More Better

I wanted to share more thought occasioned by reading Better: A Surgeon's Notes on Performance by Atul Gawande.

Eradication of Smallpox and Polio

Gawande argues in the first part of the book about the importance of diligence in medicine. It would seem hard to argue against diligence, but he points out that people go well beyond what most people would consider "due diligence" in medicine. He made me think about WHO's success in the eradication of smallpox and the campaign to eradicate polio. Think about an effort in which you start out with an endemic (and sometimes epidemic) disease affecting tens of millions of people a year and deciding that no one will ever get the disease again after your campaign. Think about the diligence involved in immunizing 90 percent of all the people in the world, and maintaining that herd immunity for an extended period. Moreover, there can not be allowed to remain any pocket of the world's population in which herd immunity decreases to the point that endemicity will occur until there is no longer any source of infection anywhere. He describes an outbreak in India in which public health officials mobilized to immunize five million people -- doing the mobilization in a month and the campaign in three days. Were we equally diligent in other development programs, great things would be accomplished/

Gawanda notes that people in the local communities he visited thought the money spent on polio could be more effectively used to combat other diseases that were more prevalent in their communities and caused them greater morbidity, disability and/or death. Makes you think! I suggest that these campaigns are fully justified on a global scale -- the benefit to the world of eradication of smallpox or polio is more than enough to justify the cost of the campaign. It is just hard for people at the local level to appreciate the external benefits realized on a global scale by mopping up the last vestiges of such a disease. The better question is why the world does not mobilize the resources needed to deal more adequately with the remaining health problems in every community.

Battlefield Medicine

In a recent posting I mentioned Gawand's account of the great effectiveness achieved in battlefield medicine in Iraq. Gawanda attributes this feat also to diligence, and surely the medical professionals providing field and backup medical attention in difficult circumstances deserve credit for exceptional diligence. I was impressed however that cutting battlefield mortality in half was also due to prevention -- flak jackets and other protective gear -- as well as getting the wounded attended to in the "golden five minutes" after being wounded. These in turn are the result of good operations research studies of the medical system and good implementation of their results.

Insurance Versus Litigation of Malpractice

In another chapter of the book, Gawand makes the point that doctors are human, and make mistakes in spite of their training and professional dedication. Indeed, they have momentary lapses of attention and make errors that they should not have made. Indeed, sometimes they follow what seems to be the right course, and would be seen as such by their peers, and things work out badly. Mass immunization is the right course for public health, but some immunized people have reactions.

In the United States, in our litigious society, we sue for malpractice a lot. Doing so probably helps make doctors even more diligent in their practice, but it does not and can not eliminate all error and bad consequences of medical practice. Unfortunately, relying so heavily on malpractice litigation costs a lot in process expenses, does not get much to most people who have suffered from the negative outcomes of treatment, and hits too many physicians for merely making human errors.

In some cases, countries have simply created a pool of funding to be distributed to those people who suffered adverse affects of medical interventions, avoiding the blame game entirely.

Peer review and better education are perhaps a better mechanisms for minimizing human error in medical practice than is malpractice litigation.

Of course, there are forms of malpractice that require legal intervention, and even criminal penalties to control. But major reforms of our medical culture might be a very good approach.