What the doctor said

Last week, one of the local dailies carried a photograph of US President George Bush jogging with Iraq war veterans fitted with prosthetic limbs. It was a positive image for me, though some of my senior colleagues thought otherwise. It was, I thought, a triumph of medicine, and the management of medicine, over war. That management is one of the themes that Atul Gawande highlights in this eminently readable book, which talks""pretty engagingly""about the dilemmas that a doctor faces, ranging from when to give up the fight for a patient to what fees to charge to the ethicality of assisting in the death of criminals condemned to die by the state. Since Gawande himself belongs to the medical profession""he is a general surgeon practising in Boston""his 200-odd pages of notes provide a rare insider view of what it takes to be practitioner of the art of medicine. He brings out the human being behind that doctor, armed with a suite of 6,600 potentially dangerous drugs, and with a licence to "open human beings up like melons".

While we, as patients, expect him to do little more than put in his best fight against an ailment, putting to use his long years of study, he has to do much more than just practise his skill. He has to liaise with the hospital bureaucracy. He has to make sure his paperwork is correct (think malpractice suits). And he has to take care of the most mundane things like washing his hands regularly. Washing his hands!! Well, many good doctors across the world don't do it as often as they are supposed to and end up passing on infections to those who have come to then to seek a cure. If one was to visit the Delhi's All India Institute of Medical Sciences (AIIMS), simple facts like doctor-to-patients ratio would rule out a regular washing of hands between patients. Gawande talks about his experience at AIIMS as a visiting surgeon and the misplaced priorities so typical of government-run healthcare systems where it was "easier to get a new MRI machine than to maintain basic supplies and hygiene." The key to saving lives, he argues, is not new laboratory science but the "infant science of improving performance, of implementing our existing know how." Coming back to the wars in Iraq and Afghanistan, though there has been a sharp rise in the number of war-wounded soldiers""Gawande quotes a December 2006 number of 26,547""there is a marked reduction in the "lethality of battle wounds...Just 10 per cent of wounded American soldiers have died...despite having no fundamentally new technologies or treatments," just by managing the system better. For instance, the Army introduced Forward Surgical Teams (FST) which provide emergency medical support right on the battle field with minimal supplies. The wounded soldier was then handed over to the next level of doctors, and the next, on to a facility in the United States. From battlefield to US is now less than four days, compared to 45 days in Vietnam. Of course there is the downside too""casualties could include doctors.

From the battlefield, you can head into a chapter on the etiquette of patient examinations. Should examination gowns by the rule? Do male physicians make women more comfortable with intimate examinations by involving a chaperone or not? However, whether the doctor was unnecessarily touch-feely or absolutely required to be so will always remain hazy territory.

Gawande also touches upon what the doctor takes home for all his trials and tribulations. He cites William Weeks, a Dartmouth professor, who has found that physicians typically work longer than in other professions and the "payoff is somewhat poorer than in other professions". There are of course those who are in it for a larger ideal than money, while there are also those who have turned the profession into a business, and earned millions of dollars in the process.

The book also has advice for doctors""connect with patients, don't complain, keep count of whatever you can, be open to change and write. The book is recommended reading for two reasons""it is an interesting, sometimes fascinating, snap of real life situations and solutions with take-aways that extend beyond the medical profession. Secondly, it will help you understand your doctor better. I am now tempted to pick up Gawande's first book too"" Complications: A Surgeon's Note On An Imperfect Science""which has already been on the New York Times bestseller list.

BETTER
A Surgeon's Notes on Performance

Atul Gawande
Penguin
Price: Rs 250; Pages: 222