The one science we expect certainty from, in which doubt should ideally have no place, but which is as likely to be applied with solid judgement as with a feeling, a guess, or an ordinary whim is medicine, practised by people who can be arrogant, insecure and might not wash their hands. And it is to this flawed, inconsistent and often amazing world that people hand their bodies over in Atul Gawande’s books.
Gawande’s first book, Complications, arose from true incidents during his training in general surgery. It explained why students operated on patients, why doctors switched off suddenly and, in a famous chapter, why one man’s enormous hunger refused to subside. The idea that medicine had layers rich with complications was brought alive in these stories. People want progress in clearly defined terms, Gawande wrote then, “but, of course, it rarely is. Every new treatment has gaping unknowns—for both patients and society—and it can be hard to decide what to do about them.” Medicine’s usual state is uncertainty, and it makes being a patient or a doctor difficult.
In the five years since his last book, Gawande has, in his job as a general and endocrine surgeon in Boston, focused on reducing surgical injuries and improving the quality of care. It is the dominant theme of his latest book, Better, which begins with a chapter on why few medical staff wash their hands, and concludes with an essay on betterment.
Gawande highlights the simple fact that while there are big budgets and incessant demands for new innovations in medicine, doing existing things well, which saves more lives sooner, is an underutilized concept. But to be better, he says, does not take genius. “It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.”
Gawande takes up diligence in a chapter based in India, where he watches a collection of doctors and volunteers attempt to limit a polio virus outbreak. He describes it as an unambitious, relentless and somewhat limited goal, but transforms its very meaning by setting it against the outbreak. Only by being relentless can an impossible task be achieved. And, yet, he remains wary of the impressive declarations by global do-gooders. “International organizations are fond of grand-sounding pledges to rid the planet of this or that menace. They nearly always fail, however. The world is too vast and too various to submit to dictates from on high.”
The grand announcements overlook what Gawande is all too familiar with: the complexities that arise from individual choices at the ground level. So varied are their choices and the effects that follow. In one episode in Complications, Gawande draws a “decision tree” with possible outcomes to a surgical procedure. As in any other profession, he writes, decisions in medical science compound themselves. When he accounted for all possible outcomes, “my tree looked more like a bush”.
Given the complications involved, how much money should a surgeon make? The question is put to Gawande after his training is complete, and he quickly understands that his salary is not connected with his abilities. It involves frequent run-ins with insurance agents, doing very un-doctorlike things. He calls for an overhaul of the American health-care system.
In India, where the problems are systemic, he instead focuses on individual drive and dedication, and describes how physicians and surgeons have adapted to the lack of proper medical equipment and have invented, in some cases, surgical operations thought impossible.
Gawande’s writings have appeared in The New Yorker and on Slate, as well as in medical journals. By his own account, his writings are more important to him, and it is remarkable to note that he began writing relatively late. His language is direct, often delicately balanced, and pretty persuasive. The episodes read as thrillers would, with periods of action interrupted by data.
They conclude mostly with the problem resolved, a life saved and, therefore, a happy ending. This is a surgeon writing, but the words could just as well have been from a writer who explores the medical profession as a new world filled with flawed, but frequently dazzling, things.