Few can doubt that Western medicine has been a phenomenal success. Heart disease kills two-thirds fewer people now than it did fifty years ago. The frequency of conditions as diverse as stroke and trauma is being gradually checked. Mortality from breast cancer has fallen by a quarter in less than two decades. Doctors would dearly like to attribute these impressive results in Western countries to their accumulated expertise and the advances of science. But as Atul Gawande points out in Better: A Surgeon’s Notes on Performance, his latest collection of lucid essays,1 the residual contradiction is that while medicine succeeds, it never seems to succeed well enough. A doctor’s report card might look creditable today. Yet it nevertheless conceals serious unresolved and unacknowledged weaknesses.
“Science and skill,” Gawande writes, are “the easiest parts of care.” What matters more, he suggests, is diligence, doing right by patients, and ingenuity. Despite these “core requirements” for progress, and the fact that doctors have been remarkably successful in all three, errors are still commonly made. These mistakes badly scar the surface of medicine’s success. “Betterment is a perpetual labor,” Gawande concludes. The trick is to understand one’s limits.
One by one Gawande’s arguments are persuasively made and elegantly illustrated with examples ranging from antisepsis to obstetrics. He describes, for example, Thomas, a previously fit seventy-two-year-old man, who one day was found to have a cancer in his left kidney. The tumor was removed surgically but, instead of Thomas’s recovering, his entire body began to swell. Eventually, he was diagnosed with Cushing’s syndrome, a condition in which the adrenal glands overproduce steroid hormone. No matter what his doctors did, they could not stop the hormone from pouring into his bloodstream. Thomas became sicker and sicker. He could not walk and he had recurrent episodes of pneumonia.
By the time Thomas got to see Atul Gawande, there was only one option left—to remove the source of the offending hormone. Although the operation to take out his adrenal glands carried its own dangers, Gawande told Thomas that his only chance of a normal life was to accept the risk. The operation went well. But Thomas suffered a series of terrible complications, culminating in four months of intensive care, a tracheostomy, and incarceration in a long-term care facility. When he last saw Gawande, he could hardly lift his head. All he could do to express himself was to cry. Gawande implies that this was one operation that should have been avoided.
Many of Gawande’s essays began life as magazine and journal articles. Their original diversity and subsequent reworking to construct a larger thesis about the failure of medicine create a difficult tension. Although the individual foundations that Gawande lays down are strong, the overall architecture of his work lacks form and substance.
By striking contrast, Jerome Groopman, a cancer specialist who, like Gawande, writes for The New Yorker, delivers an altogether sharper and more coherent critique of medicine’s mistaken direction. And while Gawande’s prescriptions are…
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