Monday, June 08, 2015

Being Mortal by Atul Gawande - A Scrub Notes Review

As long time readers of this blog (hi MJB!) likely know, Atul Gawande is quite popular around here. The general / endocrine surgeon at Brigham and Women's Hospital is also a well known contributor to The New Yorker and author of four books. His latest book is Being Mortal: Medicine and What Matters in the End.

Like his other books, this work is a mix of his previous pieces for the New Yorker as well as original writing. Gawande tackles an issue oft overlooked in his prior works and within medicine at large: what to do when medicine has no more to offer. The book unfolds by describing what occurs when medicine (and healthcare in general, including non-physician providers / caregivers) try to go beyond their limitations and fit patients to their models of care, instead of trying to shape care around patients. Anecdote by anecdote, Gawande describes patients, friends, and family members and their struggles with the healthcare-industrial complex. The overall tapestry is one of failure: the system did not work for these patients.

And how could it? The healthcare system is a Frankenstein collection of parts that has been optimized to fix simple, close-ended problems. The ear infection, the ruptured appendix, even the small breast cancer - all of these are easily tackled by the healthcare system. Where we stumble is when we attempt to shoehorn patients with complex or chronic problems into this model of one-and-done care. It simply does not work, and can often do as much harm as good.

In Being Mortal, Gawande attempts to show how in certain corners of the country, patients and providers are pushing back. From Oregon to Boston, initiatives have developed that attempt to create better environments for patients to live and to heal, without sacrificing overall outcomes. Surprisingly, in some cases, patients do better with less than with more care.

If one is to quibble with this book, it is that Gawande neglects to provide enough concrete, actionable advice about what to do regarding the issues he raises. For a general audience, he does not spend sufficient time discussing concepts like durable power of attorney, living wills, DNR/DNI orders, or even how to learn more about it. Gawande spends a chapter detailing his own trip down one flight of stairs to the geriatric center beneath his clinic and what he learned, but most of his readers are unlikely to have such easy access to a place like that. Admittedly, that is not the point of the book as it is not meant to be a self-help book about chronic health, geriatric, or end of life issues. Still, for a book that hopes to effect change, an appendix pointing out where one can learn more would have been nice.

Overall, the book is a worthwhile read for anyone who is elderly, is responsible for an elderly person, or cares for an elderly person. In other words, everyone should read this book. It is not a light-hearted read, but it is something better: an important read. While the ultimate outcome cannot be avoided, we can control how we prepare ourselves and each other for it, and in the process, live better, more fulfilling lives.

Other Books By Atul Gawande:


Previous Scrub Notes Reviews:

Monday, June 01, 2015

The Medical Student's Daily Bag

Much like students of any stripe, medical students often have many items they need to have on their person during their daily sojurns to lecture halls and wards. While this may be a bit dated, my go to bag in medical school was an earlier version of the Targus Checkpoint-Friendly Mobile Elite Laptop Bag. The other items I typically would have in my bag were:
Aww, I'm getting a little nostalgic thinking about my old bag. Anything you think should be in there that I missed? Please let me know in the comments below!

Monday, May 25, 2015

Can A Machine Replace An Anesthesiologist?

It could happen. A recent article discusses the Sedasys anesthesiology machine:
TOLEDO — The new machine that could one day replace anesthesiologists sat quietly next to a hospital gurney occupied by Nancy Youssef-Ringle. She was nervous. In a few minutes, a machine — not a doctor — would sedate the 59-year-old for a colon cancer screening called a colonoscopy.
The Johnson & Johnson device won approval from the US Food and Drug Administration in 2013, but so far only four hospitals are actively using the machine. Of course, anesthesiologists are opposed to the machine, as it threatens their livelihood. So far, they have succeeded in having the machine limited to very restricted indications, mostly simple screening procedures. The benefit of using the machine over referring physicians self-administering sedatives is that the machine can administer more powerful drugs like propofol, and more closely monitors vital signs.

Your next anesthesiologist?

What this means for anesthesiologists of the future is unclear. Will the machine stay limited to such narrow indications? Or will it gradually increase its scope, eventually displacing anesthesiologists in all but the most complex of cases? In some ways, the situation is even more dire for nurse anesthetists, as one can more easily imagine replacing them with such a machine. The question of liability is left open in the article, but I imagine most referring physicians and hospital administrators would take on the increased risk if the machine proves to improve patient volume sufficiently without sacrificing safety.

What about medical students deciding on a specialty? It is always hard to forecast the future and one certainly shouldn't make career decisions simply off of potential risks. Each specialty faces the threat of technological disruption (just ask cardiothoracic surgeons who trained before the advent of coronary cath). The world described by physicians past in books such as The House of God no longer exists, much like the world we now inhabit described in Intern will be considered antiquated in decades hence. What is a medical student considering anesthesia to do?

Each person has to answer this question for themselves. However, if you are passionate about a specialty such as anesthesia, the answer is simple: pursue it. Do not let fears of future change dissuade you from the field where you believe you can be your best. Instead of avoiding the risk, embrace it by keeping abreast of the changes in the field, staying ahead of them, and perhaps even being the game-changer within the specialty. Over time, all medical fields evolve. Make sure you choose a field where you will be excited to change to meet the future.


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