Why This Book?

This is the 6th book in my 2018 year of reading which itself is part of my One Word of "Focus" for 2018.

I am reading this book after seeing a quote from it (see below) when reading and applying Jane Bozarth's book “Show Your Work: The Payoffs and How-To’s of Working Out Loud” which was my circle goal in my 2nd circle in Q3/4 2017. My main purpose for reading Atul's book is "to read and learn from a discipline I am unfamiliar with",

I was struck by the power of those words from a doctor and I knew that doctors are busy people and would therefore find time to write a huge challenge.

I find that quote to be deeply inspirational and to get to the heart of what working out loud is actually all about. I hope it encourages those of you who are fearful or apprehensive about blogging or working out loud or showing your work or even simply being part of a WOL circle to take whatever the next step is for you. And for the rest of us, I hope it encourages us to go deeper and further in our own journeys.

My application of this book

I found the book hugely challenging, humbling and inspirational as it provided insights into the medical profession that I am not close to in any way apart from the occasional interaction with my local doctor for minor ailments primarily to date. Although I should say I had an operation for scoliosis (curvature of the spine) in the summer of 1981 (after my 1st year at university) involving the insertion of a harrington rod in my spine.

I would recommend this book to everyone. In parts it is an adventure story where you are rapidly turning the pages to find out what happens to the various people named through their various courses of treatment for their particular medical issues.

All the way through the book as I read the various chapters, I could draw analogies with the easier and less life-or-death world of me implementing new computer systems as well as other professions and job roles.

To encourage others to read the book, I highly recommend you read this abridged version of the “Afterword: Suggestions for Becoming a Positive Deviant” that effectively brings the rest of the book to a conclusion and turns the focus on you to ask what is your response.

Areas of application that I need to consider:-

How do I measure my own performance? What should I count? What is good performance for me and what is bad?
What are the basics of what I do? Do I do the basics well all the time? What is the result of me not doing those basics consistently in everything I do?
What are the areas of my life in which I need to be continually diligent and not compromise?
Am I always doing right even when there is a cost of any sort to me?
Am I continually striving to improve my performance? What measures do I need to publicise in any way to hold me accountable and to encourage me more strongly to improve?
What is the equivalent of the Apgar score that I could use on myself to gauge how I am performing in the various roles of my life?
Related to the above, and because of an emerging interest in the subject of self-care, what is the equivalent of the Apgar score for my (and others’) self-care?
The author lists 5 attributes of being a positive deviant as follows:-

Ask an unscripted question

I found a strong resonance with Edgar Schein’s “Humble Consultant”.
I do this to a certain extent but need to do this more - and more knowingly with everyone.

Don’t complain

I am already seeking to work on complaining less with some success but I do lapse. I will try harder

Count something.

This was mentioned earlier in this section. This is as per the WOL discipline of keeping score.

Write something

I do need to do reflective writing to learn from everyday experiences.
I do need to work out loud more on my day job type service delivery and not just on my learning activities such as WOL circles.

Change

I am already quite good at this and usually open to and adopting new things.
I do need to work on changes that I resist to understand and work through my resistance and then do actually change and get on with it.

Introduction

book started with example of doctor not trusting Atul to check on elderly patient with an unknown issue, checked on the patient himself, Atul called it “a small thing, a tiny act of conscientiousness”, went out of his way to check on her, not relying on nurse to tell him, because he checked on her, treatment needed both times, survived and with easier journeys that would otherwise have been the case

what does it take to be good at something in which failure is so easy, so effortless?

as a student Atul’s desire was to be competent

in the story the doctor was more than competent – he understood how the specific illness evolves and is properly treated but also specifics of how to catch & fight one in that specific patient, in that specific moment, with specific resources & people he had at hand

often we look to great athletes for performance lessons e.g. perseverance, hard work, practice, precision – all helpful for medics

but medicine has other dimensions:-

lives are on the line
decisions & omissions are moral in nature
daunting expectations

in medicine , task is to cope with illness & enable every human being to lead a life as long & free of frailty as science will allow

knowledge to be mastered is vast & incomplete

yet we are expected to act swiftly & consistently even when task needs hundreds of people for the care of a single person

expected to do our work humanely, with gentleness & concern

the stakes & the complexity of performance in medicine that makes it so interesting & at same time unsettling

story of breast cancer patient and how her op was delayed as no capacity for her op to go ahead with all the issues around that

the book is about performance in medicine

not just about canny diagnosis, technical prowess & ability to empathise with people

also about grappling with systems, resources, circumstances, people, our own shortcomings, facing obstacles of seemingly unending variety

yet somehow we must advance, refine, improve

sections of book look at 3 requirements for success in medicine – or in any endeavour that involves risk & responsibility:-

diligence

the need to give sufficient attention to detail to avoid error & prevail against obstacles
seems an easy & minor virtue (you just pay attention, right?)
BUT it is neither
it is both central to performance & fiendishly hard
told through 3 stories

medical staff washing hands
care of wounded soldiers in Iraq & Afghanistan
effort to eradicate polio from the world

to do right

medicine is a fundamentally human profession
therefore always troubled by human failings (e.g. avarice, arrogance, insecurity, misunderstandings
cover uncomfortable questions

how much doctors should be paid, what we owe patients when we make mistakes

stories in book

4 doctors & nurse who went against medical ethics and participated in executions of prisoners
when we should keep fighting for a patient and when stop

ingenuity – thinking anew

often misunderstood, not a matter of superior intelligence but of character
demands more than anything a willingness to recognise failure, to not paper over cracks & to change
arises from deliberate even obsessive, reflection on failure & constant search for new solutions
difficult traits to foster but not impossible
stories of people in everyday medicine who transformed medical care

the way babies are delivered
how incurable diseases (e.g, cystic fibrosis) are fought

examine how more of us can do the same

betterment is perpetual

we in medicine are also humans – distractible, weak, given to our own concerns

living in the messy complicated connection between being bound up in others’ lives & science

it is to live a life of responsibility

just by doing the work you have accepted this responsibility

so how does one do such work well

back to cancer patient who was able to have her op as 2 nurses worked late to do this with Atul

when you make the effort, you find sometimes you are not the only one willing to do so

[ Simon: an amazing start to a book, really draws you in.

Emotional reading this already.

Trivial comparison from me with how we keep systems up and running.

Can see this book being really helpful already re making me think about a discipline I have no experience of except as a recipient of clinical care.

The reference to ethical decisions reminding me strongly of the most challenging MOOC I have ever done – Harvard X’s Justice. Highly recommended. This is the trailer for the course (https://youtu.be/DI2NcHl1HQQ) and this is the input on how much people get paid (https://youtu.be/VcL66zx_6No). Mind-bending course but so good! Really makes you think. ]

Part 1: Diligence

On Washing Hands

story of tour of hospital with 2 people whose role was to stop the spread of infection in the hospital – stopped multiple infections spreading including fatal ones

each year 2m Americans acquire infection when in hospital, 90k die of that infection

hardest part of their job … getting clinicians like Atul to wash their hands – the one thing that consistently halts spread of infections

multiple initiatives to spread the message including incentives

typically 1/3 to 1/2 times we should are hands washed

originally discovered in 1847 by Ignaz Philipp Semmelweis (Viennese obstetrician) studied mother mortality rates where nearly zero died in home births vs 600/3k mothers at his hospital – he was ultimately dismissed from his job by his colleagues

this is Exhibit A in case of obstinacy & blindness of physicians

BUT he did not properly address his critics, he attacked them

he was a genius but also a lunatic which made him a failed genius

20 years later Joseph Lister was clearer & more persuasive & more respectful plea in The Lancet

[ Simon: good reminder that how we say things impacts the end result even if we are right! ]

finger nails a particular issue!

Semmelweis recognised ordinary soap insufficient & used chlorine solution

even with right soap need correct procedure:-

remove all jewellery
wet hands in warm tap water
dispense soap, lather all surfaces including bottom third of arms for 15-30 seconds
rinse off for 30 seconds
dry completely with disposable towel
use towel to turn tap off
repeat after every patient contact

almost no one adheres to this procedure! seems impossible!

could mean a third of time spent washing hands

can irritate the skin causing dermatitis which itself increases bacterial counts

alcohol gels used in Europe, US started later, 15 seconds and can air dry

after gel, compliance rates increased from 40 – 70% but infection rates did not change!

rising infection rates from super-resistant bacteria have become norm worldwide

policing is key to improve

there is no easy fix

operating room procedures are better at sorting this out – these just need applying elsewhere

I am not perfect!!

positive deviance idea – building on capabilities people already had rather than telling them how they had to change

asking people what they know about how to solve the problem – got lots of ideas

taking nasal swabs of patients to detect incoming infections from the start and at the end of the patient journey

[ Simon: This is speaking to me of never taking shortcuts, of always doing the right thing, getting the basics right and relentlessly doing the basics each and every time we do anything. As a project manager, lessons learned documents should be a deliverable from every project and new project teams should review these lessons learned documents within their organisations to pay close heed to what has gone before. Flippantly, yet seriously at the same time, I refer to these documents as “Repeated Mistakes” documents as the same issues often happen with concerning regularity. One of the services I have delivered in the past is programme and project recovery. Almost without exception. these workstreams can be turned round by applying the project management basics that we all know we should be doing. ]

The Mop-Up

people underestimate the importance of diligence as a virtue – can seem supremely mundane

definition: “the constant and earnest effort to accomplish what is undertaken”

can seem simplistically relentless

diligence stands as one of most difficult challenges facing any group of people who take on tasks of risk and consequence – setting a high, seemingly impossible, expectation for performance and human behaviour

cf eradicating polio in India

World Health Organisation nearly 20 years into campaign to eradicate polio globally – if succeeds, may be mankind’s most ambitious accomplishment

history of eradicating single diseases – after 100 years the only success is smallpox

explanation of 3-day campaigns in local areas to vaccinate etc

explanation of how polio virus works

global campaign involving national immunisation days (3 day periods when all children under 5 are immunised)

polio down to less than 1% of what it used to be

note that WHO does not have authority to do this – small organisation in Geneva with delegates who vote on what to do but not how to do it

story of the author seeing the oversight of the campaign in a part of India

beneath the ideal is the gruellingly unglamorous and uncertain work. If the eradication of polio is our monument, it is a monument to the perfection of performance – to showing what can be achieved by diligent attention to detail coupled with great ambition

[ Simon: amazing stories of how huge numbers of children were immunised in various parts of the world with unsophisticated supply chain systems. ]

Casualties of War

little recognised is how fundamentally important the medical system is – and not just the enemy’s weaponry – in determining whether or not someone dies

cf trauma care of shooting victims

in war firepower has increased but lethality has decreased

currently 10% of wounded American soldiers die

achieved with no fundamentally new technologies or treatments since Gulf War and difficulty in recruiting medical staff

[ Simon: as I was reading this part of the book. This amazing man – David Nott - came to mind whose story I heard on a fave radio/podcast series “Desert Island Discs”. An emotional listen, powerful stories:

“He works across three London hospitals performing general, vascular, trauma & reconstructive surgery. In addition, for the past two decades, he's spent several weeks every year working in conflict zones around the world for Médecins Sans Frontières (MSF) and the International Committee of the Red Cross (ICRC).”
https://www.bbc.co.uk/programmes/b07djzyq ]

the answer to these stats did not seem to reside in any special skills of military doctors

example of a military doctor who was known when he trained others for his unflappability, his intellect (published papers) & his 5 children born during his residency

author discovered that on asking people for “how” these results were achieved revealed intriguing effort to do something we in civilian medicine do patchily at best: to make a science of performance, to investigate/ improve how well they use the knowledge/ technologies they already have at hand – examples of simple almost banal changes that produced enormous improvements

e.g. soldiers wearing Kevlar vests

e.g. helicopter evacuation – not a golden hour but a golden 5 minutes

faster units on ground made speed of evacuation even more important

use of Forward Surgical Teams (FSTs) – medical staff in 6 Humvees just behind front line troops with Deployable Rapid Assembly Shelter (“drash”) tents as hospitals (900 sq ft) with medical ops kit – from start to working in 60 mins

focus on damage control not definitive repair for speed and kit reasons

next level of care after that Combat Support Hospitals (CSHs) – also mobile, set up in 24-48 hours, max patient stay intended to be 3 days

next level of care Level IV hospital and if patient needs more than 30 day stay back to America

initial issue to get over was medics thinking they were the best for their patients

average time from battlefield to America now 4 days (Vietnam was 45 days)

soldiers now surviving injuries that were impossible to survive in past

mortality is low but human cost remains high

stats taken of incoming injuries and outcomes despite the volume of work cf what little data is captured in civilian hospitals

military doctors sacrificing sleep to input data because they knew the data would help outcomes later – offering the only chance to do better

stats resulting in improved eye protection via more stylish (!) ones encouraged soldiers to wear them; improved bandages applicable with one hand including blood clotting agent, pack bleeding sites with gauze before operating, serial operative washouts of wounds removing infectious debris

some stats could not be addressed with responses

story of doctor Mark Taylor who died on active service while being part of a Forward Surgical Team

[ Simon: went Google-ing found this news article about the doctor above. Also found this video of medical training and this video about Lt. Gen. Nadja West (the current US Army’s Surgeon General. ]

[Simon: this part on medics in war zones did remind me that we have the tools to do amazing things collaboratively we just need to be galvanised to deploy and use those tools imaginatively and creatively to cater for all situations even if they have nothing to do with life-and-death situations. And also that it often needs crises to force us to think in these ways to get the maximum benefit. ]

Part 2: Doing Right

Naked

scene from “Kandahar” set in Afghanistan under Taliban, male physician asked to examine female patient covered head to foot in burkha, sheet between them, her 6 year old son go-between for communication with small hole in sheet for examination – the demands of decency

[ Simon: part of the clip is in the trailer for the film: https://youtu.be/H1NaHFB08I0 ]

discussion about etiquette of examination, no clear standards in USA

physical exam is deeply intimate and way a doctor deals with naked body esp when doctor is male and patient female inevitably raises question of propriety and trust

different approaches across the world of who else should be present

author tells of his first examination of a patient when he was on his own and further examples of issues with medical gowns and keeping ordinary clothes on, ultimately went to gowns!

UK standards are stringent .. a chaperone of the appropriate gender must be offered to all patients who undergo an “intimate examination” (i.e. involving breasts, genitalia, rectum) irrespective of gender of patient or doctor – chaperone must be present when male doctor performs intimate examination of a female patient; chaperone should be female member of medical team with her name recorded in notes; if patient refuses chaperone and exam not urgent it should be deferred until it can be performed by a female doctor

no such guidelines in USA so patients have little idea of what to expect from us but some minimum standards

difficulty for doctors who behave properly is that medical exams remain inherently ambiguous

what should our customs be?

reasons to consider setting tighter, more uniform professional standards:-

protect patients from harm
reduce false accusations against doctors

the measures required to achieve total prevention inevitably approach the Taliban-esque & risk harming patients by discouraging complete and thorough examinations

most important reason is simply to improve trust & understanding between patients & doctors

author explains his father’s painstaking approach as doctor as Indian immigrant in a small Ohio town

e.g. decorum in language and attire, respect for modesty, precision of examination

[ Simon: I often use “decorum” as a word in certain conversations usually in a humorous self-deprecating way. I looked up the definition:-
decorum: behaviour in keeping with good taste and propriety; etiquette ]

unsettling to find how little it takes to defeat success in medicine – fully qualified professionally technically and yet the social dimension can bring you down

it is what makes medicine so complex & fascinating

relationships are deeply personal, involving promises and trust and hope & is what makes doing well as clinician more than a matter of outcomes & stats

[ Simon: This is a great section that deeply illuminates the intimacy content in Edgar Schein’s Humble Consulting about professional relationships between those helping and those needing help. ]

What Doctors Owe

story of a malpractice case

malpractice suits are a feared, often infuriating & common event in a doctor’s life

70% either dropped or decided in favour of doctor

when doctors lose, average jury verdict $O.5m

30k to 300k in malpractice insurance premiums, neuroscientists/ obstetricians 50% more

every doctor, it seems has crazy-lawsuit story

author sat in on the case in 1st sentence above – the lawyer for the plaintiff was a former doctor

how had the lawyer come to a different understanding of doctors’ accountability than the rest of us?

author met the lawyer – why the career shift? burning out in medicine, thought he would be good at law, wife was shocked at the switch, he had always wanted to be a doctor, continual learner, started defending medics but he had no experience, went into sales mode, took cases where doctor was negligent and where doctor caused damage, how the plaintiff will come across to jurors

legal definition of negligence – “when a doctor has breached his/her duty of care”

the lawyer’s definition: finding an error that resulted in harm and doctor could have avoided it

to most doctors this is an alarming definition

lawyer’s view was negligence happens and that is why you have insurance

story of a doctor known to author whose son got cancer for which something showed up years earlier during x-ray for wisdom teeth op, doctor himself had been subject of a lawsuit and that is not what he wanted to do

when there is an issue most people talk to doctors first but the profession is now encouraging people to talk to lawyers first

medicine has offered no genuine alternative

difference in view between medics & non-medics re what should happen if a doctor is negligent

the son case was taken to court and won a change in law of statute of limitations of 3 years from time of discovery of harm not original event, also won the case … eventually became a medic himself

he is exceedingly careful in his work, set up review committee to find/analyse errors

paradox at heart of medical care is that it works so well and yet never well enough – precisely because of medical advances & successes that people are bound to wonder what went wrong when medics fail

author says typically there will be 2% of his patients for whom things will not go well

in about half those cases, things will have been unavoidable

cf baseball analogy of a player making a mistake and compare that with what happens to doctors

litigation has proven to be a singularly unsatisfactory solution – expensive, drawn out, painfully adversarial

98% of people hurt by medical errors do not sue

1% of cases get compensation

only the worst is brought out in all of us

there is alternative approach cf people injured by vaccines – fund for compensation from higher costs of vaccines but known costs, few people then also sue

problem if extended is that the scheme would be swamped – cf scheme in New Zealand with no attempt to sort out errors from bad luck – the author advocates this

the one defence of our malpractice system is that it has civilised the passions arising when a doctor has done a devastating wrong

[ Simon: interesting timing reading this section as in the UK the case of Dr Hadiza Bawa-Garbais is headline news.
Dr Hadiza Bawa-Garba wins appeal against being struck off
The Guardian article ]

Piecework

author tells of getting a medical position and being asked to name his price

most people assess this by the market

he asked colleagues, awkward convos, no answers

note that health care system requires doctors to give inordinate attention to matters of payment and expenses

tells of insurance scheme schedule for all services doctors can charge for – 600 hundred pages

doctors have been paid on piecework basis since at least Code of Hammurabi (Babylon, 18th century BC)

standardised fee schedule is a modern development

some charges have remained constant despite technology advances cutting time for certain ops dramatically

generally payments for doing procedures far outstripped payments for diagnoses

in States, decided unacceptable .. decided that payments should relate to amount of work involved

simple/ sensible principle BUT putting it into practice different matter

1985, William Hsiao, Harvard economist was commissioned to measure work involved

came up with formula – work was function of time spent, mental effort & judgment, technical skill & physical effort and stress – ended up with relative value for every single thing doctors do

Congress set multiplier to convert to cost and Medicare started using those values in 1992, private insurers followed shortly after

some re-examination and recalibration since

still a challenge for the author to say how much he should get paid using that info – he did the maths e.g. including malpractice insurance, building space, hiring people, different rates of payments from different insurers, rejected payments at 30% by insurance companies

doctors quickly learn that how much they make has little to do with how good they are but on how they handle the business aspects – e.g. their responsibility to handle the medical insurance side e.g making sure that patient is covered for the specific treatment to be done, taking payment when insurer does not pay the full amount for the treatment in question

Roberto Parillo is financial disaster specialist called in by doctors, medical practices and hospitals to sort out their financial position

she recommends:-

computerised billing
review bills sent out
review payments received
hire staff to deal with insurance companies

she says it is a war with the insurance companies

author tells of doctors saying they would not have gone into medicine if they knew when they started what they know now

William Weeks (professor, Dartmouth) done studies on work-life of doctors – high hours, less return for education & training expense

but churlish to complain – 2003 median income for primary care doctor $156,902, general surgeons like author $264,375 some specialities even higher e.g. more than half a million

in the end are we working for profits or the patients

one example of doctor who works how he wants earning $1.2m per annum for 10 years – does not let insurance companies set his terms, he takes cash and patient does the insurance company relationship management – charges significantly over the market rate

yet if this is purely a service-for-money business, if doctoring no different from selling cars, why choose to endure 12 years of medical training instead of 2 years at biz school – reason has to be that doctors remain at least partly motivated by hope of doing meaningful & respected work for people & society

any way around the insurance challenge?

1971, 33 yo intern Harris Berman (Matthew Thornton Health Plan, he was one of NH’s 3 signers of Declaration of Independence) tried alternative, Nashua (New Hampshire) with medical colleagues offered health care for fixed annual fee with no fees to insurance companies – radical experiment – paid salaries of $33k pa, reinsurance cover for costs above $50k, the scheme worked, drove efficiency in the system – over time for some just became a job with productivity issues – by mid 80s, 60k patients had joined due to controlling costs better than others, 2nd largest insurer in NH, 1986 Berman left, taken over by Blue Cross

2005 US spent $2tn, 1/6 of income on health care, $7,110 per person, 80% from insurance, 20% from patients

hospitals took 1/3, doctors 1/3, 1/3 on nursing homes, drugs, insurance admin etc, insurance premiums increased 9.2% in 2005

docs responsible for most of spending

cost of son’s care was $0.25m but he only paid $5

the source of what economists call “moral hazard”: with other people paying the bills – hence adversarial relationship patients/docs have with insurers

no reason to think this will change if changes in who picks up the tab

docs get x7 average US employee, gap growing over time, other parts of the world is x3

1/7 Americans have no insurance cover, 1/3 younger than 65 will lose cover in next 2 years

challenge of getting medical care

some day soon this must change

author accepted the job offer; discussed terms after he named his price, final question “what are the insurance benefits like?”

The Doctors of the Death Chamber

14 Feb 2006 Californian court ruling that state had to have anaesthesiologist personally supervise or drastically change the standard protocol for lethal injections due to issues in recent past executions

medical associations objected on medical ethic codes re being healers not executioners

execution has become a medical procedure in the US

challenge making medics choose between ethical codes of their profession and desires of the wider society

vital but sometimes murky differences between acting skilfully, acting lawfully and acting ethically

author interested in how medics have decided what to do in this area

different methods of execution: firing squad, hanging, gas chamber, electrocution, lethal injection

stats and stories of how long some of these have taken to kill specific individuals

lethal injection now appears to be the sole method of execution accepted by courts as human enough to satisfy Eighth Amendment requirements – largely becuase it medicalises the process

the medical profession baulked at a proposed approach to this in 1980

whilst medical associations say that an individual doctor’s opinion on capital punishment remains “the personal moral decision of the individual”

lots of actions by medics not allowed by their associations apart from provision, at prisoner’s request of sedative to calm anxiety beforehand and signing a death certificate after someone else has pronounced death – another association says medics not to be involved in the process in any way

only a pharmacists’ society allows involvement

but the States wanted medical involvement

today all 38 death-penalty states rely on lethal injections, 35 allow doctor participation, 17 require it – anonymity is promised and legal immunity provided – neither holds in every case

doctors/nurses allowed to refuse to participate including prison employees

who participates and why do they do it?

research by author – a challenge to find people to speak!

none zealots for death penalty and none had simple explanation

some just fell into it

3% of doctors aware of any guidelines covering their participation in executions

the most wary of speaking to the author were full-time prison employees

one rationalised it as part of the job and jurors had found people to be executed guilty so a wider society obligation to participate

author personally in favour of the death penalty but had not thought before of the actual process, instinctively regarded involvement of medics as wrong

his research rattled his views especially a convo with one doctor who felt obligation not to abandon inmates in their dying moments, is an end-of-life issue like other terminal diseases but involving a legal process not a medical process, people need to die in comfort (these people’s “cancer” is a court order – fully involved in executions for these reasons – fees donated to children’s shelter where he volunteers

little doubt that lethal injection can be painless/ peaceful but as courts have recognised , ensuring that it is requires significant medical assistance/ judgement

how do we reconcile conflict between government efforts to provide medical presence and our ethical principles forbidding it? shoudl our ethics change?

noted that the prisoner does not have a relationship with the medic and cannot accept/deny treatment

author’s position: stand with ethics code and if that means executions cannot happen so be it

other similar areas: use of medics for interrogating prisoners, force-feeding

given medical advances, government interest in medical skills will increase

preserving integrity of medical ethics could not be more important

most of the medics the author interviewed took their moral duties seriously

beware simply following rules … each of us has duty not to follow rules and laws blindly

in medicine, we face conflicts about what is right and best actions are in all kinds of areas

we must do our best to choose intelligently and wisely

[ Simon: This was a challenging chapter! It made me thing about capital punishment in ways that I have never done before, As always, it is good to have our assumptions and beliefs challenged, It is easy for us non-medics to dismiss the subject of capital punishment as it does not affect us directly. This chapter reminded me of our own ethics and practice and what we are prepared to do and not do. This may mean for some of us e.g. that we would not work for organisations that sell tobacco or alcohol, or are lottery- or gambling-related. For others of us, it may mean that in the course of our daily work for an organisation when we are asked to do something that cuts across everything we personally stand for whether we should stay or resign our position. ]

On Fighting

the hardest part of being a doc is not learning new skills nor strain of the work but to know what you have power over and what you do not

case explained of fear of patient of a major op that decided to go ahead but did not work out, likely never to leave hoispital

we have at our disposal today the remarkable abilities of modern medicine – learning to use them is difficult enough but understanding their limits is the most difficult task of all

fact: we spend more than 1/4 of public health care dollars on the last 6 months of life

perhaps we could spare this fruitless spending – if only we knew when people’s last 6 months would be

in the absence of certainty we want doctors who fight

story of a doctor who started treating babies who were 2 or more months premature that were historically not treated with amazing results

cf medics in war zones per earlier content in this book

we want doctors to fight in mundane as well as extreme situations

the seemingly easiest and most sensible rule for a doctor to follow is “Always fight” – always look for what more you could do

it gives us our best chance of avoiding worst error of all – giving up on someone we could have helped

in the end no guidelines can tell us what we have power over and what we do not

in the face of uncertainty, wisdom is to err on side of pushing, to not give up

but be ready to recognise when the pushing can turn to harm

the fight is to do right by our patients even though what is right is not always clear

quote from patient’s mother sent to friends and family:
”We must eradicate from the soul all fear and terror of what comes to us in the future”

Part 3: Ingenuity

The Score

human birth is an astonishing natural phenomenon – a feat involving an intricate sequence of events

explanation of how giving birth happens from months prior – if all goes well

at almost any step something can go wrong

for thousands of years, childbirth was most common cause of death for young women and infants

midwives and doctors long sought ways out of disasters – the history of ingenuity in obstetrics is the history of these efforts

examples listed – there are dozens – saved the lives of countless babies but each has a significant failure rate

surgery (ceasarean section) known as a way to save an entrapped baby for thousands of years

historically considered criminal as invariably the mother died and her life took precedence

needed development of anaesthesia and antisepsis and in early 20th century of a double-layer suturing technique to stop opened uterus from hemorrrhaging did C sections become a real option

better option was obstetrical forceps

story of forceps is extraordinary and disturbing – a life-saving idea that was kept secret for more than a century

developed by Peter Chamberlen (1575 – 1628) – 1st of long line of French Huguenots who delivered babies in London

the 1st technique that could save baby and mother

the family kept this secret for three generations but they used it in delivering obstructed babies

1670 Hugh Chambelen tried/failed to sell design to French government

later in his life he divulged it to Amsterdam-based obstetrician, Roger Roonhuysen, who kept it secret for further 60 years

secret finally emerged mid 18th century and then got wide acceptance

by early 20th century, problems of human birth seemed to have largely been solved

study in 1933 New York Academy of Medicine of 2,041 maternal deaths in childbirth in NYC, 2/3 were preventable

no improvement in death rates for mothers and newborn deaths had increased

hospital care brought no advantages – mothers better off delivering at home

many doctors did not know what they were doing … missing signs etc

follow-on report from White House … doctors may have had the right tools, but midwives without them did better

specialists in field had shown extraordinary ingenuiy … but this knowledge and instrumentation had proved grossly insufficient

needed to discover a different kind of ingenuity … how to standardise childbirth

foetal heart rate monitoring used in 90%+ deliveries, intravenous fluids 80%+ epidurals 75%, drugs to induce labour 50%

C sections 30% and rising

130m births globally each year, 4m+ in USA

some percentage will always end badly

in mid 1930s, delivering a child had been single most dangerous event in woman’s life, 1 in 150 pregnancies end in death of mother

by 1950s due to tighter standards and to discovery of penicillin and other antibiotics fell more than 90% to 1 in 2,000

but 1 in 30 newborns still died at birth

not clear how to fix

Virginia Apgar (New York) had simple idea that transformed childbirth & care of newly born – she had never delivered a baby as doctor or given birth

had combo of fearlessness, warmth & natural enthusiasm that drew people to her but was exacting about everything she did

talented violinist, made her own instruments, started flying single-engine planes at 59

she never tried to cover a mistake, she had to know the truth whatever the cost

via advice, she did not become a surgeon as was told it would be hard to attract patients as a woman) – went into anaesthesiology

administered anaesthetics to more than 20k patients

“do what is right and do it now” she used to say

had real issue with newborn care … could not influence directly so took indirect but ultimately more powerful approach – she devised a score

The Apgar Score: allowed nurses to rate condition of babies at birth on scale from 0 – 10, 2 points for each of pink all over, crying, good/vigorous breaths, moving all 4 limbs, heart rate over 100 – 10 is good, 4 or less, not good

published 1953 to revolutionary effect – forced careful observation and documentation for every baby encouraged competitive doctors to get better scores/ outcomes

globally every baby measured at 1 and 5 mins post birth

triggered lots of medical improvements including epidurals, ultrasound, foetal monitors

today in States, 1 full-term baby dies out of 500, 1 mum in 10,000

if stats from 1930s persisted would have been 27,000 mothers (now less than 500) and 160,000 newborns (now 1/8 that number)

paradox – research medics say don’t introduce into practice anything that has not been properly tested and proved effective by research centres and preferably by double blind randomised controlled trial

in 1978 ranking, obstetrics came last on use of hard evidence - and when they did do evidence, often ignored results .. and yet almost nothing else has saved lives on the scale that obstetrics has

obstetrics went about improvement like Toyota and GE: on the fly, always paying attention to results, trying to better them … that approach worked

the Apgar Score changed everything – practical, easy to calculate, gave medics immediate feedback on how effective their care was

this is unlike other areas of medicine

fate of forceps: forceps deliveries are difficult to teach, harder than C sections with those you can see what student is doing and give guidance

is medicine a craft or an industry?

if craft, focus on teaching obstetricians to acquire set of artisanal skills, research to find new techniques, accept that things will not work identically in each person’s hands

if industry, responsible for safest possible delivery of some 4 million babies a year in US, a new understanding is required, focus shifts to reliability

the C section became this answer

explanation of doing a C section

for lots of birth issues, the solution is the same … C section .. the most reliable option

every obstetrician today is comfortable doing C sections

note that they are not risk-free .. also recovery is longer and more painful than normal delivery

discussion about whether C sections should be offered routinely even when no issues

author expresses disquiet about childbirth becoming so readily surgical

in States now more than half of deliveries

we are losing connection to yet another natural process of life and seeing the waning of the art of childbirth

normal deliveries may become a lost art

C sections generate more income for obstetricians and better for planned schedules

fear of malpractice legal suits encourages C sections

the score is for babies not how we improve the mother’s experience from binary lived or died

we need an Apgar score for everything medical

author’s research group came up with a 10 point surgical Apgar score – blood loss, lowest heart rate, lowest blood pressure

1,000 patients scored: 9-10 less than 4% of complications and there were no deaths; less than 5 greater than 50% chance of complications, 14% chance of death

score encourages/pushes innovation

The Bell Curve

finding a meaningful way to measure performance is a form of ingenuity in itself

what you actually do with that measure involves another type of ingenuity

improvement ultimately requires both kinds

story of cystic fibrosis: genetic disease, 1k people diagnosed in a year in USA, major impact on lungs

difference life expectancies depending on where in USA your treatment was

this is the bell curve so not weighted at top end

e.g recurrent hernia: 1 in 10 at unhappy end to 1 in 20 in middle majority to 1 in 500 at top end; newborn deaths in neonatal ICU – average 10% with 6 to 16

bell curve is distressing for doctors to have to acknowledge – cannot say that a patient gets the best chance or that they are doing the best job they can

this info coming through now to patients for first time

doctors not used to comparing results with their peers

re performance measures: baseball teams have win/loss records, businesses have quarterly earnings, what about doctors?

Health Grades web site, for a fee, can provide some stats on specific medics but not about results

what do you measure is 1st challenge

how do you apportion blame between nature and doctors

unclear what changes could be made to improve

public ignored the rankings

want to know how doctors perform in typical circumstances

difficult gathering stats – still heavy use of paper – costly to process the paper and track individual patients if privacy allows

but this work is starting

cystic fibrosis at forefront of measuring – data captured for 40 years due to Cleveland paediatrician LeRoy Matthews, a doctor in this field starting in 1957 claiming annual mortality rate of 2% vs 20% nationally

1964 Cystic Fibrosis Foundation funded Warren Warwick to do national survey on every CF patient

median death in Cleveland 21 years old, x7 age of rest of country

no death under 6 in 5 years

Matthews treated patients as CF being cumulative disease not sudden affliction with aggressive preventive treatment to stave off onset before person became sick

his treatment became standard practice

results: 10 years by 1966, 18 by 1972

Matthews results continued to improve: early 1970s 95% treated before CF set in lived past 18th birthday

2003 life expectancy was 33 years old nationally but 47 in best centre

variability puzzling as CF care is the way we want all medicine to work: specialist centres, certification process, highly experienced doctors, standard guidelines for treatment, involved in research trials BUT still differences in outcomes

Don Berwick (Institute for Healthcare Improvement) encouraged opening up of CF stats to patients – he is influential not because of his position but powerful because of how he thinks

1999 gave talk on what was wrong with American health care – years after still being talked about (https://youtu.be/00aa6xcOXf4)

transcript sent to thousands of doctors across USA

started with story of firefighters and how leader started fire to help all firefighters escape being surrounded – known as “escape fire” – later became part of standard firefighting training, 2 died and not all heard/believed him

in the example, the team had lost ability to think coherently, to act together, to recognise that a lifesaving idea might be possible

this is what happens to all flawed organisations in a disaster and the speaker argued this is what was happening in health care

advancing complexity of knowledge/treatment but falling short on doing even simplest of tasks

argument was to fix medicine need to measure ourselves and be more open about what we are doing – routinely compare doctors and hospitals and give patients total access to info

no secrets was his escape fire

openness driving improvement if simply through embarrassment

author compared convos between doctors in 2 centres including Warwick’s to find out whether patients were complying with the agreed treatment

in the W covo, he believed that excellence came from seeing, on a daily basis, the difference between being 99.5% successful and being 99.95% successful

this is same as many areas of life but in medicine lives are lost in those differences

W’s combo of focus, aggressiveness & inventiveness is what makes him extraordinary

W had new stereo stethoscope made

W “made” new cough for output diagnosis

2 decades earlier invented mechanised chest-thumping vest for patients to wear (the Vest): meant patient could do this without need for another person

45k patients with CF & other lung diseases use it

W runs weekly patient reviews to ensure uniformity of care

not a single child/teenager has died at that centre for almost a decade, oldest patient 67

with unblinking focus on results W was able to innovate successfully – he has become almost contemptuous of established findings

we are used to thinking that a doctor’s ability depends mainly on science and skill

the lesson here and other places reported in the book is that these may be the easiest places of care

even doctors with great knowledge and technical skill can have mediocre results; more nebulous factors like aggressiveness and diligence and ingenuity can matter enormously

Don Berwick believes that subtleties of high-performance medical practice can be identified and learned – but the lessons are hidden because no one knows who the high performers really are – only if we know the results from all can we identify the positive deviants and learn from them – if we are genuinely curious about how the best achieve their results, Berwick believes, then the ideas will spread

CF now has web site that contains all results: https://www.cff.org/ – the 1st field in medicine to voluntarily do such a thing

you have to wonder whether it is possible to replicate people like Warwick with their intense drive and constant experimenting

Marshall: “You look at the rates of improvement in different quartiles, and it is the centres in the top quartile that are improving fastest. They are at risk of breaking away.”

What the best may have, above all, is a capacity to learn and change – and to do so faster than everybody else

no matter how much we improve the bell curve will always be present

will being in the lowest quartile be used against doctors? will we be expected to tell our patients? will patients leave us? will those at the bottom be paid less than those at the top

probably yes to all

some insurance companies holding back % of payments for later results

people across society are graded and in some place paid accordingly

what if I turn out to be average?

if worse, I would leave the profession

what is troubling is not just being average but settling for average

in some walks of life that may be OK

but when the stakes are our lives and the lives of our children we want no one to settle for average

For Performance

when we have made a science of performance - as we have seen with hand washing, wounded soldiers, child delivery –thousands of lives have been saved

scientific efforts to improve performance get small % of funding can arguably save more lives in the next decade than bench science

the stakes could not be higher

breast cancer: death rates fallen 25% since 1990 in industrialised countries

more than half that decline was due to increased screening

key to this working is women getting screened each year

stats: over 5 years, 1 in 7 does, over 10 years, 1 in 16

lots of reasons why the takeup is not greater including lack of reminders

$1bn spent on research but little on making screening more accessible

further 1/3 reduction possible with more screening

bigger opportunity in rest of world to raise standards just by performance

author tells story of visiting India to the town where his father was from and telling amazing stories of working with doctors in clinics

nothing especially exotic about troubles people came to surgeons with and this in itself was revealing

half patients admitted for diseases we do not see in west but unusual for them to die of such diseases

primary care and living standards improved considerably

average Indian life span 32 a few decades ago to 65 years today

very few operation slots with some queue jumping via letters from officials

what is required is rational, reliable organisation as much as resources – for surgeons in India both are in short supply

not unique to India

cardiac disease is globe’s leading killer

new lab science is not the key to saving lives – the infant science of improving performance – of implementing our existing know-how – is

these realities are demoralising

surgeons in India have persisted in developing abilities that were a marvel to witness

author thought he would be able to teach them some new things but doctors in India treat more case types than him

where they had control, e.g their skills, they sought betterment

collective cafe sessions for 15-30 mins each day swapping stories

raised their own expectations of what they could do

example of one doctor who with his team had become among the most proficient ulcer surgeons in the world

true success in medicine is not easy – requires will, attention to detail, creativity

lesson the author took from India was it was possible anywhere and by anyone even in these difficult conditions

astonishing successes could be found

each one began remarkably simply: a readiness to recognise problems and a determination to remedy them

better is possible, does not take genius, takes diligence, moral clarity, ingenuity and above all a willingness to try

Afterword: Suggestions for becoming a positive deviant

author began his new role as general & endocrine surgeon in Boston

not prepared for how small one’s place in the world inevitably proves to be

we can tend to only one person at a time

no doctor wants to believe that s/he is a bit player

people depend on us personally for their lives

hard not to feel like just a white coated cog in a machine

none of us is irreplaceable

one begins to wonder … how do I really matter?

lecture medical students, in one author decided to try to answer that question – for them and for him

5 suggestions for how one might make a worthy difference, for how one might become, in other words, a positive deviant

(1) ask an unscripted question

(from a fave essay by Paul Auster – “Gotham Handbook”)

ours is a job to talking to people, why not learn something about them?

in and amongst your questions about the medical issue, take a moment with the patient and ask an unscripted question that lets you make a human connection

if someone not interested that is fine

keep convo going for more than 2 sentences

listen, make notes of what you learn

ask others who are not patients

helps you remember who these people are so they do not blur into nothing

sometimes you will discover the unexpected

if you ask a question, the machine starts feeling less like a machine

(2) don’t complain

nothing in medicine is more dispiriting than hearing doctors complain

medicine is a trying profession, but less because of the difficulties of having to work with other human beings under circumstances only partly in one’s control

ours is a team sport but with 2 key differences – the stakes are people’s lives and we have no coaches

resist the temptation – it is boring – does not solve anything – it will get you down

be prepared with something else to discuss

see if you can keep the convo going

(3) count something

be a scientist in this world – in simplest terms, this means count something

the only requirement is that what you count should be interesting to you

if you count something interesting, you will learn something interesting

(4) Write something

makes no difference what you write or how long or what form – just write

need not achieve writing perfection but need only add some small observation about your world

do not underestimate the effect of your contribution, however modest

do not underestimate the power of the act of writing itself

because medicine is one person at a time, it can be a grind and you can lose your sense of purpose

writing lets you take a step back and think through a problem – even the angriest rant forces writer to achieve a degree of thoughtfulness

by offering your reflections to an audience, even a small one, you make yourself part of a larger world

the published word is a declaration of membership in that community and also of a willingness to contribute something meaningful to it

choose your audience

write something

(5) change

in medicine, like rest of society, individuals respond to new ideas in 1 of 3 ways:-

early adopter
late adopter
persistent sceptics who never stop resisting

make yourself an early adopter

look for opportunity to change

be aware of the inadequacies of what you do and seek out solutions

find something new to try, something to change

count how often you succeed and how often you fail

write about it

ask people what they think