By Chet Yarbrough
By Atul Gawande
Narrated by John Bedford Lloyd
“Better: A Surgeon’s Notes on Performance” is about physician and hospital performance measurement. With properly reported physician and hospital information, the author argues that doctors can make better medical decisions. Doctor Atul Gawande suggests that hospitals and physicians that report and categorize successes and failures in treatment of patients improves all who practice medicine.
As in all walks of life, there are those who work to be the best they can be, and those who work to get by. Doctor Gawande falls into the former rather than the latter category of working physicians.
Doctor Gawande is a practicing surgeon at Brigham and Women’s Hospital in Boston, an associate professor of surgery at Harvard, and a writer. “Better…” is a brief evaluation of medical service in the United States. It contains more criticism than praise of the American practice of medicine.
On the one hand, Gawande praises American military medical practice that has reduced battle field deaths with the military’s use of statistical analysis to measure and modify medical procedures. On the other hand, Gawande pointedly criticizes domestic hospitals for failing to collect and categorize medical information that measures successes and failures of doctors and hospital staff in treating patients.
Because medical treatments and results are not nationally codified, patients, doctors, and hospitals are unaware of statistically significant improvements in patient’ medical procedures and infection prevention programs. Patients have limited ways of knowing which general practitioners are more successfully treating particular diseases. Patients generally have less information about which surgeons have better surgical results, or what hospitals have fewer accidental infection outbreaks. Changes in medical procedures that improve doctor and hospital performance are handicapped by lack of relevant statistical information about medical procedures that improve patient recovery and reduce hospital mistakes.
Gawande praises doctors that focus on improving their medical performance based on statistical reports that show patient results from common medical treatments. The problem is that few medical treatment reports are based on broad doctor and/or hospital experience. He gives the example of cystic fibrosis treatments that are more effectively performed in one place than another. There is a wide discrepancy in the survival rates of cystic fibrosis patients in different treatment programs. Gawande notes that systematic questioning of patients about treatment in one clinic results in longer lives for cystic fibrosis patients; while a clinic that relies on the mechanics of treatment, without careful questioning of patient’ treatment compliance, loses patients at earlier ages. Detailed statistical studies can reveal differences in treatment of cystic fibrosis to improve patient survival rates. Differences in treatment are a life and death consequence for stricken patients.
Gawande notes that per capita cost of medical services is too high in America and gives a startling comparison of what is done in India to show how much can be done to combat disease with a fraction of what American’ patients pay. Gawande criticizes insurance industry interference in doctor/patient relationship. He vilifies Obama-care because it fails to offer any solution to insurance industry’ encroachment on doctor/patient relationship. In fact, Obama-care increases rather than decreases interference. (In fairness, the political influence of insurance industry lobbying limits legislator’ and President’ flexibility in changing American medical policy.) On the other hand, Gawande notes that Obama-care offers medical care to people who receive no health care except in emergencies which unfairly burden general tax payers and bankrupt marginally employed patients.
Gawande touches on the unconscionable fees that doctors pay for malpractice insurance to protect themselves from both nuisance and legitimate patient lawsuits. Gawande sees both sides of the issue. He interviews a surgeon that abandons his practice to become a lawyer. The doctor, turned lawyer, files lawsuits against doctors on behalf of patients that have been harmed by physician’ mistakes. Mistakes happen because the medical profession is no different from any human endeavor. A mistake at a construction site like a mistake in surgery may end in death.
Gawande suggests that doctors and hospital staffs should be held responsible for their mistakes. However, Gawande notes that insurance companies distort the process of settlement in the same way they distort medical treatment for patients. For an insurance company, settlement is strictly a matter of cost; not whether a doctor is guilty of negligence but how much it will cost to settle the lawsuit in respect to revenues received from insurance premiums. Gawande suggests that some kind of sinking fund be established by the medical profession to handle disputes between doctors, hospitals, and patients. The legal system remains a part of the process but settlements are more physician/patient related than insurance/doctor/patient related.
Gawande shines a light on dark corners of medical practice in the United States and suggests ways American medical mistakes can be reduced, methodology constructively changed, costs better controlled, and service equitably improved.