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Searching for more (book excerpt: Better: A Surgeon's Notes on Performance)

Massachusetts surgeon Atul Gawande, MD, MPH, writes about how physicians are working to improve the delivery of health care and provides examples of doing what's best for patients.

By Atul Gawande, MD, MPH, amednews contributor. June 25, 2007.

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Book Excerpt
A peek inside what's new on the shelves on topics pertinent to physicians.

This excerpt deals with how doctors grapple with deciding whether to keep fighting for a patient.

So maybe we should never hold back, never stop pushing. In the face of uncertainty, what could be safer? It doesn't take long to realize, however, that the rule is neither viable nor humane. All doctors -- whether surgeons, psychiatrists, or dermatologists -- have patients they are unable to heal, or even to diagnose, no matter how hard they try. I have several patients who have come to me with chronic, severe abdominal pain of one sort or another. And I have tried all I can to figure out the cause of their pain. I have done CT scans and MRIs. I have sent the patients to gastroenterologists, who endoscoped their colons and their stomachs. I have ruled out pancreatitis, gastritis, ulcers, lactose intolerance, and lesser known conditions like celiac sprue. But their pain has remained. Just take out my gallbladder, one patient pleaded with me, and even her internist joined in. The pain was in the exact location of her gallbladder. But the gallbladder looked normal on all the tests. So do you take out the gallbladder on the off chance it is the source? At some point you have to admit that you are up against a problem you are not going to solve and that, by pushing further and harder, you might well do more harm than good. Sometimes there is nothing you can do.

I was walking down the hallway one day, when Jeanne, one of the intensive care unit nurses, stopped me, visibly angry. "What is it with you doctors?" she said. "Don't you ever know when to stop?" That day she'd been caring for a man with lung cancer. He had had one of his lungs removed and had been in intensive care for all but three weeks of the five months since. A pneumonia that blossomed in his remaining lung early after surgery had left him unable to breathe without a tracheostomy and a respirator. He had to be heavily sedated or else his oxygen levels dropped. He received nutrition through a surgically placed gastric tube. Sepsis claimed his kidneys and the team put him on continuous dialysis. It had long ago become apparent that a life outside the hospital was not possible for this man. But neither the doctors nor his wife seemed capable of confronting this truth -- because he did not have a terminal disease (his cancer had been removed successfully) and he was only in his fifties. So there he lay, with no evident hope of progress and his doctors simply trying to keep him from falling back. This was not the only patient Jeanne had like this, either.

But as we talked, Jeanne also told me of doctors she thought had stopped pushing too soon. So I asked what she felt the best doctors did. She thought for a while before answering. Good doctors, she finally said, understand one key thing: "This is not about them. It's about the patient." The good doctors didn't always get the answers right, she said. Sometimes they still pushed too long or not long enough. But at least they stopped to wonder, to reconsider the path they were on. They asked colleagues for another perspective. They set aside their egos.

This insight is wiser and harder to grasp than it might seem. When someone has come to you for your expertise and your expertise has failed, what do you have left? You have only your character to fall back upon -- and sometimes it's only your pride that comes through. You may simply deny your plan has failed, deny that more can't be done. You may become angry. You may blame the person -- "She didn't follow my instructions!" You may dread just seeing that person again. I have done all these things. But they never come to any good.

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.

In a way, our task is to "Always Fight." But our fight is not always to do more. It is to do right by our patients, even though what is right is not always clear.

~~~

This next excerpt explores measuring quality.

Once we acknowledge that, no matter how much we improve our average, the bell curve isn't going away, we're left with all sorts of questions. Will being in the bottom half be used against doctors? Will we be expected to tell our patients how we score? Will patients leave us? Will those at the bottom be paid less than those at the top? The answer to all these questions is likely yes.

Recently, for example, there has been a rapid shift toward "paying for quality." (No one ever says "docking for mediocrity," but it amounts to the same thing.) Across the country, insurers like Medicare, Aetna, and the Blue Cross-Blue Shield companies now hold back 10 percent or more of payments to physicians until specific quality goals are met. Medicare has decided not to pay surgeons for intestinal transplantation operations at all unless the doctors achieve a predefined success rate -- and it may extend the practice to other procedures. Not surprisingly, this makes doctors anxious. I once sat in on a presentation of the concept to an audience of doctors hearing about it for the first time. By the end, some in the crowd were practically shouting with indignation: We're going to be paid according to our grades? Who is doing the grading? For God's sake, how?

We in medicine are not the only ones being graded nowadays. Firefighters, CEOs, and salesmen are. Even teachers are being graded, and, in some places, being paid accordingly. Yet we all feel uneasy about being judged by such grades. They never seem to measure the right things. They don't take into account circumstances beyond our control. They are misused; they are unfair. Still, the simple facts remain: there is a bell curve in all human activities, and the differences you measure usually matter.

I asked Honor Page [whose daughter Annie has cystic fibrosis] what she would do if, after all her efforts and the efforts of the doctors and nurses at Cincinnati Children's Hospital to ensure that "there was no place better in the world" to receive cystic fibrosis care, the program's comparative performance still rated as resoundingly average.

"I can't believe that's possible," she told me. The staff have worked so hard, she said, that she could not imagine they would fail.

After I pressed her, though, she told me, "I don't think I'd settle for Cincinnati if it remains just average." Then she thought about it some more. Would she really move Annie away from people who had been so devoted all these years, just because of the numbers? Well, maybe. But, at the same time, she wanted me to understand that their effort counted for more than she was able to express.

I do not have to consider these matters for very long before I start thinking about where I would stand on a bell curve for the operations I do. In my area of specialization, surgery for endocrine tumors, I would hope that my statistics prove to be better than those of surgeons who only occasionally do this kind of surgery. But am I up in Warwickian territory? Do I have to answer this question?

The hardest question for anyone who takes responsibility for what he or she does is, What if I turn out to be average? If we took all the surgeons at my level of experience, compared our results, and discovered that I am one of the worst, the answer would be easy: I'd turn in my scalpel. But what if I were a B–? Working as I do in a city that's mobbed with surgeons, how could I justify putting patients under the knife? I could tell myself, Someone's got to be average. If the bell curve is a fact, then so is the reality that most doctors are going to be average. There is no shame in being one of them, right?

Except, of course, there is. What is troubling is not just being average but settling for it. Everyone knows that averageness is, for most of us, our fate. And in certain matters -- looks, money, tennis -- we would do well to accept this. But in your surgeon, your child's pediatrician, your police department, your local high school? When the stakes are our lives and the lives of our children, we want no one to settle for average.

Reprinted by arrangement with Metropolitan Books, an imprint of Henry Holt and Co., LLC, from "Better: A Surgeon's Notes on Performance." Copyright 2007 by Atul Gawande. $24. Note that the work appearing herein is protected under copyright laws, and reproduction of the text in any form for distribution is strictly prohibited. The right to reproduce or transfer the work via any medium must be secured with the copyright owner.

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