Atul Gawande on Medicine's Promise and Limits

Surgeon and writer Atul Gawande's new book, Better: A Surgeon's Notes on Performance, examines how well doctors do their jobs, and how they could improve their craft.

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MADELEINE BRAND, host:

This is DAY TO DAY from NPR News. I'm Madeleine Brand.

Some people are just better than others, and arguably, Atul Gawande is one of them. He's a MacArthur Genius Award fellow. He's also a surgeon, and he's a writer. His latest book is called "Better: A Surgeon's Notes on Performance." It looks at how well doctors do their jobs and why they could do even better.

I asked Atul Gawande why those in the medical profession have to be better than just good enough.

Dr. ATUL GAWANDE (Surgeon; Author, "Better: A Surgeon's Notes on Performance'): You know, 97 percent of the time, if you come into a hospital, everything goes well. But three percent of the time, we have major complications. And we feel like that's enormous success, and yet three percent of the time in a country of 300 million people is an awful lot of injury to people that we could help try to avoid.

And the second thing is there's a bell curve. There are some people who are getting fabulous results. We have not looked to what those people are doing that's different from everybody else. But when we look, you start to see stories that tell you a lot more about what we can do to close the gap between what we already know how to do and what we actually do.

BRAND: Let's talk about the hand washing. Because hospital infections - they are a huge, huge problem. And yet, it is notoriously difficult to get doctors or nurses or any other medical professionals to routinely wash their hands. Why is that?

Dr. GAWANDE: Yeah. If you think about, you know, what's the difference with people who are great at washing their hands and those who are not, it's not that they, you know, scrub under the nails extra special carefully. They are people who recognize that in the course of the day, you might take care of 50, 75 people and have to wash your hands 100, 150 times. And there barriers to getting it done. There are barriers all around.

You know, for a nurse who has to wash her hands, or his hands, 100 times in the course of eight hours, that can - at a minute per time - that's already getting up to almost a couple of hours of your entire shift your washing hands. It's not tenable. So the people who are great at zeroing in on this look for the possibilities of failure.

They started doing things in Pittsburg, for example, like making sure that they switch entirely to alcohol-based gels, because it only took 15 seconds. They moved gloves and gowns right into the patient rooms where they could be used. They made sure dressings were available, so you weren't running back and forth. You had to think about failure in a decisive way and recognize that what we have isn't good enough.

BRAND: And you chronicle some innovations in this field, and yet they haven't seem to have caught on nationwide.

Dr. GAWANDE: Yeah. Part of it is because we haven't imagined, I think, the problem in the right way. Instead, we put obstacles in their way. And so in Pittsburg, I talk about a hospital that actually got rid of these infections. And it's partly because they looked at, what is our infection rate? They publicized it. They made themselves transparent in way that makes a lot of us uncomfortable. And then, they went to the staffs and said, what do you know that could make this better, and let's actually do it.

And it had this level of attention to detail about performance in medicine that we usually reserve just for, you know, the laboratory.

BRAND: You have a whole section in your book about malpractice and the huge amounts of insurance that doctors have to carry to fight malpractice suits. And I'm just wondering if you do admit that you're not the best at something, if you do go the way you're suggesting and having the performance published, don't you just open yourself up to lawsuits or formal complaints filed against you, or a whole host of legal problems that doctors already have to contend with?

Dr. GAWANDE: Yeah, the malpractice system is - gets in our way of being able to do good. But at the same time, it serves a certain purpose which we have to be willing to replace if we are going to argue against that system. You know, it is a system that tries to do something to help people who are harmed by what we do. And we do owe people we hurt something, especially when we've hurt them because of a mistake. Now, the reality of this system we have is that it's only one percent who actually get compensation when they are harmed.

And also, there's a large proportion of people who sue, but don't deserve compensation because they just had a bad outcome where there wasn't an error. And that's just is a sign of a kind of a broken system. I think we are faced in medicine with the reality that we have to be willing to talk about our failures and think hard about them, even despite the malpractice system. I mean, there are things that we can do to make that system better. But in the meantime, we can't say, well, you know, the malpractice system's in the way, therefore I can't think hard about these problems.

You know, there's human skills, and it's not just science. It's not just algorithms and statistics. But there is also some general pattern to the recognition that, you know, we do 40 million operations a year in the country. It's not just a craft if we want to make sure that we save as many of those people as possible. We also have to be willing to recognize that it's - that there are obstacles in the system that prevent care from being very good, and that there are directions that you can push the whole community to go, the decision making to change, so that you're saving more of those lives.

And part of what I try to weave together in this story is there's some sense of how you deal in a world with risk, acknowledge the humanity and individuality of people, but get all the advantages you can from the science and the statistics to let us get the best possible results.

BRAND: Atul Gawande, thank you very much for speaking with us.

Dr. AGAWANDE: And thank you.

BRAND: Atul Gawande is a writer and a surgeon. He's the author of the new book "Better: A Surgeon's Notes on Performance."

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