The author, Atu Gawande, is a dual professor at Harvard Medical School and the School of Public **** Health, the youngest health policy advisor to the White House, and the only physician on Time magazine's 2010 list of the world's "100 Most Influential People". Gwynedd specializes in telling stories about his own surroundings with careful observation and vivid writing style. These stories unveil the mysteries of the medical profession and help us understand what doctors think and do.
As of 2018, all four of Gwendolyn's books, The Doctor's Discipline, The Doctor's Refinement, The Checklist Revolution, and The Best Farewells, are available in Listen to This Book Every Day readings. Of particular note here is the book The Physician's Refinement. The Practice of Doctoring and The Refinement of Doctoring were published five years apart. In The Practice of Doctoring, Gwendolyn records how he grew from a rookie doctor to a skilled one; while in The Refinement of Doctoring, Gwendolyn, as a skilled doctor, is still searching for ways to continue to improve. It can be said that the change in content from "Cultivation" to "Refinement" also reflects Ge's own spiritual development as a doctor, from seeking "benevolence" to "benevolence". "The first time I saw this, it was a very good idea to go back to the old days.
Well, let's cut to the chase and go straight to another exploration of the medical industry brought to us by Ge Wende. Let's go through the story he told, from the three angles of diligence, correctness and innovation, to see the core qualities contained in the doctor's "heart of benevolence".
Part I
Let's start with the first trait that doctors need to have to "improve", diligence. Does diligence mean that doctors should treat the hospital as their home and work more with less rest? This is not what I mean. Here we are talking about diligence, refers to even in the smallest details, doctors have to continue to maintain serious and meticulous.
An example. Polio, commonly known as polio, is a highly contagious disease with very serious consequences. It has now disappeared in the vast majority of countries, but occasionally, it resurfaces in some corner of the world.
Gwendolyn tells us about a polio outbreak in 2003 in the southern Indian state of Karnataka. Karnataka is a very poor state, and the local immunization is so poor that children have no immunity to polio at all. So once a child got sick, polio could easily spread quickly from there to all of India. To avoid this, the World Health Organization plans to use more than 40,000 people, 2,000 vehicles, and 18,000 holding tanks to go door-to-door and vaccinate 4.2 million children in order to make sure that polio doesn't catch on.
Listening to these numbers you realize that this is obviously a big job. But even with such a big project, in the end it had to come down to the smallest details. For example, they have to develop a detailed plan, and then cascade the plan down to deploy the supplies and medical staff in place. The vaccinators also had to go into more than 500 villages with poor transportation to convince villagers who could not read or write much and were still wary of the vaccine to have their children vaccinated. As for the process of a large number of details, such as how to send the vaccine to each region, where to find the vaccine delivery vehicles, how to solve the problem of refrigerated vaccine ice bags, how to determine the number of people to be vaccinated in each region ...... have to be put in place in every detail.
And do you know how long they had to accomplish this? Only three days. To vaccinate 4.2 million kids in three days is unthinkable. But they did it. We don't know what kind of effort they put in, but we can imagine that they must have spent those three days rushing around non-stop, explaining with dry mouths, and working around the clock. They were able to accomplish this daunting task by the kind of extreme diligence that Gwendolen speaks of.
But the World Health Organization-led polio "sweep" is a little different from the doctors' daily work. The "sweep" is thrilling enough, and those who participate in it are inspired by the dedication and heroism involved. But more often than not, the doctors don't get the mental stimulation. In every laboratory where the lights are on late into the night, at the bedside of every comatose patient, and at the scene of every bloody resuscitation, the doctors are actually doing the same work as they were doing yesterday, the day before that, a year ago, or even ten years ago. In this constant lack of stimulation, doctors can also feel bored and slack. In this case, Gwendolyn's word "diligence" is also the antidote to the problem.
Yes, even with all the advances in medicine, it's often not the cutting-edge discoveries that determine how quickly a patient gets well, but rather the small details. It's the little things, like washing your hands.
You might say, "What's wrong with washing your hands? What's not to like about that? I'm not sure what I'm talking about, but I think it's a good idea for us to be able to do that. But I have to tell you, it's not that simple. There was a famous Austrian doctor who required doctors and nurses to wash and disinfect their hands before entering the operating room. As a result, the maternal mortality rate due to puerperal fever was reduced from 20% to 1%. Because there is enough awareness of the importance of hand washing, now doctors and nurses who have not washed their hands are never allowed to enter the operating room.
But what happens when you don't go into the operating room, but just in outpatient clinics and wards? The results can be very surprising. In the outpatient clinic and ward, really can do according to the norms of hand washing medical staff, less than 1/3. doctors also have their reasoning: "I day and night non-stop to the patient to do examination, treatment of wounds, write the medical records, which have the time to wash their hands one after another! If I washed my hands according to the norm, I wouldn't have to do anything else!" Are doctors unaware of the dangers of not washing their hands? Definitely not. They know better than anyone that many of the deadly germs that infect patients in hospitals are caused by their failure to wash their hands. But they just don't feel they have the time or the need to wash their hands one way or the other.
So is there anything hospitals can do to combat this problem? In case you haven't thought about it, hospitals have a department that specializes in controlling infections in hospitals. This department in Chinese hospitals, generally called "hospital infection department", also known as "hospital infection management department". One of the most important duties of the department is to urge health care workers to wash their hands. In order to make doctors and nurses wash their hands properly, all hospitals are trying to find ways to do so. At Gwendolyn's hospital, the staff put a lot of thought into the details. For example, installing more hand-washing sinks, supplying hand-washing gels that are easier to use, and publicizing hand-washing in each department on the website, but the effect was not obvious.
Then some hospitals realized that people usually value their own opinions more than they care about the opinions that others instill in them. So the hospitals organized doctors, nurses and even patients together to discuss what could be done to solve the problem of infections in the hospitals. Now that's a completely different situation. Everyone felt that their opinion was valued and they started to become very proactive. For example, they took the initiative to put the hand-washing gel in the right place, they took the initiative to remind their colleagues to wash their hands, and they made a conscious effort to put on gloves themselves before treating patients. A year after this change, the hospital's infection rate for a deadly bacterium has finally dropped to zero.
In times of trouble, people always hope for a one-size-fits-all solution, that everything will be solved in one fell swoop. But in medicine, it's really hard to find technological alternatives to things like hand-washing. In order to help patients better when medicine is less prone to revolutionary advances, doctors have to get the details right, wash their hands more diligently, be kinder, ask more detailed questions, and so on. It's like a rocket; to finally launch it successfully, you have to tighten every seemingly insignificant screw.
In fact, not only doctors, anyone who does something, there is a difference between being diligent or not, being attentive and not. For example, in Japan, there is a 50-year study on how to make a bowl of good rice "rice fairy", there is also a lifetime of energy are used to study, how to pinch a good sushi "sushi God". Nowadays, we often refer to the "spirit of craftsmanship", the core qualities of Gerwent here said diligence, heart.
Here, the first trait required for a doctor's refinement, diligence, has been introduced to you. We see that whether it's in a public ****ing health event like a mass vaccination, or in a small, seemingly insignificant detail like hand-washing, a doctor's diligence is pivotal to the final medical outcome.
Part 2
Let's take a look at the second trait that a doctor must possess to achieve excellence. The Chinese translation is "integrity", but the English word is "doing right", which is actually more appropriately translated as "doing the right thing". So what is the definition of "right"? 1+1=2 is mathematically correct, no doubt. But the world isn't all black and white, and doctors need to make the right choices and judgments in those gray areas where people are more likely to be happy than not.
In Gwendolyn's view, the first type of judgment that doctors need to face has to do with ethics. Hearing this you might say, what is morally right that I don't already know? But judgments about morality are sometimes not so easy for doctors. Let me give you a couple of examples.
If you were a doctor, would you get a third person to join you when you examined a patient's private parts? You don't find this question inexplicable. Some doctors feel the need to find a third person together, so as to avoid the future out of trouble can not be said; some doctors feel that they have a clear conscience, it is completely unnecessary; there are also doctors are very easy, the patient how to say how to do. Another example is, if you were a doctor, would you execute a prisoner? On this point, some doctors feel that their duty is to save lives, and it is not in line with their professional ethics to carry out the death penalty; some doctors think that I am not the one who will sentence the prisoner to death anyway, so instead of letting those unprofessionals do the job, they would rather do it themselves, and try to alleviate the pain of the prisoner when he dies. Let me ask you another question, if you are a small doctor who has just started to work for a few years, and you have a family of your own, would you risk going home and fighting with your family to subsidize the medical expenses when you meet those poor patients? Or do you just have to be ruthless and see it through to the end?
By this point, you may have also realized that in many cases, the boundaries of the word "right" are very difficult to determine, but doctors have to make the "right" choice between professional ethics and the needs of society. This is the first time that I've ever seen a doctor who was not able to make a decision about what to do, and I'm not sure that I've ever been able to do that.
After talking about moral correctness, let's talk about the second type of judgment that doctors often face, which is a big problem. It's what is the right way for a doctor to handle a medical dispute.
Generally, we all think, first of all, the attitude must be good, first with the patient to admit fault, and then compensation, this is good. But what if the doctor really didn't make a mistake? Or the doctor made a mistake, but he was worried about his own lawsuit or lose money, do not dare to tell the truth to the patient? In that case, you might say, let's go to court and file a lawsuit. But is going to court really the most just solution? In Gwendolyn's opinion, the results people are getting from medical litigation now are not satisfactory. Because medical litigation is often time-consuming, costly, and constantly involved, and puts doctors and patients on opposite sides, and ultimately the patient can rarely get substantial help. In the U.S., for example, too much of the medical compensation goes to people who don't deserve it, and of the patients who do deserve it, only about 1% actually receive it. The rest of those patients usually don't even hear an apology.
In Gwendolyn's view, the U.S. health care system is so bad that it must be reformed. And how should it be reformed? Gwendolen started by talking about the U.S. vaccine compensation system. In the U.S., there is a 0.75-cent surcharge on the cost of each vaccine, and the government uses that money to set up a fund specifically to compensate children for vaccine damage. When it comes to compensation, people don't need to spend effort identifying which damages were caused by doctor error or bad luck; as long as the damage matches the type on the Vaccine Side Effects List, the patient will receive compensation.
But while medical disputes are complex, they are relatively rare. For doctors, they usually encounter more, how to make the right choice between "continue treatment" and "abandon the patient". This is the third type of judgment that doctors often have to deal with.
You may not understand, treatment is the doctor's vocation ah, not as long as the patient has a ray of hope, the doctor must continue to rescue? Indeed, in most cases, doctors think so, and do so. And doctors' persistence does bring many miracles. For example, a long time ago, people used to think that babies born more than two months prematurely would not survive at all. But then, because of the doctors' unwavering and careful care, the vast majority of those babies survived. There are also many patients who are dying and have tubes all over their bodies who have crossed the threshold of the ghost with the full attention of the doctors.
But the professionalism of doctors who are desperate to save lives often brings them blame. Some say that the doctors' recklessness is actually a waste of valuable medical resources. In the U.S., a quarter of health care resources are spent on patients with less than six months to live, when the money could be used to help more patients with less serious conditions. But that's exactly the kind of difficult decision that doctors have to make. They're not God, they don't have the luxury of knowing exactly how long a person will live, and they don't know if a medical miracle is going to happen to one of their patients next.
What doctors can and cannot do, many people think the line between the two is simple and clear. But in reality, the hardest part of being a doctor is knowing where to stop. What is the right thing to do? What is the best thing to do? No one tells them the answers. Perhaps the simplest rule for doctors is to do the best they can and not to give up. At the very least, this will keep doctors from making the worst mistake of all, which is giving up on patients who could have been saved.
Well, to summarize for you the second trait that a doctor has to have to be refined, do the right thing. This requirement is not as simple as it sounds at first glance. In the intricacies of the medical process, doctors have to seek moral accountability, explore better ways to resolve medical disputes, and make the right choices between the dilemmas of saving and not saving. The ethical codes of the medical profession are not always correct, nor are the conventions of the outside community. Performing professional skills, following the law, and respecting morality are sometimes inherently contradictory, and sometimes entangled. Gwendolyn says he used to think the biggest hurdle for doctors was skill, but after actually practicing medicine he realized that the hardest thing for doctors is actually "understanding where the limits of your ability are, and knowing what is beyond your control." Perhaps in many cases, all doctors can do is "do their best and listen to God's will".
Part 3
Next, let's talk about the third trait that doctors need to have in order to be effective, innovation.
When you think of innovation in medicine, the first thing that comes to mind is a spotless lab, cute and pathetic mice, and cells in bottles. It seems like innovation only happens in the lab. But we have overlooked the fact that doctors, who are busy all day long in the hospital wards, are also an important force for innovation. And, compared to those who often invest hundreds of millions of dollars in laboratory research, doctors in the daily medical treatment of some seemingly insignificant small creation, in turn, can make a more direct and more significant contribution to the treatment of patients.
The Apgar Neonatal Scale, which is still widely used in obstetrics today, is a prime example of this innovation. The scale was invented in 1953 by an American anesthesiologist named Virginia Apgar. Why did an anesthesiologist make this scale for scoring newborns? It was because Apgar would often give anesthesia to women in labor, and she loved seeing newborns come into the world. At that time, however, many babies who were born in poor condition, or even just a little blue and not breathing normally, were treated by obstetricians and gynecologists as "stillborns" and left to die. Apgar felt this was unreasonable, but as an anesthesiologist, she couldn't directly challenge the OB/GYN's authority. So she took a less direct but more effective approach and devised this scale.
The Apgar Scale is surprisingly easy to follow: it scores newborns on the color of their bodies, their breathing, their heart rate, their limb movements, and their responses to stimuli. But surprisingly, this simple scale achieved surprising results. Not only did it allow for a more objective evaluation of the condition of newborns, but doctors, in an effort to get higher scores for the babies they delivered, began to care more about the condition of those babies. They took better care of the babies that had been treated as "stillborn". Later, almost all hospitals around the world used the Apgar Scale to evaluate babies. It was soon discovered that even if a baby's score was bad one minute after birth, it could be good five minutes later with oxygen and warmth. So hospitals set up neonatal intensive care units. Not only that, but doctors have found that babies born under local anesthesia, such as spinal anesthesia and epidural anesthesia, score higher compared to those born under general anesthesia. So, the type of anesthesia used for labor and delivery is starting to get attention.
This seemingly trivial scale has saved countless children's lives and revolutionized obstetrics.
This is the first time that we've seen a new generation of researchers who have been working on a new technology for a long time, and we've seen a new generation of researchers who have been working on a new technology for a long time, and we've seen it in the past. Gwendolyn feels that compared to the high sounding laboratory research of gene deciphering, stem cell therapy, and cancer vaccines, small innovations on the clinical front are actually more likely to reap huge rewards.
Taking breast cancer as an example, the U.S. government and private foundations spend nearly a billion dollars a year researching new treatments for breast cancer. Few people realize that just by improving the comfort and convenience of mammograms, the death rate from breast cancer could be reduced by a third, because if mammograms are comfortable and convenient enough, women are more likely to insist on annual exams, and breast cancer can be detected and treated as early as possible.
Gawande's realization of the enormous potential value of clinical innovation comes from his observation that in many parts of the world, the best hope for saving lives is through locally adapted innovations, not biological or genetic research.
For example, after completing his surgical training, Gawande once traveled to India, his ancestral home, as a visiting physician. He had some sense of superiority, thinking that as a first-rate trained physician in the United States, he would surely be able to give the Indian doctors some guidance. But he soon realized that, in the absence of advanced instruments and equipment, patients and in front of the crowded time, on the contrary, it is those who look at the unimpressive Indian doctors are more able to treat the sick to save lives. Here, a doctor with inexpensive second-hand laparoscopy, has created a repair of gastrointestinal perforation of the surgical method. The incision is small, the operation is short, there are fewer complications, and the recovery is still fast. The subtlety of this surgery is enough to dazzle American doctors who have sophisticated equipment.
Also in this hospital, when a child with severe hydrocephalus came to see the doctor, the doctors, without the necessary drains and without a skull drill, used a hemostat in their hands to grind out a hole in the child's skull, and then put in the trimmed and sterilized cottage drains to save the child's life.
These stories are heartbreaking, but they also let us know that no matter where we are or what the environment is like, as long as there is a spirit of ingenuity and a strong willingness to experiment, every doctor has the potential to find truly valuable innovations. Doctors should never pin all their hopes on luxurious medical equipment, nor should they attribute their inability to do anything to the embarrassment of the environment or the stagnation of medical research. The cure is not only advanced equipment and laboratory results, it also includes the solution of each specific problem, to grasp the seemingly unusual innovation on.
This is the third quality of physician refinement that this book is about, innovation. In this section, Gwendolyn emphasizes not so much the high-profile scientific revolutions in the lab, but the nuanced innovations and creations that doctors on the front lines of the clinic make to the process of diagnosis and treatment. These seemingly insignificant innovations by clinicians are often more rewarding than costly basic research.
In The Doctor's Finest, Gwendolyn tells us that the art of medicine is skill, but it is also the art of the heart. A veteran doctor does not mean he is an excellent doctor. A doctor to realize from the professional to excellence in the "refinement", not by professional and technical excellence, but from the "benevolence" to the "benevolence" of the sublimation. The "heart of benevolence" of a doctor needs to include three important qualities in particular: diligence, correctness and innovation. Specifically, "diligence" means the willingness to put in strenuous efforts, as well as continuous seriousness and meticulousness in work attitude; "correctness" includes the moral sense of not being ashamed of one's conscience, exploring better ways to solve medical disputes, and making the right choice between saving and not saving; while "correctness" includes the moral sense of not being ashamed of one's conscience, exploring better ways to solve medical disputes, and making the right choice between saving and not saving. The "right" includes moral integrity, searching for better ways to resolve medical disputes, and making the right choice between saving and not saving; and the "innovation" emphasizes the down-to-earth, concrete improvements that doctors make in their daily medical practice.
At the end of the book, Gwendolyn asks the question, how can one person become more valuable and make a difference in his or her profession? He shares several pieces of advice, two of which I think are particularly good and will help not only physicians, but also those of you who are in other professions, to rise to the top of your peers more quickly.
One piece of advice is to be diligent about statistics. It doesn't matter what the stats are, you just have to find some points that interest you and keep the stats going, and you might get something unexpected. For example, Gwendolyn once counted how many doctors would leave gauze and other things inside their patients after surgery. Later, based on the statistics, Gwendolyn and his colleagues designed a device to automatically supervise the gauze.
It seems to me that Gawande's goal in encouraging people to do statistics is really to keep people focused and observant in their own fields. And prolonged focus and observation often leads to the discovery of small problems that are usually often overlooked. For example, Amazon has done a round of reforms to improve the speed of logistics. Once their packing process is like this: for example, customers ordered a book, a bottle of wine, the two sorters go to different categories of shelves to find. But if you look for the book with an hour, looking for wine took three hours, then the time to match the goods is at least three hours. That's too much of a delay.
So then how did they solve this problem? It is to count a lot of sales data, and put those things that customers often buy on the nearest shelf. The sorters were able to pack the most orders in the shortest amount of time, and speed was instantly increased. You see, innovation doesn't need to be earth-shattering. Even small problems can reinvent an entire system if you can identify and solve them.
Another piece of advice that Gwendolyn mentioned was to be diligent with your writing. Writing isn't always for writers, and it doesn't always have to be a full-blown article out every time. Record what you see and think at work, whether it's a few paragraphs on a blog, a story or poem, or an article for an academic journal. Writing allows one to take a break from the daily chores and think y about the issues that are on one's mind. More importantly, we can share our inner feelings with readers through our words. Whether this readership is large or small, we may gain recognition from their affirmation and support, and see the wider world from rebuttal or criticism. Maybe after writing more, you can also be like Gwendolyn, through constant observation and summarization, to re-understand their own careers, and establish a high-dimensional perception of the profession.