For Performance

I am sure many of you will be working away in preparation for UCAT. When you are over this hurdle you will be met with personal statements, Advanced Highers and interviews. Within all this chaos, it is very easy to feel overwhelmed, powerless and feelings of imposter syndrome. All of this is normal and you are certainly not alone.

In the final chapter of his book, Gawande reminds us that success can be found “remarkably simply, with a readiness to recognize problems and a determination to remedy them.” Although the medical application process is an inevitably slow and difficult process, in the words of Gawande “it does not take genius, it takes diligence.” Having gotten offers from all 4 of the medical schools I applied to, as well as getting into my first choice with the three As I have achieved at advanced higher, I can attest to this sentiment. There were times, such as after I failed a chemistry test, were I felt powerless but through diligence I was able to power through and would eventually achieve an A in chemistry in my final exam. So when in doubt, stay diligent and trust the process.

Book of the week: Better: A Surgeon’s Notes on Performance by Atul Gawande

This week’s theme of ingenuity is the topic covered by Gawande in the third section of his book “Better.” The author draws upon 3 key stories, one of which will be covered this week.

Gawande opens in an operating room, where he is engaged in a conversation with an anesthesiologist. He finds out that they had cystic fibrosis. On discussing the impact this has had on the anesthesiologist’s life, Gawande asked them a question:

“What would be more likely to save your life: investment in laboratory science or efforts to improve how existing medical care performs?”

The author claims that the answer most people would come to is investment in laboratory science; in 1989 when scientists discovered the gene for CF, that would have seemed a wise choice. But the anesthesiologist counters this with his answer:

“Although I have not let go of the hope of a cure for CF, I don’t think it will happen in time to help me. Instead, my hope lies in monitoring and improving clinical performance using know how already in existence. I believe that of all the work being done, this is the one that would save more lives.”

This thought provoking conversation leads Gawande to a discussion on the topic. He claims that although it is important to innovate, the medical community have still not fully utilized the tools science has already given us. Furthermore, he adds that when we have made a science of performance (e.g the Apgar Score, hand washing) thousands of lives have been saved. Thus, he states that despite only a minuscule portion of scientific budgets going to the scientific effort to improve performance, it has the possibility to save more lives in the next decade than bench science.

In order to support this point, Gawande presents the treatment of breast cancer as a case study:

“Consider breast cancer, rates have fallen by around 25% in the industrialized countries since 1990. A study of data from a US breast cancer registry recently showed that at least 1/4 and likely more than half of that decline was simply due to increased use of mammography screening by woman.”

Mammography saves lives by allowing breast cancer to be caught and treated while they are still small, hopefully before they have spread. Gawande goes on to give the shocking statistic that:

“Over 10 years only 1/16 of women get mammograms, whereas it is recommended that they do once a year(at the time of writing).”

Reasons behind this are: how time consuming, uncomfortable and difficult it usually is; how expensive it is for people without insurance coverage; and how rarely reminders are given. The US government and foundations spend close to a billion dollars a year on research for new treatments in breast cancer, but little on innovations to improve the ease of and access to mammography screening. Considering this information, Gawande claims:

“Studies have shown that more consistent use of this one technology alone would reduce deaths from breast cancer by one third. This is just one example of what improving performance in medicine could achieve.”

Gawande then explores this idea of “raising performance, not expanding on genetics research” to another part of the world: India. Before starting his surgical training in America, the author decided to spend 2 months in India(his ancestral home) as a traveling surgeon in hospitals across the country. One of the hospitals he visited was a district hospital that served different villages in the surrounding area. Despite serving a population of more than 2 million people, it has only 9 general surgeons. Every morning the surgeons arrives to several hundred people, at least 200 are there for the surgery clinic. On seeing this, Gawande could only wonder how they did it? How could the surgeons possibly take care of all the patient’s conditions and manage to sleep, live and survive for themselves?

He saw how the surgeons made compromises out of necessity. With no time for a complete exam, a good history, or explanation, the surgeons relied mainly on quick, finely honed clinical judgements; sending a few patients out for X-rays and lab tests, and diagnosing the rest on the spot. Additionally, everywhere he went in India surgeons had learnt how to dose and administer chemotherapy themselves in makeshift treatment rooms, planned and delivered radiation themselves, before finally performing surgery.

Gawande then goes on recall how, to his surprise, there was nothing exotic about the troubles most people came to the surgeons with. As living standards and quality of primary care has increased in India, people increasingly suffer from gall-bladder problems, cancer, hernias, car crash injuries as opposed to cholera for example. In fact, the number one cause of death in India is now coronary artery disease. However, the Indian healthcare system was not designed to deal with such illnesses. It was designed primarily for infections disease, the Indian government’s annual healthcare budget of just $4 per person is woefully little for infectious disease and impossibility inadequate for something like a heart attack. For example, at least 50 of the 200 some patients in the hospital Gawande was at turned out to need an operation. But the hospital only had staff for 15 such operations per day. This was the case for everywhere he traveled. 

Even in AIIMS, among the countries best staffed public hospitals, there were waiting lists for essential operations. To make matters worse, these lists were full of corruption, with the powerful and well connected being pushed up the list.

The author then thinks to his time visiting another hospital, were the three surgical wards overflowed with patients. Here, surgeons were not only against the number of patients, everywhere they lacked essential resources and they lacked the basic systems that in the west suregons can count on to do their jobs. Gawande points to the night he saw a 35 year old man die from a perfectly treatable lung collapse:

“I found him sitting up in a cot, holding his knees, his eyes full of fear. His chest X-ray showed he was in critical condition. Organizing the simple life saving procedure, was found to be beyond the hospitals capacity (i.e needed chest tube but hospital out of stock). So the patient ran to the streets to buy a chest tube from a cart. On his return, with his newly bought chest-tube, no one could locate an instrument set with a knife to make an incision. The man had no pulse for 10 minutes before they found a knife that could be used to drain the fluid. It was no use, the man was dead.”

This is a perfect example of how despite supposedly being free for patients, some public hospitals in India must routinely ask patients to obtain their own drugs, tubes, mesh for hernia repairs and suture material. Gawande claims that such problems reflect more than a lack of money. In the same hospital where he saw the 35 year old man die, where basic equipment was lacking, the emergency ward had just two nurses and filth was everywhere that you stepped. At the same time, there was a brand new CT scanner and a gorgeous angiography facility that must of cost 10s of thousands of dollars to build(similar facility shown in Figure 1). To add to this, more than one doctor told him that it was easier to get a new MRI machine then to maintain basic supplies and hygiene. Such machines have become the symbols of modern medicine. However, Gawande counters this, saying:

“To view them this way is to misunderstand the nature of medicine’s success. Having a machine is not the cure, understanding the ordinary mundane details that must go right for each particular problem is.”

Figure 1- Similar Hybrid Angiography-CT facility¹

Gawande then shifts the focus to outside India, where demographics in places throughout the East are changing swiftly. In Pakistan, Mongolia and New Guinea, the average life expectancy has risen to over 60 years. In Srilanka, Indonesia, Vientam and China, it is more than 70 years. As a result, rastes of cancer, traffic accidents and problems like diabetes are exploding worldwide. Cardiac disease has become the world’s leading killer. However, the author claims that, given the evidence he has presented: “new laboratory science is not the key to saving lives. The science of improving performance, of implementing our existing know how is.”

Thinking back to his time as as traveling surgeon in India, he recalls his astonishment at the abilities of the surgeons there- claiming that their skills outstrip those of any he knows in America. The core of this is their wide range of expertise in treatment in a wide range of conditions. This leads Gawande to ask himself, why?

“There was much the surgeons had no control over: the overwhelming flow of patients, the poverty, the lack of supplies. But where they had control (i.e their skills), these doctors sought betterment.”

He also points to their attitudes. They believed they could do anything they set their mind to. They believed they were not only part of the larger world but that they could contribute to it. This was fueled largely by their group comradery and communication amongst each other, swapping storied from their cases from the day during their afternoon tea break.

An example of their skill was in the development of a new surgical technique by one of their attending surgeons: the laparoscopic repair of the ulcerous perforation using a quarter inch incision. Said procedure was presented at a conference, where it was revealed that the procedure had fewer complications and a far more rapid recovery than standard procedures. In this remote, dust covered town, in Maharashtra, the surgeon and his colleagues had become among the most proficient ulcer surgeons in the world.

In his concluding paragraph, Gawande claims:

“True success in medicine is not easy. It requires will, attention to detail and creativity. The lesson I took from India was that this success is possible anywhere by anyone. I can imagine few places with more difficult conditions, yet astonishing successes could be found and each one began remarkably simply, with a readiness to recognize problems and a determination to remedy them. Arriving at meaningful soloutions is an inevitably slow and difficult process. Nevertheless, what I saw was : better is possible. It does not take genius, it takes diligence. It takes moral clarity. It takes ingenuity. And above all it takes a willingness to try.”

Thanks for reading,

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1. https://www.hillrom.com/en/surgical-strategic-alliances/hybrid-operating-rooms/hybrid-angiography-ct-imaging/