August 03, 2020
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Washed Your Hand Of Ethics?

Then this first-person medical report is a must-read. For all its lapses, it's an honest spot diagnosis.

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Washed Your Hand Of Ethics?
Better: A Surgeons Notes on Performance
By Atul Gawande
Penguin India Pages: 222; Rs: 250
Atul Gawande’s first book Complications was about training to be a surgeon in the US. In his second book, he steps back from the immediacy of the learning experience and, using a part-story, part-informative style, records A Surgeon’s Notes on Performance. Gawande’s eye for detail and his discernment in prising out truths (though uncomfortable) make Better a worthy book. He’s at his best when he talks about simple issues—like hand-washing—and when he brings in his personal travails as he moves ahead in his career.

India is a strange country but the US is stranger. In this highly developed nation, 90,000 lives are lost each year due to hospital-acquired infections. Studies show that medical staff are often responsible for spreading infection, and that merely washing one’s hands before and after contact with patients reduces risk significantly. Read the book to find how tough it still is to convince medical professionals to follow this basic rule. In India too, even capable and experienced doctors, pleading the press of work, neglect such an obvious precaution. Maybe I like this chapter so much because it shows how difficult it is to get people—especially clever people—to do simple things.

We doctors have made our work increasingly complex and no longer have the ability to see or understand simplicity. How well we know it. Gawande quotes a doctor in a government hospital in Maharashtra saying it is easier to get an mri machine or a CT scanner for the hospital than basic facilities like running water or medicines. (There are other disconcerting truths about Indian doctors, which, if Gawande had delved into them, would send many ducking for cover.)

He visits rural hospitals in India and writes with admiration about the surgical expertise of our doctors, and their flair for innovation in the face of adversity. He writes, "...the abilities of an average Indian surgeon outstripped those of any Western surgeon I know." This may be a well-intentioned exaggeration but it isn’t far from the truth.

Gawande is positive about the polio eradication programme in India and his reports are accurate. But the reality also is that the government of India allowed itself to be persuaded by the who to accept aid, and when the aid dried up due to ‘donor fatigue’, it had to spend a thousand crore rupees each year to keep the programme going. There are more dangerous diseases like tuberculosis and malaria killing millions. Our government spends only a fraction of this amount on them. Talk about priorities.

Gawande approvingly describes the tiered referral system by which the US surgeons deputed to work in Iraq perform emergency operations on horrendous injuries and send them on to centres in Europe and then the US. Thus a seriously injured patient can reach the best US surgeons within four days of the accident. This has brought the overall death rate of American casualties down to 10%. (What of Iraqi casualties?) My own experience with gunshot injuries in Bihar is that if the first surgery is quick and efficient, referral to higher centres is rarely necessary. Giving intensive training to surgeons based in Iraq is better than flying the wounded (with life-support systems and teams) home for treatment.

The story of Gawande’s own initiation into surgical practice is a must-read for those of us who speak bitterly about expat doctors raking it in by the million. US doctors undergo specialist training for six gruelling years before setting up practice. They must recover their medical fees from hard-nosed insurance companies. This, even in India, is never easy. In a chapter on lawsuits, Gawande has described how trigger-happy the American public is when it comes to suing doctors. A surgeon, on average, is sued every six years. How many of us can handle the stress? In the US you have to, or forget the millions.

I’m not sure which of Gawande’s books I prefer. Perhaps Complications is better but then Better is more complicated and informative. I loved this book for its clear-sightedness and perspicacity, and for the author’s wonderful skill at explaining medical details in an interesting way. He is a first-rate writer. I wish though that he hadn’t wrapped it all up by giving five points on ‘How to be a Positive Deviant’. The title of the book and the writing itself tell you that extremely well. Summing it up in the end makes it look like a how-to book—the type strictly meant for the specifically challenged—which this book certainly isn’t.

(Nambisan is a surgeon and novelist)

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