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:

• Atul Gawande: The Man Behind "Complications"
• Atul Gawande and "Better" - A Medical Student's Review
• Does "The Checklist Manifesto" Apply to Medical Students? 

Medical School Graduation Gifts

It's almost that time of year again, the so-called "Dads & Grads" season for gift buying. However, if you have a special someone graduating from medical school (or PA school or NP school or nursing school etc), the occasion is particularly special. As with past gift guides, the goal is to find a gift that is particularly relevant for someone graduating with a healthcare-related degree. Whether the gift is silly and fun, or more serious and intended to help them form good habits and become an outstanding health practitioner, as always, it's the thought that counts.

This time around, I will try to break the gift guide down by budget: under $25, $25 to $100, and over $100.

Under $20
The always popular Giant Microbes have a wide range of medically-themed plush toys. For example, the budding neurologist or neurosurgeon may appreciate the brain cell:

 

For a more introspective gift, many medical memoirs are available in paperback, including Scrub Notes favorite surgeon/author Atul Gawande:

 

$25 to $100
Love the Giant Microbes, but want more? Get the whole set!

For devices like the iPad suggested below, a Bluetooth keyboard case is an excellent addition. Kensington is a solid brand, and the keyboard case allows use as both a note-taking device and a reader, simply by flipping the cover. The backlit version is particularly useful in dimly lit lecture halls!

Over $100
The budding scholar will need something to port all their notes and knowledge around in. Both for reading as well as for medically related apps, the clear leader is the Apple iPad. With the introduction of the iPad Air and the Mini, the tablets have become small and light enough to carry around all day in a hospital, with the battery life to match. Remote access apps also make it easy to check electronic medical records or imaging remotely when needed. Increasingly, digital devices are becoming the 21st century's stethoscope.

However, the 20th century's stethoscope still remains an essential tool of the clinician as well as a classically stylish gift:

Speaking of classic gifts, a leather doctor's bag certainly fits the bill:

Hopefully these gifts bring a smile to your medical graduate's face. Don't feel like buying something? You could always go the more personal route and either make them something yourself or cook them a nice meal. Have a gift idea that I missed? Please include it in the comments below. Cheers!

Can Pit Crews Heal Medicine?

Atul Gawande recently gave a TED talk entitled "How Do We Heal Medicine?" (check it out below).

In the talk, he harkens back to the central thesis of his recent book The Checklist Manifesto: How to Get Things Right that medicine has become too complex for physicians to act as cowboys and instead should adopt the paradigm of a pit crew, utilizing teamwork and the humble checklist to solve problems and avert emergencies.

Is this really true though? Can "pit crews" heal medicine? To extend the analogy a bit, can a pit crew win the Indy 500? Try as they might, they would be completely unable to do so without three critical people: the team owner, the driver, and the pit crew boss. Honestly, all analogies fall apart at some point, and this one is already near the breaking point, but bear with me another moment. The patient in some ways is like the owner: he has the most at stake, yet relies on others to achieve his goal (a win). Similarly, the patient has her health on the line, and relies on medical professionals to get them to the finish line. To do so, they need a driver - someone who is pushing for that result. Ideally, the healthcare "driver" would be the patient's primary care physician - the doctor who is harnessing the resources of the "pit crew" of professionals to deliver the desired result. Unfortunately, all too often, this does not come to pass.

I suppose Gawande's true argument is that physicians and healthcare professionals should adopt some of the tactics of a pit crew, not literally become one. While necessary, this does not solve the dilemma from a patient's perspective. The patient has the most at stake, yet enters the healthcare arena under-informed and under-empowered. In complex cases, even their PCP may become overwhelmed by the complexity of their care. To remedy this, the incentives need to be reassessed. Currently, PCPs like all other providers get paid based on what they do. If it cannot be coded, it cannot be reimbursed. The sad reality is that there is no financial incentive for a PCP to have a thoughtful conversation with a patient, to visit them at home when they are very ill, or to even visit them in the hospital. With that link between patient and primary doctor under siege, the 'pit crew' of professionals in the hospital lack a driver, the PCP, the physician who knows the patient best. As our current system shows, our healthcare pit crews can still do amazing things - they just may not be in line with the patient's wishes.

Ultimately, the changes Atul Gawande advocates are certainly necessary. The concern I have is that they oversimplify the problem. Without working on strengthening the doctor-patient relationship at its core, any improvement to the efficiency of the hospital will not necessarily yield the benefits in patient satisfaction or healthcare outcomes we as a society desire.

 

Happy 2012!

Happy new year! Last year was a difficult one for Scrub Notes - life got busy and challenging, and posting became infrequent. However, with a new year, we have a new plan to keep Scrub Notes active and useful for all our readers. Have any comments? Suggestions for topics you want addressed? Guest post? Let us know by contacting Scrub Notes today!

As we closed out 2011, we reviewed Atul Gawande's book 'The Checklist Manifesto' and how it could apply to medical students. After posting the review, this video clip of Gawande discussing his book and the Obama healthcare reforms was brought to our attention. The content is a little dated, but still interesting to listen to. Check it out!

Gawande is eloquent as usual, but he somewhat dodges some of Rose's questions. For example, when Rose asks what kind of system would be ideal in Gawande's mind, he simply avoids answering the hypothetical by noting its lack of basis in reality. However, that's the point: Rose wants to establish a baseline set of goals that a system should aspire to, even if it is not feasible in reality. Check it out, and let us know your opinion!

Updated 2015-12-20

Does 'The Checklist Manifesto' Apply To Medical Students?

This post is long overdue, but I finally got around to reading Atul Gawande's most recent book The Checklist Manifesto: How to Get Things Right. Longtime readers of Scrub Notes are likely aware that I'm a big fan of Gawande's writing. His first book Complications has practically become required reading for pre-med students. His second effort Better continues along the same vein. However, The Checklist Manifesto is Gawande's first major effort to move beyond merely an anecdotal descriptive text on the trials and tribulations of practicing medicine into the area of shaping policy and medical practice. And, to this reader, he makes a fairly convincing argument, utilizing extended examples from diverse fields such as piloting, building construction, and finance.

Gawande's argument primarily targets his fellow surgeons. However, what can medical students learn from his text? Can the humble checklist help a medical student succeed in learning the necessary knowledge to succeed in medical school? I doubt any serious study has been done in this area, but intuitively, the answer is yes. As Gawande suggests, try a checklist.

But, what does trying a checklist mean for a student? The checklist is meant to address a systemic problem, not an individual one. Gawande targets fellow surgeons because they run the ORs: they have primary responsibility for the patient's well-being as well as for insuring that the OR runs well. A trainee like a medical student typically simply plays their assigned role. However, therein lies the problem.

By simply playing an assigned role, the student learns from their environment in a haphazard way. Some ORs meticulously run through time-outs and other preparatory procedures; others perfunctorily mention them or even avoid them except for the most necessary ones. However, the student's responsibility ultimately is to the patient, not to maintaining a culture of complacency that he or she may find herself in. By creating and running through their own mental checklist prior to any patient encounter or procedure, you can ensure that you and your team avoid making unnecessary mistakes that may cause the patient harm. Even if you feel powerless on a team or service, your personal checklist can help ensure that you are doing your utmost to serve the patient. Although this may not be the 'heroic' side of medicine, as Gawande notes, the effects can be profound in terms of safety and patient care.

Beyond patient safety, taking the time to craft a checklist can help you break down a complex procedure into simple steps. As you are learning and practicing the procedure, focusing on these simple steps will make it easier to learn the procedure and learn to do it the right way in a safe manner. Gawande emphasizes this in his subtitle: How To Get Things Right. And that's what any student wants to do: get things right.

 

Updated 2015-12-20

Top Medical Titles On The Amazon Kindle

The last few posts have covered the various advantages of the Kindle (Should iPads Be Mandatory?, The $99 Kindle), but as we all know: content is king. So, you may be rightly asking yourself, what titles can I find on the Kindle?

Here are some key medical textbooks / titles already available on the Kindle specifically for the USMLE exams:

• First Aid for the USMLE Step 1, 2010
  The standard textbook for studying for Step 1 on your ereader. And before you fret, remember the Kindle version still lets you highlight, annotate, and even search the text.
  
• First Aid Q&A for the USMLE Step 1, Second Edition
  
• First Aid- Cases for the USMLE Step 1 : Second Edition
  
• First Aid for the USMLE Step 2 CK, Seventh Edition
  
• First Aid Q&A for the USMLE Step 2 CK, Second Edition
  
• First Aid Cases for the USMLE Step 2 CK, Second Edition
  
• First Aid for the USMLE Step 2 CS, Third Edition
  
• First Aid for the USMLE Step 3
  

Additionally, there are many general medical books / medical titles available as well, including journals:

• The New England Journal of Medicine
  The flagship American medical journal
  
• Harrison's Manual of Medicine
  The premier comprehensive textbook of internal medicine in the palms of your hands
  
• First Aid for the Medicine Clerkship, Third Edition
  
• Case Files Internal Medicine, Third Edition
  
• First Aid for the Surgery Clerkship
  
• The Gawande Collection:
• Complications: A Surgeon's Notes on an Imperfect Science
• Better: A Surgeon's Notes on Performance
• The Checklist Manifesto: How to Get Things Right

Poke around the Kindle Store and you'll be amazed at what you can find. The medical section is surprisingly more complete than one might expect. Have fun Kindling!

Updated 2015-12-20

How To Scrub For Surgery

Scrubbing into an OR is part of any medical school education, but one that does not seem to be formally discussed much. A medical student's first time in an OR can be an intimidating experience for this reason. The OR has its own rules and culture, which may seem byzantine at first to the uninitiated. For me, the worst part was getting into the OR: specifically, how do I scrub for surgery?

I've tried to address this previously in posts like:

• Tips On Scrubbing In
• Tips On Scrubbing In, Part 2

Perhaps you might be wondering why I am so concerned about scrubbing for surgery. Well, hearing about my first time might explain. The experience was horrible. I was doing a 1 month rotation in Mexico City, Mexico between my first and second years of medical school. I had never been in an OR before, much less on a rotation of any kind. Even though I had watched people in scrub in several times before I ever had to, there were all sorts of subtleties that escaped my notice. When my time finally came, the attending simply said "Go scrub" in Spanish with no instructions. The washing wasn't too bad, but putting on the gown was a disaster. I did not understand what to put on first, what I could touch, how to turn. The nurses tried to help, but I was already stressed and my Spanish wasn't that good! The instructions yelled in Spanish just confused me more! Finally, after struggling for a few minutes, I managed to get scrubbed in, but you can imagine how little confidence the surgeon had in me after that performance. While my little mistakes are no match for those of a resident placing a central line for the first time (as described in 'Complications' by surgeon Atul Gawande), they still left an indelible impression on me. Entering an OR for a laparoscopic procedure (heh, or IR suite) is not so daunting these days, but I'll never forget my first time!

Updated 2015-12-18

Practical Gifts for Medical Students: A Holiday Gift Guide

Tis the season to be... well, consumers. I imagine some of you are considering buying gifts for loved ones who happen to be medical students. Well, what better time for a medical student holiday gift guide, right? While there are many general gift guides out there, some funny and some sentimental, the aim of this one is to point out practical gifts for medical students, ones that they may not care to buy for themselves but would appreciate receiving. In no particular order:

• A Stethoscope - An excellent gift, especially for first or second year students who have yet to enter clinical rotations. Stethoscopes can be somewhat pricey on a student budget, but a nice one makes for a great investment. There's a wide selection of stethoscopes out there though, so shop around for one that makes the most sense for what your gift recepient is interested in. I personally have a Littmann Cardiology III (black) and think it's great. It's high quality, durable, and good for general use (which means, for most medical students). Plus, it looks quite professional.
• First Aid for the USMLE Step 1 2009 - Heh, to the person you'd rather see spend the holiday in the library. Still, I kind of wish I'd started looking at this earlier during medical school, so it really would be practical
• Palm TX Handheld - A nice tool to have around on rounds, especially with Epocrates loaded on it. Any time your patient is put on a new funny-sounding medicine, you can quickly look it up, as well as add notes about the drug. There is a lot of other medically-related software out there for the Palm as well, such as patient tracking software.
• Medically-Related Leisure Reading - Sometimes, when a medical student wonders "Why am I going through all this?" it's nice to read a regular book addressed to a general audience about medicine and why doctors do what they do. My favorites are:

1.  How Doctors Think by Jerome Groopman
2. Complications: A Surgeon's Notes on an Imperfect Science by Atul Gawande
3. Better: A Surgeon's Notes on Performance by Atul Gawande as well

• USMLE Step I Qbank - If you know your gift's recepient is a second year medical student and about to take USMLE Step I, consider paying for a QBank for them. There are several options out there, but Kaplan is one of the most popular. Have them try out the service before purchase with the Qbank Challenge, which lets them do a sample test of 10 or so questions (the full Qbank has 2000+ questions):
  
  
  
• Amazon.com Gift Card - The reality of medical school is that any medical student will have to study A LOT. To do so, this requires textbooks and review guides. An Amazon gift card will help any student easily purchase the texts and reviews they need, which can be a significant cost of medical education for a student, after tuition.
  
  
  
  

Hopefully this guide contained some good ideas. Have one of your own? Feel free to add it in the comments below. Happy holidays!

Updated 2015-12-18

Atul Gawande and the Medical Writing Staff at The New Yorker

I've recently noticed that The New Yorker has excellent and engaging science and medicine articles. Of note are three recent pieces about Asperger's syndrome/autism, retroviruses, and preventing nosocomial infections.

In Parallel Play, the author discusses his lifelong struggle with Asperger's Syndrome. Of course, as a child, he did not know he had such a diagnosis, and so he went through life merely with a sense that he was different. It is interesting to see the prism through which he constructed his world in his own words. Often, as students and doctors, we only see a patient's symptoms, but rarely are we able to experience and understand the world exactly as they do.

In Darwin's Surprise, the author explores the role that retroviruses have played in human evolution. In fact, some scientists have been able to go back through the human genome and not find fragments of old viruses, but also recreate them! (Think Jurassic Park, but on a micro scale). These paleovirologists argue that the inclusion of these viruses into our DNA can provide protective benefits against such disease like AIDS. One thing I didn't know prior to reading this is that apparently some scientists argue that humans developed placentas and live birth (vs eggs) as a response to these retroviruses. Something to ponder...

In an article entitled The Checklist (which eventually forms the basis for the book titled The Checklist), Atul Gawande argues for the use of a simple checklist in order to save lives. He describes how the complexity of modern medicine has gone beyond even the most organized specialists and experts. However, by using something as simple as a checklist, medical care improved greatly in several hospitals and the number of line infections decreased dramatically. Written in Gawande's usual style, the article highlights the need for physicians to pay more attention to how exactly medicine is delivered, even if it takes away from the so-called 'art' of medicine.

While all the articles are somewhat lengthy, I think they're all good reads. Check out The New Yorker if you have a few minutes to spare.

Updated 2015-12-07

Atul Gawande and "Better" - A Medical Student's Review

As a med student, and one who had recently completed his surgery rotation, I feel I had a relatively unique perspective while reading this book, as compared to most readers. It was also interesting to read this book and gauge my reactions, relative to how I reacted when reading Gawande's prior book Complications. When I read Gawande's first book, I had not yet started medical school, and had at best, an educated lay person's background. I found the stories there intriguing and confirmed my romantic notions of medicine. This book mirrors my own internal evolution to a certain degree. Less romanticized, more practical, it discusses more of the everyday issues in medicine, ones that I see often as a student out on the wards. People do not wash hands as much as they should, the science of efficiency has not been applied to medicine, and the book takes us all to account for that. While medical technology has become remarkably efficient and high-tech, the actual delivery of medicine leaves much to be desired. Anyway, I digress.

The book reads very much like Complications. Gawande presents 12 separate essays about different aspects of healthcare, from the advances in obstetrics to the lack of investment in studying the provision of care to the doctors who are involved with executing prisoners who have been given the death penalty. Unlike Complications though, Gawande injects more of his own personal opinions after a more dispassionate presentation of each subject. The writing is sparse and clear, making it easy to read. Some of the chapters read almost like a medical Profiles in Courage

However, unlike Complications, this book did not leave me feeling as enthralled. Perhaps I have become jaded by medicine, or perhaps the topics of 'improving' medicine are simply not exciting. I think I liked Complications better simply because it dealt with more esoteric issues. While I agree with Gawande that the topics covered in Better are more important and can potentially affect many more people, the cases covered in Complications are simply more intriguing, such as the woman with necrotizing fascitis, or the reporter who sweat too much.

Overall: 9 out of 10 - a good engaging read that covers many important and relevant topics.

Updated 2015-12-06

Atul Gawande: The Man Behind "Complications"

Updated 2015-12-06

Merry Christmas! I hope everyone reading this is having a happy holiday.

As you may have noticed from the quote on the sidebar, like many students, I am a fan of Atul Gawande. For those of you who haven't read this book Complications, it is a great book describing the life of a surgical resident. However, even if that isn't your field of interest, the book is still an engaging read with a sober look at the harsh realities and present state of medicine and medical education. If you're interested in the book, check this out:

If you've already read the book, or just want your Christmas present, well.. here it is: Slate articles written by Gawande before he got big. They're still quite interesting, even if a bit dated. Enjoy!

Update: Gawande has also been a staff writer at The New Yorker since 1998. Many of Gawande's New Yorker articles form the source material for his books.

Rev 20200228