This is a book about performance in medicine. 3 major sections. First is on diligence, the necessity to pay attention to detail to avoid error and prevail over obstacles. The second is around doing the right thing – the ethical dimension of medicine, and the third is around ingenuity. This is not about intellect but arises ‘ from a deliberate, even obsessive reflection on failure and a constant searching for new solutions.’
Diligence is underestimated as a virtue probably because it is so mundane. Looks at the examples of hand-washing in hospitals (the absence of which remains the single greatest source of in hospital infections) and the fight to eradicate Polio through vaccinations and military surgical teams.
In recent wars in Iraq and Afghanistan just 10% of wounded soldiers die. But this has been achieved without any fundamentally different technologies or treatments and in spite of the chronic shortage of general surgeons. What the military have done is make a science of performance to investigate how well they use the knowledge and technology they already have.
E.g. Enforcement of troops wearing body armour and thinking in terms of a golden 5 mins rather than a golden hour. To achieve this the Army developed Forward Surgical Teams (FSTs). They can set up a fully functioning hospital with 2 operating tables and 4 ventilator equipped recovery beds in under 60 mins. These units concentrate on damage control not definitive repair. Once stabilized they are moved back often still under anesthesia to Combat support Hospitals (CSHs).
This adjustment took a change in culture as surgeons were reluctant to pass on incomplete work. Casualties on average now take 4 days to get back to the US, in Vietnam it was 45 days.
For each patient over 75 different pieces of data are collected and recorded – all so that the data could be analysed and patterns could be identified. In US hospitals there is very little such info captured.
Case study into Obstetrics because of the way they have evolved to innovate. In comparison to other fields which tend to follow an evidence based process. In obstetrics if something seemed worth trying it was tried. This is more akin to how Toyota innovates – constant changes but always with attention to what happens, is it better?
The Apgar score changed everything, simple, easy to calculate this innovation is used almost universally and has saved thousands of lives. The score not only gave a single measure of how the patient was doing but a handrail for how to improve this. Gawande is now trialling a surgical apgar score a 10 point rating to define how well or badly a patient has come through a procedure.
Cystic fibrosis and the bell curve. For over 40 years the CF Foundation has gathered data from all CF treatment centres. This began because a paediatrician named LeRoy Matthews was treating CF patients in a children’s hospital in Cleveland and claimed to have an annual mortality rate of less than 2%. At the time this seemed a truly preposterous claim to anyone else in the field where national mortality rates were closer to 20%. A research grant from the CF foundation to look into the treatment data of all centres began in response.
Spotlighting what the best treatment centres do differently has over time dramatically increased life expectancy of CF patients. The secret is what Matthews realised and relentlessly focused on ever since, you do whatever you can and whatever it takes to keeps the patients lungs clear of mucos. Excellence – being the outlier at the far right of the bell curve comes from seeing on a daily basis the difference between 99.5% and 99.95% successful.
‘What the best may have, above all, is a capacity to learn and change – and to do so faster than everyone else.’
Gawande often illuminates his own research and understanding by looking at what people do when they are constrained without resources. Practitioners in India and Africa for example are often extremely innovative precisely because they do not have access to the latest technology.
In India he saw the impact of the surgeons afternoon tea habit for 30 mins they all met in a café and talked about what they had done and how it had gone. Just this habit alone drove them constantly to aim higher than getting through the day.
Many improvements could come from performance improvements – particularly around consistency for example, washing hands, taking meds, annual screenings for common cancers. Yet little research or thought goes into this element of the equation. With breast cancer, annual screening, would probably reduce annual deaths by a third. Over a 5 year period in the US only 1 women in 7 will maintain a consistent annual screen.
5 Suggestions for becoming a positive deviant.