Author: Atul Gawande
This book is a brilliant exploration of the key traits which the author says are critical for doctors to maintain best clinical practice. The book makes the case that observing diligence, doing right, and innovation, are obligations for doctors who have opted ‘to live a life of responsibility‘ (pages 9 and 21).
The author describes diligence, the first obligation, as ‘the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles’. He says this ‘fiendishly hard’ task is ‘central to performance’, but most people underestimate it because it seems ‘supremely mundane‘ (pages 8 and 28). He illustrated the disregard for diligence with how infrequently doctors and nurses observe the simple, but effective, practice of hand-washing between patients (page 15).
The author demonstrated the importance of doing right by exploring the consequences of medical error. For example, he illustrated how 0.5% of physicians face disciplinary action during their career as a result of accusations of sexual misconduct (page 76-83). He noted that this tragedy may easily be averted by the simple practice of having a chaperone present when a doctor examines a patient of the opposite gender. He however pointed out that the universal adoption of this simple practice is hindered by inconsistent guidelines. In discussing another serious breach, medical negligence, the author tried to come to terms with the contrast between the inevitability of many medical errors, and the significant harm that they cause (page 99 and 106). In his attempt to strike a balance between fault-finding and restitution, he recommended what he feels is a fair compensation system, based on an existing system for people harmed by vaccines (page 108).
The book defined innovation, the third criterion for good clinical practice, as a process that ‘arises from deliberate, even obsessive, reflection on failure, and a constant searching for new solutions‘ (page 9). The author illustrated this with an analysis of the numerous innovations which have, over time, made pregnancy and labour very safe for mother and child. One such innovation, which the author praised for its simplicity and impact, is the Apgar score. This early warning system, now adopted universally, predicts distress in the newborn within a minute of birth (pages 169-200). The author lauded Virginia Apgar, the anaesthesiologist who developed this important tool, saying she is ‘exacting about everything she did’ (page 185). Other innovations include the discovery, by the Viennese obstetrician Ignac Semmelweis, that puerperal sepsis is transmitted by doctors and nurses, and preventable by simple hand-washing (pages 15-16).
Typical of the author’s style, the book is full of striking stories of his patients, all carefully picked to emphasise relevant points and show the human side of medical practice. Many are from his personal experience, such as when, as a medical student, he observed a diligent senior resident doctor repeatedly check on a sick patient, eventually picking up the signs that saved her life. The author said ‘it was a small thing, a tiny act of conscientiousness‘, but ‘it is this little act that I have often thought about since’ (pages 2-3). The author’s stories of dedication include how English teacher, Virginia Magboo, had her breast cancer surgery on time only because two theatre nurses ‘volunteered to stay late’ (pages 4-10).
The book discussed a variety of related topics such as the global effort to eradicate poliomyelitis (pages 29-50), the balance between altruism and fee-payment (pages 112-129), and physician involvement in capital punishment (pages 130-153). The author discussed the need for doctors to resist the urge to treat patients at all costs by recognising and understanding ‘the practical and humane limits of their practice’, and the limits of modern medicine (page 157). The book cited many health leaders such as paediatrician Donald Berwick who argues that ‘to fix medicine… we need to… measure ourselves and be more open about what we are doing’ (page 214). The author concluded that ‘true success in medicine… requires will, attention to detail, and creativity’, as well as ‘a readiness to recognise problems and a determination to remedy them’ (pages 245-246). He makes five essential recommendations for better performance, urging doctors to become ‘positive deviants‘ (pages 251-257).
This book is characterised by excellent prose and full of beautiful anecdotes. This is the typical style of the author who also writes for The New Yorker. It is a relatively short book but the lessons it teaches are profound, going to the core of what it is to be a doctor. The author highlights the simple, but frequently overlooked, duties of medical care. He reminds us to take the extra care and attention that make all the difference. The stories the author tells sometime appear too detailed, but they all effectively serve to illustrate his important points.
This qualities of diligence, doing right, and innovation are essential for medical practice. These are basic qualities of good healthcare, and the author has rightly attempted to put them back at the heart of modern medicine. The book teaches invaluable lessons and I highly recommend it to all doctors.
- Publisher, Place, Year: Profile Books, London, 2007
- Number of Chapters: 11
- Number of Pages: 273
- ISBN: 978-1-86197-657-4
- Star rating: 5
- Price: £9.95