If you are one of the growing number of older Americans who scan the newspaper obituaries of strangers—at what age did the Grim Reaper strike, and how?—Atul Gawande’s new book is for you. But it is not for the elderly alone. This is the fourth of the Boston surgeon’s book-length discussions of modern medicine, its frontiers, its promises and hazards. Its easy, informative style will be familiar to those who read his medical pieces in the New Yorker.
For most of human history, as Gawande has observed, ignorance was the handicap of medicine. Think, for instance, of the bleeding for routine bronchitis that probably killed George Washington and the obstinate ignorance of germ theory before Joseph Lister. As recently as the 1950s, specialists in heart disease (then, as now, the number-one killer, though lately much ameliorated) were, by today’s standards, clueless. Now the cure of coronary artery disorders is all but routine.
But this isn’t a recipe for complacency. With ignorance vanquished in so many areas of medicine comes the challenge of underperformance—“necessary fallibility,” as Gawande calls it. Today there is far more know-how: A recent World Health Organization inventory identifies some 13,000 treatable conditions, syndromes, and disorders. But know-how is often bypassed or ignored in ways that Gawande, who practices endocrine surgery, discusses with candor. He is a physician who levels with the public (and his own patients) about the limits of treatment and the stark failures, including his own. As he puts it, surgeons still “practice on people.” There is no other way to learn the craft.
Two of his major causes stand out. No other physician, so far as I am aware, has done more to promote two simple, nontechnical precautions: hand-washing, a miraculous preventative of infections; and the checklist, borrowed from aviation, which is of special value in operating rooms. In The Checklist Manifesto (2009), he describes how, in the early days of human flight, those who flew airplanes learned, by deadly failures, about the risk of overlooking routine steps (enough fuel for the distance?). The remedy was the checklist, which captains may be seen going through today, no matter how experienced or how familiar the prospective journey. Gawande helped plan and conduct a recent WHO global study of operating-room procedures in eight countries. The results were so startling as to be at first disbelieved: “The rate of major complications for surgical patients in all eight hospitals fell by 36 percent after the introduction of the checklist. Deaths fell 47 percent. . . . Infections fell by almost half.”
These outcomes show what happens when practitioners surrender smugness and run through a simple list of steps. As for the precaution of hand-washing, it has been a struggle, but a fruitful one, to persuade doctors and nurses (and the public) to wash hands effectively and to use the antiseptic gels that had become routine in Europe.
It seems clear that it was the recent decline and death of Gawande’s father—a surgeon with a large urological practice in Ohio, where Gawande grew up—that inspired Being Mortal, whose subject all must face.
Gawande has since undergone a humane education, though his profession is still short of geriatric specialists. His theme here is that the care of aging and death has been over-medicalized: Half of lifetime medical outlay in the United States occurs in the last six months of life, and the question is, for what benefit? “The experiment has failed,” he says, in part because physicians are fixers, trained to treat remediable conditions. But for many of the elderly, there is an equal if not greater need for relief from boredom and depression, and for being allowed personal autonomy: We wish, above all, “to be allowed to remain the writers of our own story,” as did Gawande’s father.
Gawande is an advocate of the relatively new idea of “assisted living,” which aspires to “sustenance of soul,” autonomy, and privacy. He tells the story of one innovator in the field who designed a facility with locks on doors and who flooded his nursing home with parakeets, dogs, and cats, causing patients to take a new interest in life and, far from incidentally, causing a drastic drop in medication and death: “The number of prescriptions . . . per resident fell to half that of the control nursing home. Psychotropic drugs for agitation, like Haldol, decreased in particular. The total drug costs fell to just 38 percent of the comparison facility. Deaths fell 15 percent.”
A confession: I can’t write impersonally about the author, whom I have known as a friend and as the son-in-law of close friends since his college years, when he began to court my wife’s sometime ballet student, a fellow student at Stanford. He and I had shared a common privilege: study at Oxford on the same coveted scholarship. Beyond that, however, I have watched his growing knack for transforming medicine—a sometimes prosaic if fascinating subject—into art. It seems that, in his younger days, someone had admonished him: “To be a writer you will need something to write about.” Could I have said anything so pompous? I hope not, and he denies it. But whether or not I said it, he has found “something to write about.”
Edwin M. Yoder Jr. is the author, most recently, of Vacancy: A Judicial Misadventure.
