One surgeon's prescription for better care: Diligence

At 7 a.m. Tuesday, Atul Gawande stood behind a big wooden lectern in the auditorium of the Children's Hospital of Philadelphia, lecturing on "The Idea of Performance in Medicine."

Based on the title, it could have been a real snooze-fest. Indeed, continuing-education seminars for hospital staff usually end with a rush for the doors.

But this one was different. Gawande, 41, is a Harvard-educated general surgeon, Rhodes scholar and winner of a MacArthur "genius award." He is also a prolific writer (New Yorker magazine, New York Times, slate.com) on a provocative topic: the imperfections of our health-care system.

His just-published second book, Better: A Surgeon's Notes on Performance, offers a keen-eyed look at the human frailties and foibles that make medicine almost as much luck as science. He concludes that unglamorous virtues - diligence, ingenuity and doing the right thing - distinguish those who perform better.

"The trick of it is to understand that failure is easy," Gawande told his audience here, sounding rehearsed but not stagey. "It's just a decimal point away as you write a prescription. It's just a slip of the hand in the operating room."

James Steven, Children's Hospital's chief medical officer, invited Gawande to speak - and waited six months for an opening in his schedule - because "he's obviously a thought leader."

If that sounds pretentious and preachy, Gawande is neither. In his essays and interviews, he fondly describes his parents, both doctors who emigrated from India. He recounts his young son's heart surgery. And he gratefully credits his wife, Kathleen Hobson, for enabling his frenetic professional pace by being the "backstop" for their three children in Newton, Mass.

In seeking examples of betterment, Gawande has examined the mundane to the miraculous: the problem of clinicians spreading germs by not washing their hands between patients. (He admits to lapses in his own practice at Brigham and Women's Hospital in Boston.) The improvement in soldiers' mortality rates during the Iraq war, despite a lack of better technology. The daunting campaign to eradicate polio in India, one of the world's last reservoirs of the disease.

Last week, he focused on the example of two top-notch hospitals that treat children with cystic fibrosis, a genetic disease that clogs lungs with infection-prone mucus.

Visiting each, Gawande couldn't see why one hospital had better results and survival rates than the other. Then he watched the "stooped, frumpy-looking" 76-year-old director of the better program exhort a recalcitrant, tongue-studded teenager to be more diligent about her daily breathing treatments, even though her pulmonary function tests had worsened only slightly.

"He believed that excellence came from seeing, on a daily basis, the difference between being 99.5 percent successful and being 99.95 percent successful," Gawande said. "Many things human beings do are like that, of course: catching fly balls, manufacturing microchips. Medicine's distinction is that lives are lost in those slim margins."

His talk was inspiring, but to his fans it also had to be familiar. The night before, as commencement speaker at the University of Pennsylvania School of Medicine, Gawande gave a condensed version of the same address, which was based on one of his published essays, which became grist for his new book.

Might he be in danger, a reporter asked as he left the lectern, of becoming stale or overexposed?

The answer had to wait. He was rushed into the hallway to sign copies of Better and his first book, Complications: A Surgeon's Notes on an Imperfect Science, which were being snapped up by the dozens.

Despite the din, he chatted briefly with each purchaser. Before running off to catch a 10 a.m. flight, he answered the question.

"I'm not so much worried about overexposure," he said. "But I am worried about getting ahead of myself, about not having enough time to do the research before I say something. It took me a year to write an essay on aging for the New Yorker. Now, I have to do two articles for the New York Times - in a month."

In other words, he's struggling to practice what he preaches about that underrated virtue of diligence.

View book reviews, interviews and a gallery of photos via http://go.philly. com/health

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