Harvard Public Health Review
The Pen and the Scalpel
Surgeon and acclaimed writer Atul Gawande probes problems at the intersection of surgery, public health, and human experience. His goal is to boost quality and reduce error.
Atul Gawande is a scribe with a scalpel: a surgeon-scientist and National Book Award nonfiction finalist who writes for both The New England Journal of Medicine (NEJM) and The New Yorker. Wielding cautery and cursor with equal grace, he probes a broad range of thorny issues in medicine and public health, from the fallibility of physicians to the question of how India's health system copes on less than $20 per person per year. By casting doctors and patients in a deeply human light, colleagues say his stories will impact medicine in ways few studies can.
Gawande, an assistant professor in the Department of Health Policy and Management at HSPH, is known for raising questions that haven't been asked before. Last fall, when American casualties in the Iraq and Afghanistan wars hit the 1,000 mark, Gawande began wondering about the nature of soldiers' injuries and the military's strategies for saving lives. In October, he arranged to spend a day at the Walter Reed Army Medical Center in Washington, D.C., reviewing patients' status with Army surgeons as a visiting surgeon. During routine "war rounds," he learned that the Army's databank held death and injury statistics that were posted on the web, but had yet to be analyzed in any coherent way.
The startling result of this day trip--a report for NEJM titled "Casualties of War: Military Care for the Wounded from Iraq and Afghanistan"--is trademark Gawande: a combination of aggressive reporting and fresh-eyed analysis, with major implications for health policy. The article, published on December 9, 2004, ranked 5th on NEJM's "top 10" list of stories receiving the most media coverage that year. Its message reached millions around the world.
What Gawande reveals is a dramatic evolution in the nation's system of battle care. The death rate among the wounded is just 10 percent, the lowest in U.S. history, he writes. Thanks to a new triaging system, body armor, and lean, mobile surgical units, surgeons are now saving soldiers who once would have died--even those with horrific head wounds and hopelessly mangled limbs. No longer can body count alone be taken as a measure of war's intensity.
While the article highlights the triage system's astonishing successes, it also exposes unsettling problems. General surgeons are in short supply. Hospitals are overwhelmed by Iraqi civilians who need care. Drug-resistant bacteria are epidemic. And the future of unprecedented numbers of severely disabled young veterans is an open question, Gawande writes. Will society be ready when they come home?
GAWANDE IS GLAD SOMEONE'S paying attention. His goal, after all, is improving health systems--which for surgery means doing research to boost safety and curb errors. In the U.S., he says, the stakes are high: The average American undergoes nine surgeries in a lifetime.
Like most surgeons, Gawande, an assistant professor of surgery at Harvard Medical School, is driven by an impulse to fix what's broken. But his public health perspective--emphasis on prevention--is unusual. When he's not treating patients one by one as a general and endocrine surgeon, he's asking questions that will impact thousands: What are the patterns by which avoidable complications occur? What changes to systems and procedures might make surgery safer?
and slender, Gawande, 39, projects a steely self-assuredness. But
colleagues say he is far from the surgeon stereotype--the cocky fighter
pilot, Napoleon with a knife. His relaxed, candid style invites lively
back-and-forth exchanges. On a vacation break in Colorado with his
wife, Kathleen Hobson, and their three children, he talked by cell
phone about his goals as director of research for the new Center
for Surgery and Public Health, a collaboration between HSPH and
Harvard Medical School based at Brigham and Women's Hospital.
"Through work others have done, we know that practice makes perfect, and that volume seems to matter," he said. "But given the fact that most surgery in the U.S. is not done in high-volume factories--it's done in rural and suburban settings, in community hospitals--the puzzle for us is, How do we make surgery something that's consistently done well, no matter where you go?"
Gawande's interest in quality and safety is a switch from his former focus on health care financing. In 1992, Gawande took a year off from Harvard Medical School to work for President Bill Clinton as a health policy adviser. But as a surgeon-in-training at Brigham and Women's, he remembers, "The things that troubled me day to day were everything from, 'How was I allowed to practice on people?' to 'How do we deal with patients' complications?'"
To keep his hand in the public policy discussion, Gawande started vivisecting his training experiences in an on-line column for Slate. The New Yorker's editors took note. His third story for the magazine, "When Doctors Make Mistakes," was a riveting account of his and others' fumblings that fingered systems failures, not bad doctors, as the chief cause of medical errors. In 2002, this essay and others were published by Henry Holt and Company as Complications: A Surgeon's Notes on an Imperfect Science. In addition to being a finalist for a National Book Award, the book was named Amazon.com's best nonfiction title, and Time magazine called it one of the year's five best. To date, Complications has sold roughly 250,000 copies in the U.S. Asked how many have been distributed in the other 100 countries or so where the book is in print, Gawande says he has no idea.
Blending case studies, personal reflections, and hard-edged reporting, Gawande's essays float across issues, from what doctors should do about incompetent colleagues, to whether a global campaign against polio makes sense, to the byzantine system by which American doctors make money. With a piercing insight that can be discomforting even to himself, he reveals an esteemed profession to be a flawed, uncertain enterprise, yet one that will inevitably improve as long as physicians are willing to engage in self-scrutiny.
HSPH's Lucian Leape, the dean of medical errors research and a longtime member of the Health Policy and Management faculty, says Gawande's writing has been a tour de force for the patient safety movement. "Atul will have more impact than almost anyone around because of his ability to get people to think about themselves in a different way," he predicts. A former pediatric surgeon, Leape launched the movement in 1994 by showing that in the U.S., as many as 98,000 patients die from preventable errors each year.
don't think we've ever had a writer like Atul in medicine. He's our
Mozart," Leape says. "It's not his style, it's his insight--his
soul. Yes, you can do studies. But Atul will get people to change
how they do things."
Ironically, Gawande wasn't keen on studying at HSPH. He already had several degrees, in political science, biology, ethics, and medicine. But his boss at Brigham and Women's, Chairman of Surgery Michael Zinner, urged him to get an MPH. In 1999, Gawande did just that, starting with the School's summer Clinical Effectiveness Program, which he calls "unbelievably fabulous."
At the School, Gawande got hooked on errors research. For his first errors paper, he helped other researchers analyze 15,000 patient records from Colorado and Utah hospitals. Three percent of patients suffered death, disability, or a prolonged hospital stay from some form of error, the researchers found. Two-thirds of mistakes occurred in surgery, either in the OR or in decision making outside of it. Half of these missteps--among them, postoperative bleeds, wound infections, botched technique--were avoidable.
What were their causes? Gawande wondered. "People have suggested everything from fatigue, to a lack of nursing staff, to HMOs, to bureaucracy, to experience--whether you have a high-volume surgeon or not," he says.
To learn more, he modeled his next study after one that had helped make anesthesiology dramatically safer a few decades earlier. By interviewing surgeons about mistakes they had made, he identified risk factors for error. The Number One factor was inexperience: surgeons had either been in training or were doing procedures new to them. Number Two was communications breakdowns. Gawande and colleagues are now re-evaluating these results by mining malpractice case files, which are rich in detailed documentation regarding how surgical care goes wrong.
A 2003 study thrust Gawande into the media spotlight. He investigated how "retained objects"--clamps, retractors, sponges--got left inside patients, despite nurses' long-standing practice of counting them. These problems seemed so crazy--so blatantly negligent--that they inspired a prime-time monologue by comedian Jay Leno.
What kind of idiot would leave a retractor in a patient?' is what
we all think to ourselves," Gawande muses. The consequences
can be serious, he says, "because at a minimum, we have to take
patients back to the OR."
A key question was: Are such failures due to people? Or systems? "I went in thinking, 'Maybe it's people,'" Gawande admits. "But it turns out it's systems. People were following the rules, but stuff still got left in patients." Three factors put patients at highest risk: emergency procedures, unanticipated changes in a procedure, and obesity.
That study is exciting, Gawande says, because it points to potential solutions. His team is now testing a form of bar-coding technology--"what you see in grocery stores"--to keep track of sponges, the item most commonly left in patients. Come next winter, the researchers should know whether this tactic works.
Some risk factors are hard to tease apart, and harder still to modify. Take experience. Is it a matter of practice? Age? To find out, Gawande and his collaborators will enlist young surgeons in their first three years out of training (surgeons, in fact, like Gawande himself, who's now two years beyond his eight-year residency). Their patients will be divided into two groups. One group will get usual care. For the other, the young surgeons will verbally walk through each case with a senior surgeon before heading into the OR. What the researchers want to know is, will a preoperative review with a more experienced practitioner cut down on patients' complications?
It's essential to test ideas before changing practice, Gawande warns. Without data, there is no proof that a new strategy will work, and no reason for doctors to change their behavior. There is also no hope of transforming an entrenched culture that blames individuals, not systems, when things go wrong.
GAWANDE SAYS HE'S STRUGGLING A BIT to set research priorities. "There are just so many wide-open avenues," he says. In the long run, he wants to look beyond the U.S. to developing nations.
It's an interest reflected in his New Yorker stories, where he has described the World Health Organization's campaign to eradicate polio, and in NEJM, in which he chronicled his two-month journey into the gritty realm of public health care in India, his ancestral home. In that nation of one billion people, skilled surgeons have scant resources to treat complex chronic diseases, such as cancer and diabetes. To skirt long waiting lists, even the poor scrape cash together to pay for private care. To tackle the enormous problems of resource-poor nations, the Center for Surgery and Public Health will equip surgeons with public-health skills in epidemiology, statistical analysis, and other realms, Gawande says.
his research continues, so too will his writing. "In every piece,
I try to ask and answer questions at the edge of what we do, and
offer solutions based on whatever evidence is available," he
explains. "I find I can answer more questions by getting deeply
inside a story than I can spending two years on a clinical trial."
Gawande is modest about what his writing has accomplished. His colleagues are in awe.
Says HSPH's Leape: "Through The New England Journal of Medicine and The New Yorker, Atul is preaching to the right people--policy makers, the people in the power structure in health care, politics, government, academia." He chuckles. "If Atul had Good Housekeeping, he'd have a trifecta."
HSPH Professor Don Berwick, leader of the influential Cambridge-based Institute for Healthcare Improvement, says he's "amazed" by the wave of positive email that hit him after Gawande's "The Bell Curve," a New Yorker essay published in December 2004, within three days of "Casualties of War." In part, the essay describes Berwick's role in persuading U.S. cystic fibrosis centers to share their highly variable treatment results with patients. Gawande uses one patient's tale to expose a harsh truth: Doctors' and medical centers' performance ranges from outstanding to poor, with most falling somewhere in "the great undistinguished middle." This reality is disturbing, Gawande writes. But patients will suffer as long as doctors resist measuring, and revealing, their successes and failures.
According to Berwick, whom Modern HealthCare magazine calls the third most powerful man in U.S. health care, Gawande's stories about real people grip doctors in ways that research studies don't. "When I talk with doctors, the technical view has no traction; it doesn't speak to them," says Berwick, a professor of Health Policy and Management at HSPH and of clinical pediatrics at Harvard Medical School. "During an intellectual discussion about data, doctors tend to distance themselves from the content, and the passion is gone. You're only dealing with one side of the brain, and the resistance to change seems to be on that side. But when you tell a story, doctors can draw on an experience, an emotional response, from their own lives."
Gawande's own assessment is restrained. "I've heard from pediatric pulmonologists who say they've changed the way they practice, and from patients who want to know, 'Is my center in the top five?'" he says. "That story has brought home how variable care is, how much measuring our outcomes matter, and our uncomfortable sense that we have to be held accountable to patients."
And as for the impact of "Casualties of War"? Gawande is skeptical that his piece will change the lives of soldiers or military physicians. There is no very scientific way to measure this, in any case. But according to his contacts in Washington, many Congressional leaders have requested details and budget figures in the wake of that article, he says. Meanwhile, other researchers' investigations of soldiers' injuries are getting media play. The issue is on the front burner.
Gawande's expectations are high for the new Surgery and Public Health center, which will bring public health's population-based, systems-oriented mindset to surgery. But he has "miles to go," he says, before he'll feel satisfied, either as a surgeon or as a writer.
" I'm very nervous about being graded myself," he admits. "I'm far from being as good as I want to be."
Karin Kiewra is the editor of the Review and associate director of Development Communications for HSPH.
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