once in a while (I’m pretty obsessed with cleanliness but you do you) . It seems blatantly obvious that Doctors cannot. There are millions of infections inside the hospital. “They’re gonna be poking around inside of me,” you might say “I don’t want hands that touched the toilet seat or the hand that touched someone with some virulent disease inside my small intestine.” And you would be right, yet according to Gawande (citing the Us Centers for Disease Control) over 2 Million Americans contract a disease while in the hospital, and soberingly 90,000 die from that disease. The simple cause: workers aren’t washing their hands.
Gawande uses a story from his own hospital to ultimately get to his message. He describes the efforts that sanitation experts at his hospital have taken to encourage hand washing. He also offers an example of a successfully sanitized hospital, where diligent attention was taken to each and every site where contamination might occur.
Gawande also steps outside of the hospital into the villages of India and the shell-shocked roads of Iraq. In India, he describes the effort to eradicate Polio. The medical professionals approached this seemingly impossible task with vigor. Not just focusing on the medicine, they also made sure to uphold the honor of their program. They would not force anyone to get the vaccinations nor would they rebuke anyone for refusing. They would readjust their strategy after a rejection and then move on. In Iraq, he analyzes the feat performed by US surgeons, who saved thousands, US soldiers and Iraqi civilians alike, despite being woefully unequipped.
Diligence may seem dull or inconsequential, but just a few extra minutes tying down loose ends could be the difference between life and death for a patient. The diligent doctor is the good doctor.
In “Doing Right,” Gawande delves into the thorny question of ethics. Medicine is one of the few sciences where ethics take center stage. The doctor must also be a philosopher, balancing the questions of morality, health, propriety, and pragmatics. Gawande makes this the longest chapter, perhaps because of the variety of ethical conundrums, each of them eliciting a new kind of emotion. He begins with the check-up.
Doctors are one of the few people who see us intimately. If we kept our shirts and pants on during a checkup, it would be impossible to diagnose. This intimacy brings up ethical questions. Can a doctor ever be too touchy with a patient? We know that not all doctors are ethically sound. Horrific actions by USA gymnastics Physician Larry Nassar have proven that. The patient needs to feel safe during a checkup, otherwise they won’t “check up” at all. Gawande outlines the steps he takes and the steps that others take. One such step is saving a chaperone supervise the examination, though this practice seems to be relatively uncommon. His analysis is even more interesting. He says “the social dimension matters as much as the scientific dimension.” That wasn’t really something that I had considered. Before reading this book, I had forgotten that behind the practice, there was a profession
Gawande also discusses litigation against physicians in great detail. The practice of medicine is examined and policed in great deal for good reason. If a software engineer makes a mistake, it probably isn’t that bad. If a doctor makes a mistake, it could be life threatening. The ethics of mistakes are somewhat intriguing. At what point is a doctor truly negligent? Gawande elucidates the seemingly murky situation through stories. One involves a doctor who sued his own hospital while the other explores malpractice from a doctor turned malpractice lawyer. Each of these stories serves to explain the situation without jargon.
The book then throws a flurry of ethical problems with the profession at the reader, including doctor pay, when to pull the plug, and the relationship between medicine and the death penalty. These scenarios give you an insiders look into the life of a doctor. From the perspective of someone interested but outside the profession, it seems daunting. My original impression of medicine was that of a strict science, but after this book, I’ve learned that medicine is multi-faceted. It is certainly a strict science, but it’s also a social, ethical, and philosophical science.
In his final chapter on ingenuity, Gawande discusses birth in greater detail. His 2-page explanation of how birth happens is honestly much clearer than my health textbook. He goes through different birthing procedures, and later expands into medical procedures in general. A major theme is simplicity. Many of the ingenuities doctors dream up on the spot are simple adjustments or simple techniques that make the job better.
“Better” is a must read for anyone, not just those interested in medicine. The stories are actually engaging and, for once, the cliche “I couldn’t put this book down” is accurate.