Insights from Better: A Surgeon's Notes on Performance

Gawande’s Better is a well-written reflection on his career as a surgeon. Here are some things I learned (comments/caveats in brackets):

• Hospitals do a lot of work to try to make sure people don’t get infected while at the hospital. Despite this, hospital infection rates are very high [internet says about 1/30]. During a surgery, there is a person on the team whose job it is to interface with the outside world, preventing other members of the surgical team from having to get dirty and rescrub.

• During the Persian Gulf War, soldiers were getting injured because they weren’t wearing their Kevlar vests. Researchers examining the data noticed this fact and once officers were held responsible, soldiers started wearing vests more consistenty and battlefield fatality rates dropped. In another case, surgeons noticed a high incidence of blinding injuries. Turns out soldiers weren’t wearing their eye protection because it was ugly.

• Typical general surgeons work 63 hours per week. There is a standardized table created by some government to decide how much surgeons can bill insurance companies for various services. This table doesn’t get updated very often, so the pricing of many things aren’t calibrated to current technologies that might make some surgeries much easier, e.g. cataract surgery. Some surgeons only deal with cash and command much higher prices. [I’ve paid like 5k for SMILE eye surgery that seemed like it was basically all done by a really fancy laser, with the surgeon doing some small manipulations at the end.]

• A quote about the development of forceps, and instrument for manipulating babies still in the womb to allow for less dangerous births:

  • The story of the forceps is both extraordinary and disturbing, because it is the story of a lifesaving idea that was kept secret for more than century. The instrument was developed by Peter Chamberlen (1575–1628), the first of a long line of French Huguenots who delivered babies in London. It looked like a pair of big metal salad tongs, with two blades shaped to fit snugly around a baby’s head and handles that locked together with a single screw in the middle. It let doctors more or less yank stuck babies out and, carefully applied, was the first technique that could save both the baby and the mother. The Chamberlens knew they were onto something, and they resolved to keep the device a family secret. Whenever they were called in to help with a mother in obstructed labor, they ushered everyone else out of the room and covered the mother’s lower half with a sheet or a blanket so that even she couldn’t see what was going on. They kept the secret of the forceps for three generations. In 1670, Hugh Chamberlen, in the third generation, tried and failed to sell the design to the French government. Late in his life, he divulged it to an Amsterdam-based obstetrician, Roger Roonhuysen, who kept the technique within his own family for sixty more years. The secret did not get out until the mid-eighteenth century. Once it did, it gained wide acceptance. At the time of Princess Charlotte’s failed delivery in 1817, her obstetrician, Sir Richard Croft, was widely reviled for failing to use forceps to assist. In remorse for her death, he shot himself to death not long afterward.

• The Apgar score is a way to rate babies on a 10-point scale on color, crying, breathing, limb movement, and heartrate. It’s a very simple way to measure how “healthy” a baby is and thus how “good” the birth was. It’s plausible that the development of this scale had a big effect on allowing faster iteration on birthing methods, drastically reducing death rates. In the US today, a full-term babies dies 1/500 of the time and a mother 1/10,000. [I’m kind of suspicious of “the development of the score was super important” kind of stories because it generally feels like there’s other stuff going on behind the widespread adoption of stuff that basically probably everyone knew. Perhaps it isn’t a huge tragedy that no one was being systematic before the Apgar score. I wouldn’t be surprised if it was a big tragedy, but I wouldn’t be that surprised if the story is much more complicated either.]

• Foreceps and c-sections are two ways of delivering babies when things get complicated. In studies, properly used foreceps result in outcomes that are comperable to c-sections with much less recovery time required by the mother. However, the use of foreceps is very hard to teach because it requires giving feedback on the use of the instrument when it’s out of sight. C-sections are very easy to teach because the teacher can see everything the student is doing. As such, the c-section has become the standard for tricky births. In the US, about 30% of babies are delivered via c-section.

• In India, hospitals often don’t have enough medical equipment to treat people. There are also stores in India that sell medical equipment. [Not sure why these two things are simultaneously true, probably money reasons.]. Sometimes, people will come in for an examination and the doctor won’t have the necessary equipment, so they’ll write the patient a perscription for that equipment. If the patient is able to buy it for themselves, then they can get the procedure done. [Not sure if this is the full story, parts of it don’t seem to make that much sense].