Making a list, checking it twice...

I really enjoyed Gawande's book. I may read his follow-up Better: A Surgeon's Notes on Performance.

I agree with Doug that the central theme of the book is the essential human-ness of medicine, even surgical medicine. I have a couple thoughts on that front:

First, although Gawande talks about the dramatic improvement in mortality numbers among anesthesiologists, he doesn't to my recollection mention safety checklists (which is a bit odd, since Gawande has been a vocal advocate of such checklists; maybe he came to it after writing the book).

I was wondering what you think of checklists, Doug? My impression (and its nothing more than that) is that most surgeons view them as a hassle, something that is nice in theory but lousy in practice, not worth the effort, etc. And understandably so; I know the highly formalized type of check-list activities I do for work are an annoyance.

But I think the bigger issue is that perhaps doctors feel it is juvenilizing to have to run the checklist, that pride or ego maybe gets in the way. And not just for individual doctors, but sociologically within the subculture, making it difficult even for doctors who wouldn't mind running a checklist before surgery to do so in the face of colleague disapproval. I don't know; maybe all this is off-base, constructed more from fictionalized views of medicine than reality, but if it is reality I think it's a very understandable one, and one that fits with Gawande's larger narrative.

Second, I was talking with a ward member the other day about the book. Her husband is starting a two-year internship in pediatric radiology at Children's hospital in Boston. I wondered whether Americans have a tendancy to mythologize Doctors more than other cultures do, and thus have less tolerance for the human element of medicine. She said that she certainly feels that to be the case. She said she feels exactly the same sort of mistaken expectations when she tells people that her husband is a surgeon as when she tells people that her father-in-law is a General Authority.

I think we do mythologize doctors, and I think Gawande would like to temper that to some degree, and I think it is healthy to do so. I also think, however, that doctors (and society in general) also receive some benefits from that mythologizing inclination. Specifically, I think people are more likely to trust and have faith in doctors than they otherwise might. This goes to the patient autonomy question, I suppose. As Doug says, in some ways patients are terrible decision makers when it comes to their treatment options. Given the trend toward patient autonomy, eroding the myth of The Doctor could lead to even worse decisions on the part of the patient as they come to see doctors more and more as imperfect, fallible human beings. Perhaps this is why Gawande calls for a move back to the old model of doctors largely deciding what is in the patient's best interest.

One thing that Gawande didn't talk about that I think is particularly timely is the intersection of medicine and public policy. I was recently chatting with a friend who is an Air Force doctor. He went on at some length about the ways in which specialization is increasing, how it is driving policy more and more, and how general practioners are getting squeezed out as a result. His statement, if I remember correctly, is that because the Medicare advisory board is dominated by specialists, they are able to set rates that they feel are appropriate, which means the finite pot of money is increasingly split up with a bias toward recompensing specialists. This has echoes in the health care debate today as they talk about different payment models, like paying per positive patient outcome rather than per procedure. Anyway, not really on topic but something I find fascinating.

Thanks for the great read, Doug.

We've now reached the end of the second book club round. I think we should all take December off and start up again with a January selection. Anyone not on the following list who would like to make a selection, let me know either in the comments or via email: Peter, Alvin, Paul, Glenn, Rob, Doug, Jesse, Karl (Jesse and Karl, I know you've been quite busy with other things and haven't followed along with the book club this round. But if you have time I'd love to keep you in as making one selection, even if that's the only month in which you're able to participate. If you don't feel like you can do that, just let me know and we'll skip you this time around).

I'll give it until next week sometime for anyone who wants to to amend the list, then I'll use my patented, handy-dandy randomegizer to choose an order for the participants.