College level writing response(200-300 words)

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Better “What Doctors Owe” pp. 84-111, "The Doctors of the Death Chamber” pp. 130-153, , “On Fighting” pp. 154-166 and “The Bell Curve” pp. 201-230

  1. Choose one chapter to respond to in 200-300 words. Below are some guiding questions for each chapter.
  2. In 100 words or less, describe your best topic idea for the CP. Why does this topic interest you? How does it relate to health or human performance? Which of the library's research strategies have you used so far?
  3. Once you have posted, respond to two other posts by either offering additional insight or making a suggestion. Please skip to the next if someone already has two responses.

What Doctors Owe

  • What is the central claim of this chapter? How has it changed the way you think about medicine?
  • In what way do the ideas in this chapter reflect your values or beliefs? In other words, do the ideas in this chapter resonate in a more general sense?

Doctors of the Death Chamber

  • What was your response to “Doctors of the Death Chamber?” Did it change the way you thought about anything?
  • What do you think about the following quote from the chapter (agree, disagree, why?):
    • “The real depressing thing is that if you don’t get to these people before the age of three of four or five, it’s not going to make any difference in what they do. They’ve struck out before they even started kindergarten. I don’t see [execution] as saying anything about that” (145).

On Fighting

  • What is the central claim in this chapter? How do you know? Choose the sentence that you consider to be the thesis or central idea.
  • Why is this chapter effective? (or ineffective?) How does Gawande draw his audience in to his argument? Pick one or two strategies he uses. How can you use them in your own writing?

The Bell Curve

  • In “The Bell Curve,” Gawande makes several claims about how we should improve health care. What is one of these claims?
  • What are the reasons behind the claim that you chose?
  • How might these reasons change if he were addressing the board of a hospital? How might the reasons change if he were addressing a government entity?

Any Chapter

  • You may also answer the following questions for any chapter:
    • What is effective about Gawande's writing? Choose a specific passage (if it is longer than 4 lines, just summarize it and give the page number) and explain why it is effective. How might you incorporate this strategy in your own work?

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31915_ch00.i-v.qxd 2/1/08 3:06 PM Page i ‘A searing, deeply humane collection of essays about medical practice that has all the makings of a modern classic’ Sunday Times ‘Rich in fascinating detail … as engaging to the layman as to the practising or studying doctor’ Economist ‘Reading him is rewarding’ TLS ‘An introspective, enthusiastic, gifted and thoughtful storyteller … A brilliant diagnosis of medicine’s ills’ British Medical Journal ‘A fascinating study’ Irish Tatler ‘Gawande is an accomplished author and doesn’t shy away from hot topics like malpractice, while his writing is clear and refreshingly free from off-putting medical jargon.’ Sunday Tribune ‘Riveting’ Irish Examiner Atul Gawande is one of the world’s most distinguished doctors. A 2006 MacArthur Fellow, he is a general surgeon at the Brigham and Women’s Hospital in Boston, a staff writer for the New Yorker, an associate professor at Harvard Medical School and the bestselling author of Complications: A Surgeon’s Notes on an Imperfect Science, also published by Profile. He lives with his wife and children in Newton, Massachusetts. 31915_ch00.i-v.qxd 2/1/08 3:06 PM Page ii a l s o b y At u l G awa n d e Complications: A Surgeon’s Notes on an Imperfect Science 31915_ch00.i-v.qxd 2/1/08 3:06 PM Page iii Better 31915_ch00.i-v.qxd 2/1/08 3:06 PM Page iv Better A S u r g e o n ’ s N ot e s o n Pe r f o r m a n c e 31915_ch00.i-v.qxd 2/1/08 3:06 PM Page v Atul Gawande 31915_ch00.vi-xii.qxd 5/2/08 11:06 Page vi This paperback edition published in 2008 First published in Great Britain in 2007 by PROFILE BOOKS LTD 3A Exmouth House Pine Street London EC1R 0JH www.profilebooks.com First published in the United States of America in 2007 by Metropolitan Books Copyright © Atul Gawande, 2007, 2008 Several of these chapters have appeared, in different form, in the New Yorker and the New England Journal of Medicine 1 3 5 7 9 10 8 6 4 2 Designed by Meryl Sussman Lavavi Printed and bound in Great Britain by Bookmarque, Croydon, Surrey The moral right of the author has been asserted. All rights reserved. Without limiting the rights under copyright reserved above, no part of this publication may be reproduced, stored or introduced into a retrieval system, or transmitted, in any form or by any means (electronic, mechanical, photocopying, recording or otherwise), without the prior written permission of both the copyright owner and the publisher of this book. A CIP catalogue record for this book is available from the British Library. ISBN 978 1 86197 657 4 This book is printed on FSC certified paper Cert no. TT-COC-002227 31915_ch00.vi-xii.qxd 2/1/08 3:06 PM Page vii For my parents and sister 31915_ch00.vi-xii.qxd 2/1/08 3:06 PM Page viii 31915_ch00.vi-xii.qxd 2/1/08 3:06 PM Page ix Contents Introduction 1 Part I Diligence 11 On Washing Hands The Mop-Up 29 Casualties of War Part II Doing Right Naked 73 What Doctors Owe Piecework 112 13 51 71 84 31915_ch00.vi-xii.qxd 2/1/08 3:06 PM Page x The Doctors of the Death Chamber On Fighting 154 Part III Ingenuity 167 The Score 169 The Bell Curve 201 For Performance 231 Afterword: S uggestions for B ecoming a P ositive D eviant Notes on Sources Acknowledgments 259 271 249 130 31915_ch00.vi-xii.qxd 2/1/08 3:06 PM Page xi Better 31915_ch00.vi-xii.qxd 2/1/08 3:06 PM Page xii 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 1 Introduction S everal years ago, in my final year of medical school, I took care of a patient who has stuck in my mind. I was on an internal medicine rotation, my last rotation before graduating. The senior resident had assigned me primary responsibility for three or four patients. One was a wrinkled, seventy-something-year-old Portuguese woman who had been admitted because—I’ll use the technical term here—she didn’t feel too good. Her body ached. She had become tired all the time. She had a cough. She had no fever. Her pulse and blood pressure were fine. But some laboratory tests revealed her white blood cell count was abnormally high. A chest X-ray showed a possible pneumonia—maybe it was, maybe it wasn’t. So her internist admitted her to the hospital, and now she was 31915_ch01.001-275.qxd 2 2/1/08 3:06 PM Page 2 Better under my care. I took sputum and blood cultures and, following the internist’s instructions, started her on an antibiotic for this possible pneumonia. I went to see her twice each day for the next several days. I checked her vital signs, listened to her lungs, looked up her labs. Each day, she stayed more or less the same. She had a cough. She had no fever. She just didn’t feel good. We’d give her antibiotics and wait her out, I figured. She’d be fine. One morning on seven o’clock rounds, she complained of insomnia and having sweats overnight. We checked the vitals sheets. She still had no fever. Her blood pressure was normal. Her heart rate was running maybe slightly faster than before. But that was all. Keep a close eye on her, the senior resident told me. Of course, I said, though nothing we’d seen seemed remarkably different from previous mornings. I made a silent plan to see her at midday, around lunchtime. The senior resident, however, went back to check on her himself twice that morning. It is this little act that I have often thought about since. It was a small thing, a tiny act of conscientiousness. He had seen something about her that worried him. He had also taken the measure of me on morning rounds. And what he saw was a fourth-year student, with a residency spot already lined up in general surgery, on his last rotation of medical school. Did he trust me? No, he did not. So he checked on her himself. That was not a two-second matter, either. She was up on the fourteenth floor of the hospital. Our morning teaching conferences, the cafeteria, all the other places we had to be that day were on the bottom two floors. The elevators were notoriously slow. The senior resident was supposed to run one 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 3 Introduction 3 of those teaching conferences. He could have waited for a nurse to let him know if a problem arose, as most doctors would. He could have told a junior resident to see the patient. But he didn’t. He made himself go up. The first time he did, he found she had a fever of 102 degrees and needed the oxygen flow through her nasal prongs increased. The second time, he found her blood pressure had dropped and the nurses had switched her oxygen to a face mask, and he transferred her to the intensive care unit. By the time I had a clue about what was going on, he already had her under treatment—with new antibiotics, intravenous fluids, medications to support her blood pressure—for what was developing into septic shock from a resistant, fulminant pneumonia. Because he checked on her, she survived. Indeed, because he did, her course was beautiful. She never needed to be put on a ventilator. The fevers stopped in twenty-four hours. She got home in three days. What does it take to be good at something in which failure is so easy, so effortless? When I was a student and then a resident, my deepest concern was to become competent. But what that senior resident had displayed that day was more than competence—he grasped not just how a pneumonia generally evolves and is properly treated but also the particulars of how to catch and fight one in that specific patient, in that specific moment, with the specific resources and people he had at hand. People often look to great athletes for lessons about performance. And for a surgeon like me, athletes do indeed have 31915_ch01.001-275.qxd 4 2/1/08 3:06 PM Page 4 Better lessons to teach—about the value of perseverance, of hard work and practice, of precision. But success in medicine has dimensions that cannot be found on a playing field. For one, lives are on the line. Our decisions and omissions are therefore moral in nature. We also face daunting expectations. In medicine, our task is to cope with illness and to enable every human being to lead a life as long and free of frailty as science will allow. The steps are often uncertain. The knowledge to be mastered is both vast and incomplete. Yet we are expected to act with swiftness and consistency, even when the task requires marshaling hundreds of people—from laboratory technicians to the nurses on each change of shift to the engineers who keep the oxygen supply system working—for the care of a single person. We are also expected to do our work humanely, with gentleness and concern. It’s not only the stakes but also the complexity of performance in medicine that makes it so interesting and, at the same time, so unsettling. Recently, I took care of a patient with breast cancer. Virginia Magboo was sixty-four years old, an English teacher, and she’d noticed a pebblelike lump in her breast. A needle biopsy revealed the diagnosis. The cancer was small—three-quarters of an inch in diameter. She considered her options and decided on breast-conserving treatment—I’d do a wide excision of the lump as well as what’s called a sentinel lymph node biopsy to make sure the cancer hadn’t spread to the lymph nodes. Radiation would follow. The operation was not going to be difficult or especially hazardous, but the team had to be meticulous about every step. On the day of surgery, before bringing her to the operating room, the anesthesiologist double-checked that it was safe 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 5 Introduction 5 to proceed. She reviewed Magboo’s medical history and medications, looked at her labs in the computer and at her EKG. She made sure that the patient had not had anything to eat for at least six hours and had her open her mouth to note any loose teeth that could fall out or dentures that should be removed. A nurse checked the patient’s name band to make sure we had the right person; verified her drug allergies with her, confirmed that the procedure listed on her consent form was the one she expected. The nurse also looked for contact lenses that shouldn’t be left in and for jewelry that could constrict a finger or snag on something. I made a mark with a felt-tip pen over the precise spot where Magboo felt the lump, so there would be no mistaking the correct location. Early in the morning before her surgery, she had also had a small amount of radioactive tracer injected near her breast lump, in preparation for the sentinel lymph node biopsy. I now used a handheld Geiger counter to locate where the tracer had flowed, and confirmed that the counts were strong enough to indicate which lymph node was the “hot” one that needed to be excised. Meanwhile, in the operating room, two nurses made sure the room had been thoroughly cleaned after the previous procedure and that we had all the equipment we needed. There is a sticker on the surgical instrument kit that turns brown if the kit has been heat-sterilized and they confirmed that the sticker had turned. A technician removed the electrocautery machine and replaced it with another one after a question was raised about how it was functioning. Everything was checked and cross-checked. Magboo and the team were ready. By two o’clock I had finished with the procedures for my 31915_ch01.001-275.qxd 6 2/1/08 3:06 PM Page 6 Better patients before her and I was ready too. Then I got a phone call. Her case was being delayed, a woman from the OR control desk told me. Why? I asked. The recovery room was full. So three operating rooms were unable to bring their patients out, and all further procedures were halted until the recovery room opened up. OK. No problem. This happens once in a while. We’ll wait. By four o’clock, however, Magboo still had not been taken in. I called down to the OR desk to find out what was going on. The recovery room had opened up, I was told, but Magboo was getting bumped for a patient with a ruptured aortic aneurysm coming down from the emergency room. The staff would work on getting us another OR. I explained the situation to Magboo, lying on her stretcher in the preoperative holding area, and apologized. Shouldn’t be too much longer, I told her. She was philosophical. What will be will be, she said. She tried to sleep to make the time pass more quickly but kept waking up. Each time she awoke, nothing had changed. At six o’clock I called again and spoke to the OR desk manager. They had a room for me, he said, but no nurses. After five o’clock, there are only enough nurses available to cover seventeen of our forty-two operating rooms. And twenty-three cases were going at that moment—he’d already made nurses in four rooms do mandatory overtime and could not make any more. There was no way to fit another patient in. 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 7 Introduction 7 Well, when did he see Magboo going? “She may not be going at all,” he said. After seven, he pointed out, he’d have nurses for only nine rooms; after eleven, he could run at most five. And Magboo was not the only patient waiting. “She will likely have to be canceled,” he said. Cancel her? How could we cancel her? I went down to the control desk in person. One surgeon was already there ahead of me lobbying the anesthesiologist in charge. A second was yelling into the OR manager’s ear on the phone. Each of us wanted an operating room and there would not be enough to go around. A patient had a lung cancer that needed to be removed. Another patient had a mass in his neck that needed to be biopsied. “My case is quick,” one surgeon argued. “My patient cannot wait,” said another. Operating rooms were offered for the next day and none of us wanted to take one. We each had other patients already scheduled who would themselves have to be canceled to make room. And what was to keep this mess from happening all over again tomorrow, anyway? I tried to make my case for Magboo. She had a breast cancer. It needed to be taken out. This had to happen sooner rather than later. The radioactive tracer, injected more than eight hours ago, was dissipating by the hour. Postponing her operation would mean she would have to undergo a second injection of a radioactive tracer—a doubling of her radiation exposure—just because an OR could not be found for her. That would be unconscionable, I said. No one, however, would make any promises. * * * 31915_ch01.001-275.qxd 8 2/1/08 3:06 PM Page 8 Better This is a book about performance in medicine. As a doctor, you go into this work thinking it is all a matter of canny diagnosis, technical prowess, and some ability to empathize with people. But it is not, you soon find out. In medicine, as in any profession, we must grapple with systems, resources, circumstances, people—and our own shortcomings, as well. We face obstacles of seemingly unending variety. Yet somehow we must advance, we must refine, we must improve. How we have and how we do is my subject here. The sections of this book examine three core requirements for success in medicine—or in any endeavor that involves risk and responsibility. The first is diligence, the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles. Diligence seems an easy and minor virtue. (You just pay attention, right?) But it is neither. Diligence is both central to performance and fiendishly hard, as I show through three stories: one about the effort to ensure doctors and nurses simply wash their hands; one about the care of the wounded soldiers in Iraq and Afghanistan; and one about the Herculean effort to eradicate polio from the globe. The second challenge is to do right. Medicine is a fundamentally human profession. It is therefore forever troubled by human failings, failings like avarice, arrogance, insecurity, misunderstanding. In this section I consider some of our most uncomfortable questions—such as how much doctors should be paid, and what we owe patients when we make mistakes. I tell the stories of four doctors and a nurse who have gone against medical ethics codes and participated in executions of 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 9 Introduction 9 prisoners. I puzzle over how we know when we should keep fighting for a sick patient and when we should stop. The third requirement for success is ingenuity—thinking anew. Ingenuity is often misunderstood. It is not a matter of superior intelligence but of character. It demands more than anything a willingness to recognize failure, to not paper over the cracks, and to change. It arises from deliberate, even obsessive, reflection on failure and a constant searching for new solutions. These are difficult traits to foster—but they are far from impossible ones. Here I tell the stories of people in everyday medicine who have, through ingenuity, transformed medical care—for example, the way babies are delivered and the way an incurable disease like cystic fibrosis is fought—and I examine how more of us can do the same. Betterment is a perpetual labor. The world is chaotic, disorganized, and vexing, and medicine is nowhere spared that reality. To complicate matters, we in medicine are also only humans ourselves. We are distractible, weak, and given to our own concerns. Yet still, to live as a doctor is to live so that one’s life is bound up in others’ and in science and in the messy, complicated connection between the two. It is to live a life of responsibility. The question, then, is not whether one accepts the responsibility. Just by doing this work, one has. The question is, having accepted the responsibility, how one does such work well. Virginia Magboo lay waiting, anxious and hungry, in a windowless, silent, white-lit holding area for still two hours more. 31915_ch01.001-275.qxd 10 2/1/08 3:06 PM Page 10 Better The minutes ticked, ticked, ticked. At times, in medicine, you feel you are inside a colossal and impossibly complex machine whose gears will turn for you only according to their own arbitrary rhythm. The notion that human caring, the effort to do better for people, might make a difference can seem hopelessly naïve. But it isn’t. Magboo asked me if there was any real prospect of her having her operation that night. The likelihood, I said, had become exceedingly small. But I couldn’t bring myself to send her home, and I asked her to hang on with me. Then, just before eight o’clock, I got a text message on my pager. “We can bring your patient back to room 29,” the display read. Two nurses, it turned out, had seen how backed up the ORs had gotten and, although they could easily have gone home, they volunteered to stay late. “I didn’t really have anything else going on anyway,” one demurred when I spoke to her. When you make an effort, you find sometimes you are not the only one willing to do so. Eleven minutes after I got the page, Magboo was on the operating table, a sedative going into her arm. Her skin was cleansed. Her body was draped. The breast cancer came out without difficulty. Her lymph nodes proved to be free of metastasis. And she was done. She woke up calmly as we put on the dressing. I saw her gazing upward at the operating light above her. “The light looks like seashells,” she said. 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 11 Part I Diligence 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 12 31915_ch01.001-275.qxd 2/1/08 3:06 PM Page 13 On Washing Hands O ne ordinary December day, I took a tour of my hospital with Deborah Yokoe, an infectious disease specialist, and Susan Marino, a microbiologist. They work in our hospital’s infection-control unit. Their full-time job, and that of three others in the unit, is to stop the spread of infection in the hospital. Th ...
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