I stumbled on to “Better” at a crossword store in Mumbai. Picked it up immediately after spending a minute browsing through the book… The book turned out to a great read.

So, with that experience behind, I ordered the other two books written by the author Dr. Atul Gawande. His first book which is extremely popular is “Complications”. “Better” is his second book and recently he came out with a book titled “Checklist Manifesto” . With very high expectations, I began reading “Complications” and by the end of it , the book did not disappoint me.

This book talks various incidents in the medical field under three themes which are Fallibility, Mystery and Uncertainty .

image Fallibility

The image of bad doctors ,for most of us  , are doctors who do evil things with their patients. However the author recounts a different experience. There are lot of good doctors who become bad doctors, and what he means by bad, is that they unknowingly do harm to the patient , more so because of their personal problems. Be it divorce , alcohol, burnout , or plain neglect to be constantly aware of the patient needs drives some of the doctors to do more harm than the status quo of the patient. Some doctors , as it seems, forget the nature of human fallibility and the consequences of dealing with such doctors becomes rather tricky for the hospital and the supporting staff.

For people like me, who have no clue what goes on in the medical world, it was interesting to read about the way doctors learn from their mistakes, individually & collectively.  The author mentions about M&M, Morbidity and Mortality conference where the docs talk about their mistakes. The purpose of such meeting is to discuss faults, failures in various surgeries that were undertaken by the respective hospitals.

Another interesting aspect mentioned about the field of anesthesiology is the way the docs are prepared and trained. A life size computer driven mannequin is used to to train anesthesiologists. It reminds me of the book “Talent Code”, where there are umpteen number of examples where learning was accelerated when there was an environment to make errors and quickly learn from them. The computer driven mannequin served the same purpose. With out harming any real human being, the docs learnt about various errors and hence they could deliver superior performance in the real world.

I can related one thing I have been doing for the past few years ONLY, though I should have done this much much earlier. Whenever I learn something , I try to simulate data and examine the results, rework and get the formula / estimate being talked about. Simulating data and then working on this data has given me an idea about the things that could go wrong in an analysis. I can test all sorts of bias and see whether my analysis holds good.  I have increasingly started living, examining, testing in this artificial simulated world for the real world offers very few data points and the mistakes , if they happen, you pay a heavy price.

The book talks about Shouldice hospital, a case in point of specialization and focus. In most of hospitals 10-15% of hernia operations fail. But not at Shouldice hospital. Why ? What’s so special about this hospital ? Well, it turns out that Shouldice hospital employs about dozen surgeons who don’t do anything but hernia operations. They do about 680 hernia operations per year , more than a surgeon would do in a life time. So, this repetition of the same type of operation day in day out, changes the way the docs at Shouldice hospital think about their problems. In Gladwell’s words, may be the sheer # hrs logged by the docs performing hernia operations makes them outliers. In Gawande’s words, Repetition changes the way the docs think. Most of the activities are done automatically with doctor’s mind focused on those little nuances of the patient’s health which are crucial to the make or break of an hernia operation.  This is a beautiful case which shatters the myth that doctors should dish out individual customized treatment. Well it sounds good in theory, but as far as stats are concerned, systems , error induced learning, # of hrs logged in doing that activity play a far more important role in the overall success rate of a hospital , in the context of a specific surgery.

“The key then to perfection is routinization and repetition”

So, to think of it, if a job at a company is routine and repetition, then probably there is a chance for you to master something. If you are working on multiple projects in a year, ya , you might know a lot of things , but it is unlikely that you will master something!! . When you hear your friend / coworker saying “ My job sucks because it is routine..”.. Well,  I guess you can sympathize with them not because of the situation they are facing, but because they are not utilizing the situation that something is routine and repetitive , to master it.

The author mentions another interesting point about high performance surgeons versus the rest. He quotes a few research studies which bring out the point that , highly successful surgeons are those who are willing to engage in sustained training. Skill and Confidence in surgery is learnt through experience, haltingly and humiliatingly. So, one’s willingness to practice is all that matters. High performers are clearly those who put in a greater amount of deliberate practice. This means that,

“The most important talent may be the talent for practice itself”

image Mystery

This part of the book deals with various mysteries surrounding the field of medicine, which we outsiders think that docs have all the solutions in the world. The author takes the reader through a few essays that deal with issues that doctors consider it a mystery . Some of the mysteries explored are the mystery of pain in a human body, mystery of nausea , mystery of blushing in a person, mystery of overeating. With specific instances for each of these above mentioned issues, the author drives home the point that science has no clear cut answers to identify symptoms and offer remedies to the patients.

image Uncertainty

In the world of stats, there is a term called “ Aggregation Bias” . This basically means that if you observe an effect at a global level, you cannot generalize at a local level. For example, if you think have data from all the major cities in India about 2 variables, Y being income levels, X being % educated population . Lets say you make a model out of these two variable only. You might see some effect of education on the income levels. Can you generalize it to every person in every city..No ..This effect is valid at a city level. By applying it to an individual, you are assuming that the city and % educated population are independent. Are they ? They need not be and in most cases they are not. So, this aggregation bias is a killer for most of the social sciences papers that have been published..You see some effect at a macro level but you cant say anything at a local level.

Ok, why is the above stuff relevant to the book? Well, doctors are trained on general rules and general symptoms etc. Basically you can think of it as imparting education at a macro level. However when they work with the patients, do those rules, heuristics, education etc help ? Well , to some extent says the author. More likely it is not going to help . Author gives an analogy of ice cubes. If you study the properties of a set of ice cubes, you can be reasonably sure about the property of an individual  ice cube..Alas!! humans are complex species. So, the doctors always face uncertainty in dealing with their patients and this part explores a few uncertainties that are part of everyday life of docs.

image Takeaway :

The book is a real page turner which gives one , an insider’s look in to the medical field. Your understanding about Fallibility, Mystery and Uncertainty will definitely be more richer after reading this book.