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Better

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Tracy Cleary

on 12 November 2013

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Transcript of Better

Better

Atul Gawande

The Book
How does the title of each section and the titles of each "chapter" reflex on what is being spoken?


The Score

(Pg 174) Doctors introduced infection because they examined more infected patients than midwives did and because they failed to watch their contaminated hands. (Semmelweis)

(Pg 179) "Doctors may have had the right tools, but midwives without them did better"

How can we relate this back to what was discussed in the TW book?
In what ways has childbirth been "medicalized"?




Cesarean Sections- never a real option until the late 19th century when anesthesia and antiseptics were regularly used and the 20th century when a double-layer suturing technique could stop the open uterus from hemorrhaging. (Pg 177)

(Pg 197)
Are C-sections safe?
Americans are skeptical but Britain and Israel believe they lover maternal morality.

(Pg 198) The Skeptics: C-section delivery suspiciously convenient of obstetrician's schedule's, paid better for hour than vaginal birth, fear of malpractice suits make obstetricians preform more c-sections.

What do you think?
For Performance
The convenience of necessary checkups such as mammograms. They're time consuming, uncomfortable, expensive, and we blame women themselves for not looking into their health earlier.

Because this issue exists on an international scale, how would we go about ameliorating this situation?

In Uti, (Gawande's father's hometown)

Interesting clinical practice of medicine: if villagers are sick they visit a health center where a doctor comes once a week to preform procedures. If they need desperate help, they are sent to a small, nearby hospital. If it is an emergency, they are sent to a larger hospital 75 miles away.

How does this show the culture in India and represent their current health care situation?
Terrible Living Conditions- not enough beds to house patients. Beds had to be shared for adequate treatment to be administered.

How would you feel if this was also occurring in the United States?


Rather than using equipment to confirm most illnesses, nor adequate history, physicians were required to rely on their experience and judgement to make a diagnosis.

How is this connected to the history of medicine that we have studies? Is India still living in America's past?
Physicians/Surgeons often had to have experience in multiple fields rather than specifications within their field because specialists were rare. "They compromised out of necessity".
How does this connect to what we know about the evolution of medicine?


No waiting lists- Surgeons took patients with the most pressing issues and when resources were available.
How would that go over in the United States?

Death from disease that formally plagued the county such as waterborne diarrhea, tuberculosis, and malaria is now rare due to the improvement in both living conditions and primary care in India.

Simple surgical procedures could not occur or could be deadly due to lack of resources, patients often had to find their own supplies.
The Bell Curve
(Pg 205) The Bell Curve shows most doctors and hospitals provide average care and average outcomes.

Gawande makes a point to note how people rank doctors and hospitals.
Is it valuable? Is there a fair way to do it? Do you see the connection to what is happening here to what is also happening to school teachers?
(Pg 227-228) "Paying for quality" and "docking for mediocrity"
Is it helpful or harmful?

Why are some doctors considered "better" than others?
Cystic Fibrosis has been far ahead of other medical fields in the levels of care

LeRoy Matthews view was different, he saw a disease that wasn't out of nowhere but as a cumulative disease (Pg 210)
---Treat before symptoms are visible
After the Warwick report, CF care around the country changed to follow Matthew's method

Should other diseases be approached this way?

What do you think are some factors preventing other fields from having the same degree of care measurement that Cystic Fibrosis care has?
Doctors are not keen on acknowledge the bell curve because everyone is expected to give patients the best chance of survival, but according to the bell curve, some patients will have a better chance than others depending on where they go for treatment.

Do you think that is so?

Obstetrics Methods to save lives: (Pg 176-177)

Crochet/Cranioclast
- a long, sharp pointed instrument, often with a claw-like hooks, which birth attendants used in desperate situations to perforate and the fetus's skull, extract the fetus and save the mother.

Loveset Maneuve
r- a breech baby with it's arms trapped above the head, you take the baby by the hips and turn it sideways, then take an arm and sweep it down over the chest.

Mariceaumellie- Veit Maneuver
- you place your finger in the baby's mouth, which allows you to pull forcefully while still controlling the head.

Woods corkscrew maneuver
- reach in, grab the baby's posterior shoulder, and push it backwards to free the child.

Rubin Maneuver
- you grab the stuck, anterior shoulder and push it forward toward the baby's chest to release it.

McRoberts maneuver
- sharply flex the mother's legs up onto her abdomen and lift her pubic bone off the baby's shoulder


Nameless maneuver
- fracture the clavicles and pull the
baby out.

Apgar
: the first woman to be admitted to the surgical residency at Columbia University College of Physicians and Surgeons in 1933 (Pg 185)

-Babies born malformed, too small, or just blue were placed out of sight to die
-Apgar scale was developed to rate newborns on a scale from 0-10.
-Doctors got competitive to get better scores


"Evidence Based Medicine" (Pg 188)
How research physicians believed a profession could advance, the idea that nothing ought to be introduced into practice unless it has been properly tested and proved effective by research centers

A major shift in valuing the life of the mother more than the child to valuing the life of the child more than the mother.
We rate the babies health, why not the mother's?
What caused this?

Is medicine a craft or an industry?
-If medicine is a craft then you focus on teaching obstetricians to acquire a set of artistic skills. Many baby techniques needed skill and mastery. (Pg 192)

-If medicine is an industry, responsible for the safest possible delivery for about 4 million babies a year in the US alone. Reality of the fact that 42,000 obstetricians could not safely master all the techniques. Aim for the predictability with the highest possibly number of outcomes.

Factors Influencing Medicine

Access (Pg 214)- "As medicine tries to cope with advancing complexity of knoledge and treatment, it is falling short in preforming even the simplest of its tasks.

Malpractice (Pg 87)- "Malpractice suits are a feared, often infuriating, and common event in a doctor's life... the cost of defense is high, and when doctor's lose, the averge jury verdict is half a million dollars"

Profits (Pg 125)- "They weren't going to make more money seeing these unnecessary patients, and they found a way to make sure we became more efficient.

How Factors differ in Military Medicine
Malpractice- Service members are not able to sue providers
Profitability- Absense of a medical market place and the competition that results
Access- Often lack the convenience of referring patients to specialist and access to advanced treatments forcing providers to be well rounded and efficient.



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