Better: A Surgeon's Notes on Performance

Better: A Surgeon's Notes on Performance

by Atul Gawande

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Product Details

ISBN-13: 9780312427658
Publisher: Picador
Publication date: 01/22/2008
Edition description: Reprint
Pages: 288
Sales rank: 39,996
Product dimensions: 5.55(w) x 8.17(h) x 0.76(d)
Lexile: 1100L (what's this?)

About the Author

Atul Gawande, a 2006 MacArthur Fellow, is a general surgeon at the Brigham and Women's Hospital in Boston, a staff writer for The New Yorker, and an associate professor at Harvard Medical School and the Harvard School of Public Health. His first book, Complications: A Surgeon's Notes on an Imperfect Science, was a New York Times bestseller and a finalist for the 2002 National Book Award. Gawande lives with his wife and three children in Newton, Massachusetts.

Hometown:

Newton, Massachusetts

Date of Birth:

November 5, 1965

Place of Birth:

Brooklyn, New York

Education:

B.A.S., Stanford University, 1987; M.A., Oxford University, 1989; M.D., Harvard Medical School, 1995

Read an Excerpt

Better

A Surgeon's Notes on Performance
By Atul Gawande

Henry Holt and Company

Copyright © 2007 Atul Gawande
All right reserved.

ISBN: 978-0-8050-8211-1


Chapter One

On Washing Hands

One ordinary December day, I took a tour of my hospital with Deborah Yokoe, an infectious disease specialist, and Susan Marino, a microbiologist. They work in our hospital's infection-control unit. Their full-time job, and that of three others in the unit, is to stop the spread of infection in the hospital. This is not flashy work, and they are not flashy people. Yokoe is forty-five years old, gentle voiced, and dimpled. She wears sneakers at work. Marino is in her fifties and reserved by nature. But they have coped with influenza epidemics, Legionnaires' disease, fatal bacterial meningitis, and, just a few months before, a case that, according to the patient's brain-biopsy results, might have been Creutzfeld-Jakob disease-a nightmare, not only because it is incurable and fatal but also because the infectious agent that causes it, known as a prion, cannot be killed by usual heat-sterilization procedures. By the time the results came back, the neurosurgeon's brain-biopsy instruments might have transferred the disease to other patients, but infection-control team members tracked the instruments down in time and had them chemically sterilized. Yokoe and Marino have seen measles, theplague, and rabbit fever (which is caused by a bacterium that is extraordinarily contagious in hospital laboratories and feared as a bioterrorist weapon). They once instigated a nationwide recall of frozen strawberries, having traced a hepatitis A outbreak to a batch served at an ice cream social. Recently at large in the hospital, they told me, have been a rotavirus, a Norwalk virus, several strains of Pseudomonas bacteria, a superresistant Klebsiella, and the ubiquitous scourges of modern hospitals-resistant Staphylococcus aureus and Enterococcus faecalis, which are a frequent cause of pneumonias, wound infections, and bloodstream infections.

Each year, according to the U.S. Centers for Disease Control, two million Americans acquire an infection while they are in the hospital. Ninety thousand die of that infection. The hardest part of the infection-control team's job, Yokoe says, is not coping with the variety of contagions they encounter or the panic that sometimes occurs among patients and staff. Instead, their greatest difficulty is getting clinicians like me to do the one thing that consistently halts the spread of infections: wash our hands.

There isn't much they haven't tried. Walking about the surgical floors where I admit my patients, Yokoe and Marino showed me the admonishing signs they have posted, the sinks they have repositioned, the new ones they have installed. They have made some sinks automated. They have bought special five-thousand-dollar "precaution carts" that store everything for washing up, gloving, and gowning in one ergonomic, portable, and aesthetically pleasing package. They have given away free movie tickets to the hospital units with the best compliance. They have issued hygiene report cards. Yet still, we have not mended our ways. Our hospital's statistics show what studies everywhere else have shown-that we doctors and nurses wash our hands one-third to one-half as often as we are supposed to. Having shaken hands with a sniffling patient, pulled a sticky dressing off someone's wound, pressed a stethoscope against a sweating chest, most of us do little more than wipe our hands on our white coats and move on-to see the next patient, to scribble a note in the chart, to grab some lunch.

This is, embarassingly, nothing new. In 1847, at the age of twenty-eight, the Viennese obstetrician Ignac Semmelweis famously deduced that, by not washing their hands consistently or well enough, doctors were themselves to blame for childbed fever. Childbed fever, also known as puerperal fever, was the leading cause of maternal death in childbirth in the era before antibiotics (and before the recognition that germs are the agents of infectious disease). It is a bacterial infection-most commonly caused by Streptococcus, the same bacteria that causes strep throat-that ascends through the vagina to the uterus after childbirth. Out of three thousand mothers who delivered babies at the hospital where Semmelweis worked, six hundred or more died of the disease each year-a horrifying 20 percent maternal death rate. Of mothers delivering at home, only 1 percent died. Semmelweis concluded that doctors themselves were carrying the disease between patients, and he mandated that every doctor and nurse on his ward scrub with a nail brush and chlorine between patients. The puerperal death rate immediately fell to 1 percent-incontrovertible proof, it would seem, that he was right. Yet elsewhere, doctors' practices did not change. Some colleagues were even offended by his claims; it was impossible to them that doctors could be killing their patients. Far from being hailed, Semmelweis was ultimately dismissed from his job.

Semmelweis's story has come down to us as Exhibit A in the case for the obstinacy and blindness of physicians. But the story was more complicated. The trouble was partly that nineteenth-century physicians faced multiple, seemingly equally powerful explanations for puerperal fever. There was, for example, a strong belief that miasmas of the air in hospitals were the cause. And Semmelweis strangely refused to either publish an explanation of the logic behind his theory or prove it with a convincing experiment in animals. Instead, he took the calls for proof as a personal insult and attacked his detractors viciously.

"You, Herr Professor, have been a partner in this massacre," he wrote to one University of Vienna obstetrician who questioned his theory. To a colleague in Wurzburg he wrote, "Should you, Herr Hofrath, without having disproved my doctrine, continue to teach your pupils [against it], I declare before God and the world that you are a murderer and the 'History of Childbed Fever' would not be unjust to you if it memorialized you as a medical Nero." His own staff turned against him. In Pest, where he relocated after losing his post in Vienna, he would stand next to the sink and berate anyone who forgot to scrub his or her hands. People began to purposely evade, sometimes even sabotage, his hand-washing regimen. Semmelweis was a genius, but he was also a lunatic, and that made him a failed genius. It was another twenty years before Joseph Lister offered his clearer, more persuasive, and more respectful plea for antisepsis in surgery in the British medical journal Lancet.

One hundred and forty years of doctors' plagues later, however, you have to wonder whether what's needed to stop them is precisely a lunatic. Consider what Yokoe and Marino are up against. No part of human skin is spared from bacteria. Bacterial counts on the hands range from five thousand to five million colony-forming units per square centimeter. The hair, underarms, and groin harbor greater concentrations. On the hands, deep skin crevices trap 10 to 20 percent of the flora, making removal difficult, even with scrubbing, and sterilization impossible. The worst place is under the fingernails. Hence the recent CDC guidelines requiring hospital personnel to keep their nails trimmed to less than a quarter of an inch and to remove artificial nails.

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 a 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 patient.

Almost no one adheres to this procedure. It seems impossible. On morning rounds, our residents check in on twenty patients in an hour. The nurses in our intensive care units typically have a similar number of contacts with patients requiring hand washing in between. Even if you get the whole cleansing process down to a minute per patient, that's still a third of staff time spent just washing hands. Such frequent hand washing can also irritate the skin, which can produce a dermatitis, which itself increases bacterial counts.

Less irritating than soap, alcohol rinses and gels have been in use in Europe for almost two decades but for some reason only recently caught on in the United States. They take far less time to use-only about fifteen seconds or so to rub a gel over the hands and fingers and let it air-dry. Dispensers can be put at the bedside more easily than a sink. And at alcohol concentrations of 50 to 95 percent, they are more effective at killing organisms, too. (Interestingly, pure alcohol is not as effective-at least some water is required to denature microbial proteins.)

Still, it took Yokoe over a year to get our staff to accept the 60 percent alcohol gel we have recently adopted. Its introduction was first blocked because of the staff's fears that it would produce noxious building air. (It didn't.) Next came worries that, despite evidence to the contrary, it would be more irritating to the skin. So a product with aloe was brought in. People complained about the smell. So the aloe was taken out. Then some of the nursing staff refused to use the gel after rumors spread that it would reduce fertility. The rumors died only after the infection-control unit circulated evidence that the alcohol is not systemically absorbed and a hospital fertility specialist endorsed the use of the gel.

With the gel finally in wide use, the compliance rates for proper hand hygiene improved substantially: from around 40 percent to 70 percent. But-and this is the troubling finding-hospital infection rates did not drop one iota. Our 70 percent compliance just wasn't good enough. If 30 percent of the time people didn't wash their hands, that still left plenty of opportunity to keep transmitting infections, indeed, the rates of resistant Staphylococcus and Enterococcus infections continued to rise. Yokoe receives the daily tabulations. I checked with her one day not long ago, and sixty-three of our seven hundred hospital patients were colonized or infected with MRSA (the shorthand for methicillin-resistant Staphylococcus aureus) and another twenty-two had acquired VRE (vancomycin-resistant Enterococcus)-unfortunately, typical rates of infection for American hospitals.

Rising infection rates from superresistant bacteria have become the norm around the world. The first outbreak of VRE did not occur until 1988, when a renal dialysis unit in England became infested. By 1990, the bacteria had been carried abroad, and four in one thousand American ICU patients had become infected. By 1997, a stunning 23 percent of ICU patients were infected. When the virus for SARS-severe acute respiratory syndrome-appeared in China in 2003 and spread within weeks to almost ten thousand people in two dozen countries across the world (10 percent of whom were killed), the primary vector for transmission was the hands of health care workers. What will happen if (or rather, when) an even more dangerous organism appears-avian flu, say, or a new, more virulent bacteria? "It will be a disaster," Yokoe says.

Anything short of a Semmelweis-like obsession with hand washing has begun to seem inadequate. Yokoe, Marino, and their colleagues have now resorted to doing random spot checks on the floors. On a surgical intensive care unit, they showed me what they do. They walk in unannounced. They go directly into patients' rooms. They check for unattended spills, toilets that have not been cleaned, faucets that drip, empty gel dispensers, overflowing needle boxes, inadequate supplies of gloves and gowns. They check whether the nurses are wearing gloves when they handle patients' wound dressings and catheters, which are ready portals for infection. And of course, they watch to see whether everyone is washing up before patient contact. Neither hesitates to confront people, though they try to be gentle about it. ("Did you forget to gel your hands?" is a favored line.) Staff members have come to recognize them. I watched a gloved and gowned nurse come out of a patient's room, pick up the patient's chart (which is not supposed to be touched by dirty hands), see Marino, and immediately stop short. "I didn't touch anything in the room! I'm clean!" she blurted out.

Yokoe and Marino hate this aspect of the job. They don't want to be infection cops. It's no fun, and it's not necessarily effective, either. With twelve patient floors and four different patient pods per floor, they can't stand watch the way Semmelweis did, scowling over the lone sink on his unit. And they risk having the staff revolt as his staff did against him. But what other options remain? I flipped through back issues of the Journal of Hospital Infection and Infection Control and Hospital Epidemiology, two leading journals in the field, and the articles are a sad litany of failed experiments to change our contaminating ways. The great hoped-for solution has been a soap or a hand rinse that would keep skin disinfected for hours and make it easy for all of us to be good. But none has been found. The situation has prompted one expert to propose-only half jokingly-that the best approach may be to give up on hand washing and get people to stop touching patients altogether.

We always hope for the easy fix: the one simple change that will erase a problem in a stroke. But few things in life work this way. Instead, success requires making a hundred small steps go right-one after the other, no slipups, no goofs, everyone pitching in. We are used to thinking of doctoring as a solitary, intellectual task. But making medicine go right is less often like making a difficult diagnosis than like making sure everyone washes their hands.

It is striking to consider how different the history of the operating room after Lister has been from that of the hospital floor after Semmelweis. In the operating room, no one pretends that even 90 percent compliance with scrubbing is good enough. If a single doctor or nurse fails to wash up before coming to the operating table, we are horrified-and certainly not shocked if the patient develops an infection a few days later. Since Lister we have gone even further in our expectations. We now make sure to use sterile gloves and gowns, masks over our mouths, caps over our hair. We apply antiseptics to the patient's skin and lay down sterile drapes. We put our instruments through steam heat sterilizers or, if any are too delicate to tolerate the autoclave, through chemical sterilizers. We have reinvented almost every detail of the operating room for the sake of antisepsis. We have gone so far as to add an extra person to the team, known as the circulating nurse, whose central job is, essentially, to keep the team antiseptic. Every time an unanticipated instrument is needed for a patient, the team can't stand around waiting for one member to break scrub, pull the thing off a shelf, wash up, and return. So the circulator was invented. Circulators get the extra sponges and instruments, handle the telephone calls, do the paperwork, get help when it's needed. And every time they do, they're not just making the case go more smoothly. They are keeping the patient uninfected. By their very existence, they make sterility a priority in every case.

(Continues...)



Excerpted from Better by Atul Gawande Copyright © 2007 by Atul Gawande. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

Table of Contents

Contents

Introduction...............................................................1
Part I Diligence...........................................................11
On Washing Hands...........................................................13
The MoP-Up.................................................................29
Casualties of War..........................................................51
PART II Doing Right........................................................71
Naked......................................................................73
What Doctors Owe...........................................................84
Piecework..................................................................112
The Doctors of the Death Chamber...........................................130
On Fighting................................................................154
Part III Ingenuity.........................................................167
The Score..................................................................169
The Bell Curve.............................................................201
For Performance............................................................231
Afterword: Suggestions for Becoming a Positive Deviant.....................249
Notes on Sources...........................................................259
Acknowledgments............................................................271

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Better: A Surgeon's Notes on Performance 4 out of 5 based on 0 ratings. 71 reviews.
Anonymous More than 1 year ago
Although not quite as good as Complications, Gawande's book "Better" is a worthwhile read. This collection of essays is an interesting read for anyone interested in the psyche of a doctor. I enjoyed it, and read it in just a few days. As a physician myself, I find his writing to be engaging, honest, and insightful. Overall, one of the better books about medicine that I've read. If you like this one, I recommend that you read Complications, as well as Dr. Michael Collins' book "Hot Lights Cold Steel" and Dr. Anthony Youn's book "In Stitches." These are some of my favorite medical non-fiction, and you won't be disappointed!
Anonymous More than 1 year ago
I really enjoyed this book! Glad that I had some friends recommend this to me!!
Bastek More than 1 year ago
As always Dr Gawande makes you stop and think about your daily routine. Great examples of how to improve our daily routing and strive to make your better best.
amaqueira on LibraryThing 3 days ago
This book was great. Gawande incorporated stories throughout the book that made the topic at hand even more relevant. I enjoyed his writing style as well as his eye-opening honesty about the medical field.
Harlan879 on LibraryThing 3 days ago
I was a little disappointed by this book. I like Gawande's writing quite a bit, and the idea of measured performance that he talks about is really important, but the book as a whole didn't cohere as well as it ought to have. Taken as a series of essays, almost all of the essays were really interesting, and most spoke to his central issue, but I expected to be a little more wowed by his insight. Still, recommended for those interested in how medicine can and should be improved.
nursejane on LibraryThing 3 days ago
Nothing to write home about. Fine. Quite interesting, but still just fine. Almost dripping with Gawande's love for he and his fellow doctors (Am I biased? yes. Am I right to be? Probably)
wandering_star on LibraryThing 3 days ago
This book of essays, by a practising doctor, argues that what makes the most difference in the quality of modern medical care is not technical skill as such, but "diligence and ingenuity" and attentiveness. It's a well-written book, with each chapter using one or more case studies to illustrate the point, but for me, the book lacked the 'so what' - it said "this is so", but not "this is so, because..." or "this is so, therefore...". This meant that it seemed like a primer on issues in contemporary medicine, but without too much wider relevance.
mellybean36 on LibraryThing 3 days ago
When I first picked up this book, I thought it would be a collection of memoirs about, well, making patients better. I was prepared to be entertained, but nothing out of the ordinary. I was pleasantly surprised when I realized that this was a book about making medicine better - the way we practice, our outcomes, our ethics. It's not just a book for doctors or people in medicine, but can really be read and appreciated by just about anyone. Additionally, I really like Atul Gawande's writing style - it is direct, easy to follow his train of thought, and he gives strong evidence for every point he makes. I also liked the way the book is set up - the chapters are relatively short, so it's in very manageable chunks and can easily be put down and picked up again. I think that one of the marks of a really great book is one that makes you think, even well after you've finished reading it. I'm sure this will be one of those books, as I hope to keep some of its principles in mind as I become a resident and beyond.
SqueakyChu on LibraryThing 3 days ago
It is a sincere pleasure to read/listen to these essays of Dr. Atul Gawande. He is such an articulate and thoughtful individual. Here are some of the topics he addresses: (1) diligence in hospital workers' handwashing, (2) eradicating polio in India, (3) increasing survival outcomes of war-wounded American soldiers, (4) using chaperones, (5) being the target of medical malpractice, (6) explaining how health insurance impacts a physician's practice, (7) medical ethics (or lack thereof) in assisting with legal sytem-mandated executions of criminals, (8) the choice of performing Caesarian sections, (9) the idea of improving medical care by paying for improved performance by surgeons, and (10) seeking excellence in care of cystic fibrosis patients. In the end, Dr. Gawande presents some simple (and yet profound) ideas for improving oneself (as a physician). Even if you haven't the time to read this whole book, simply pick one essay. My guess is that you will be very impressed by what you read and will easily choose to read even more.
LivelyLady on LibraryThing 3 days ago
This is a collection of medicine and health related articles by a young doctor. Some of the issues are correctable and some are not: injection control in the hospital, what we have done to childbirth, the death penalty and who is to administer it, med-mal, and healthcare in India. Very good and well written with lots to think about. I hope he updates it in a decade.
aliciamalia on LibraryThing 3 months ago
Like Gawande's previous book Complications, Better is a thoughtful, entertaining, and informative work. Without being pedantic or overly technical, he touches on major issues influencing modern modern medicine and the world at large. I like his mix of personal anecdotes and actual research. This is definitely a book that is worth reading, whether or not you're in medicine.
Anonymous More than 1 year ago
Better: A Surgeon's Notes on Performance by Atul Gawande was written with a superior way of thinking and all from personal experiences and stories, which makes a significant difference if personal connection interests you. Gawande writes in a way that can make statistics and medicine seem fun for people who might not find it so interesting. Certain sections of the book were extraordinarily interesting and others weren't; for “me”, the parts that were the best not just- included information about “disease” but actually included well-developed characters also. I particularly found that the repetition of Cystic Fibrosis mentioned in the book tended to be monotonous. So much is conceded in the book, things people may not have known are revealed and with that can come some consternation. Overall, I would say that Better was an admirable piece of writing. Gawande shows that not just his surgical skills are state-of-the-art, but also that his writing can be just as exceptional and marvelous.
Anonymous More than 1 year ago
Read for school....such an imyeresying and well written book! Highly reccomend
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MimiMA More than 1 year ago
Dr. Gawande seems to be first, an excellent doctor, second, one who keeps wanting to learn more about good medical care and ,third, one who is able to communicate what he has learned to us non-medical people in such a way that we, too, learn much about good medical care and are willing to search for it.
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