Chapter Summaries for Better by Atule Gawande

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Mr. Gawande starts his literature on washing hands. He introduces two friends a microbiologist and an infectious disease specialist. Both work hard and diligently against the spread of diseases just like Semmelweis who is mentioned in the chapter. Something I learned, that not many realize, is that each year two million people acquire an infection while they are in the hospital. Mainly because the clinicians only wash their hands one-third to one-half as many times as they should. Semmelweis, mentioned earlier, concluded in 1847 that doctors themselves were to blame for childbed fever, which was the leading cause of maternal death in childbirth.

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The best solutions are apparently the sanitizing gels that have only recently caught on in the U.S.

Then there was an initiative to make the sanitizing easier for all. The engineer Perreiah came up with solutions that gave the staff more time which was revolutionary in itself but the format worked only under his supervision. After he left it all went down the drain, so, Lloyd a surgeon who had helped Perreiah decided to do more research and was excited when he encountered the positive deviance idea, the idea of building on people’s capabilities instead of trying to change them.

The idea worked and even got funding for ten more hospitals across the country. At the end of the chapter Dr.Gawande ponders upon the idea of how many he has infected because of his lack of cleansing. Chapter 2: The Mop-Up

This chapter starts off with the difficulty of diligence.

Yet there are some who have managed to deliver that expectation on an incredible scale. The task of distributing polio vaccines to millions of people, many in rural areas, was evidently a long and complicated task. The WHO had a team of only hundreds and had to teach the necessary vaccination procedures to the volunteers and local representatives, people who went door to door in all of these areas. Their target for the introduction of the vaccine was 90%.It was definitely complicated to try to keep the supplies in a constant outpour when there were only so many. For example, the vaccines needed to stay on ice to be effective.

Something that seemed counterproductive and bothersome was the lack of information in some places. For example, some villagers didn’t even know the vaccines were coming that day so they had been missed and others blinded by their ignorance didn’t want to vaccine their children. One such case led to a woman who refused the vaccines for her child but later went on to regret it when her own daughter’s legs lay limply aside. Gawande traveled with a Pankaj who made rounds checking on the progress of the volunteers and making corrections as necessary. The diligence in reporting gave the WHO the necessary information to learn from that mop-up. The commitment to accumulating meaningful data and the commitment to studying and learning from that data is just as important as the actual process of vaccination itself. Chapter 3: Casualties of War

Casualties of War, covers the efforts of battlefield surgeons in Iraq and Afghanistan to save as many wounded in the wars as possible. A Forward Surgical Team (FST) can set up all their equipment in the combat zones in less than 60 minutes. The travel time of a seriously wounded soldier from the frontlines back to the US averages 4 days; in Vietnam, it occurred in an average of 45 days, which as any doctor knows every second is crucial. The focus of the FSTs is "damage control, not definitive repair."

The wounded are then sent on to a temporary treatment facility immediately; if their injuries are serious they are then sent back to the US within a few days. The goal is for each level of treatment to give the patient the best chance for survival and then trust the next step in the chain to do its part to carry on the treatment. Gawande relates the incredible story of one individual with blast injuries who was opened up at the FST, received life-saving surgery and had arteries tied off, then he was cleaned out, packed with ice, and sent on an air evacuation; still left open from surgery with a note taped to him explaining what was done to the nearest combat hospital and a new surgical team.

By analyzing the patterns of injuries and treatment, other basic life-saving measures were implemented. For example, soldiers coming into treatment were found to be without their Kevlar. When asked why? They would complain about the weight, the heat, and the discomfort. Orders were issued that Kevlar was to be taken seriously and the injuries became less frequent. Gawande's point is that reporting is vital to
diligence just as it was for the WHO supervisor fighting malaria; these doctors recorded the details and results of each case. They understand, as Gawande writes, that "vigilance over the details of their own performance offered the only chance to do better. Chapter 4: Naked

The chapter is titled "Naked" and concerns the exam room etiquette that doctors and patients expect from one another and often uncomfortably tiptoe around. There is an allusion to a movie that has the female patient separated by a dark blanket like screen from the doctor. The doctor’s son who is about six years old is the communicator. Even though they are clearly audible to each other they wait until the boy speaks to them. This is the matter of decency. According to this literature some doctors feel uncomfortable with the whole process. There is really no established ground as to how to go about it. The author relates anecdotally that some patients and doctors find that having a "chaperone" present makes things worse.

For example, when asking a female nurse to come in when a male doctor is examining a female patient makes the patient more nervous than before. The patient perhaps did not sense a cause for concern and is then put on the defensive. Most of all it's about trust. The author relates occasions in which he felt aversion for the gowns but when the matters seemed to get to awkward or difficult he resulted to the exposing gowns. One out of every two hundred physicians is disciplined for sexual misconduct. Interns of both sexes on an average have had at least one incident of patient-initiated sexual behavior. So it is not uncommon for the situation to be more than just tricky. The chaperone helps both sides, the patient and the doctor, if any situation were to arise. Chapter 5: What Doctors Owe

What Doctors Owe, the fifth chapter of Better continues the discussion of doing right and focuses on malpractice lawsuits. The main focus of this chapter is a doctor-turned-malpractice lawyer; he stands out because most doctors hate malpractice suits. Even the lawyer says he hated them as a doctor. He said he was sued three times and two were nuisance suits with no basis, but the third was a case in which he made a medical error which led to the harm of his patient. He appeared to feel legitimately bad about it. He argued that the system allows those who are harmed to come forward and receive some compensation which makes them better able to deal with their injury. Former Dr.Lang took up a case against Dr.Kenneth Reed for the Barbara Stanley trial.

Reed had diagnosed melanoma on Barbara and insisted an extensive surgery was needed and she refused it because it seemed disfiguring to her. He got a ‘second opinion’ and the tests for melanoma came back negative. Two years later the growth reappeared. She died but not before telling Lang she wanted to sue Reed. Doctors strive to care for patients as best as possible, but of course there are instances where they make honest mistakes or are plain negligent, and that has to be addressed because it is the patient who pays. The downside of malpractice, as Gawande argues it, is that it is an essentially adversarial system which pits patients against doctors against insurance. He argues that it brings out the worst in all parties involved. Chapter 6: Piecework

Piecework, is on doctors' pay and its inevitable connection to the health insurance industry. According to this chapter every hospital has a Master Chart of prices for every imaginable health care procedure. Everything from a checkup to a surgery is listed with the price which is later charged to a patient, which inevitably is forwarded to an insurer. This raises an interesting question because it also sets limits on what doctors can make. If you are paying doctors via the Master Chart, then the more diagnosis they perform, the more they are getting paid. Either that or they can charge above the standard rate. One such doctor mentioned in this chapter did just that. He was considered an expert in a certain field and charged nearly ten times the standard rate.

He also mandated payments in full by patients, none of this pay-through-insurance mess. He did great business and was paid more than most doctors while doing less work. Another potential solution was attempted by a doctor-run health care cooperative in Vermont. Several doctors with different specializations grouped together and charged patients a flat rate, while they took flat salaries. They were therefore able to manage the efficiency of their medical care. Their network grew, and eventually they added doctors of other specializations. Eventually the co-op became one of Vermont's biggest insurers, ironic because they were trying to get away from the big insurance methods. Sure enough, size brought problems. The head and founder of the network left after a certain point, somewhat disappointed with the outcome. He cautions at the end of the article that at some point soon, the apparently untenable insurance and reimbursement system will need to be changed for the benefit of doctors and patients.

Chapter 7: The Doctors of the Death Chamber
The Doctors of the Death Chamber. This sections starts off with the death of Michael Morales by lethal injection. Under the typical protocol the anesthesiologist administers the sodium thiopental which is expected to halt breathing within a minute of the administration. Then the paralytic agent is introduced, followed by a fatal dose of potassium chloride. Then later, the judge found that at least eight patients had not stopped breathing when the technicians gave the paralytic agent. The California Medical Association, the AMA, and the ASA immediately opposed such participation in a prisoner’s death as a clear violation of the medical ethic codes. The author was intrigued by how the Doctors and Nurses sorted between acting skillfully, acting lawfully, and acting ethically in such situations.

Ever since the Gregg v. Georgia matter only two prisoners were executed by firing squad, three by hanging, and eleven by gas chamber. Pages 132 and 133 had details about the extent of each form of punishment. Some like the famous George Wallace were unlucky and had to endure physical pain for an extended amount of time. Many doctors, even though forbidden from participating, still take part in the execution. Some will help or just pronounce the prisoner dead, either way they can’t help feeling they are doing something wrong as reported by some of the interviewed doctors. They can’t help but feel they themselves are the executioners. Chapter 8: On Fighting

This chapter is based on the “fight” so to say some patients have to deal with. The story of a high school history teacher is an example of someone who was willing to risk the complications of life just to be able to live it. He had a reappearing cancer in his left kidney. Through many setbacks he was last seen in a long-term care facility. Despite the great advancements in his health he seemed to be in worse shape physically than before and then he was confronted with the realization that he might not be able to walk ever again. Not only are they, the patients like Thomas, fighting but so are the doctors in charge.

Another story about a young twelve year-old Callie had a similar reappearing tumor that came back just as big as before despite all the treatment. Although her family kept fighting, eventually her parents thought it was too cruel to keep Callie living such a difficult life. Many cases have been found that just by the doctors’ fight for a patient’s survival the odds get better for the patient. Many premature babies thought dead were brought back to life and were even able to live as a normal a life as possible. The topic of this chapter was: Never Stop Fighting, because even when the odds are against your favor there is always that one person we wished the doctors never stopped fighting for. Chapter 9: The Score

The Score starts off with Rourke’s experiences as a doctor delivering babies. Then the moment comes when she herself has to give birth. She knew the process and wanted the procedure to go as smoothly as possible. The thing she was most afraid of was losing control of what was done to her. The chapter delves deeply into the process of giving birth. For example, the dilation of the cervix, etc. Needless to say it is a complicated process which in consequence led to many child and young women’s deaths earlier on in history. The most problematic is the exiting of the child’s head. There have been many methods that can be effective if used correctly, but deadly in other situations for liberating the child. The concept of the forceps when it first appeared had been kept secret for more than a century. The device was developed by Peter Chamblin. The score relates to the Apgar score that was created to ‘measure’ the child’s chance of survival rate. This helped some cases that looked frugal before that, look hopeful. Chapter 10: The Bell Curve

This chapter deals with the outliers overall. Dr. Gawande relates a story about a child named Annie. Annie was diagnosed with cystic fibrosis. It is a recessive disorder therefore, despite ten million people carrying the gene; about a thousand American children are diagnosed with it per year. Her parents took her to Cincinnati Children’s and despite the hospitals effort they were negligent to say that they were not among the country’s top centers for children with cystic fibrosis. It used to be assumed that differences between doctors and facilities were insignificant. When plotting a graph of the results for each hospital it was expected to see a shark’s
fin but instead what was seen was a bell curve. LeRoy Mathews was at the top of that bell curve. As other hospitals adapted to Mathew’s ideas his facility just kept improving at a tremendous rate. In 2001 CF tried a new approach with its patients. They were open. They were willing to speak about how other facilities were doing versus theirs. Berwick a former pediatrician was giving grants to hospitals that were willing to try his idea. Not a single family left the program. CF improved greatly after that. Warwick was another positive deviant. He was aggressive, and inventive. He came up with a cough to be able to get the more accumulated mucus out. The chapter sums up with the overall constant fight against settling for the average. Chapter 11: For Performance

For Performance. This chapter sums the book up and is its own piece. It starts off with an introduction of a fellow doctor of his who has CF. Then we are led to a see how a certain Dr.Motewar in the Nanded hospital deals with the mass of people needing attention and care. The man was of ordinary appearance yet he saw at least 36 patients in three hours, most had serious complications. What was astounding to the author were the many skills developed by these doctors. He had lower expectations so to say. There was a man who died from a treatable lung collapse because of the lack of instruments.

It is very common for patients to have to go out and buy their own medical instruments and medications for the procedures to be held. Dr.Motewar and his colleagues had developed a better procedure for ulcer removal despite the conditions and lack of equipment they have. Many techniques that seem almost crude and basic were actually life saving. The doctors from which the author observed in the chapter had their own methods which would not have ‘flown’ in the United States. This chapter’s topic was about the never-ending search for a better performance in any situation you have.