In 1925, at the glorious, brutal height of roaring ’20s excess, Sinclair Lewis introduced a new kind of protagonist to the American literary imagination: the tortured, truth-seeking medical hero. He named this hero (who he insisted was not actually a hero) Dr. Martin Arrowsmith, and gave him his own novel, Arrowsmith, the story of the young doctor’s struggle to navigate the competing forces of idealism and greed, curing and commercialism. Written with characteristic flashes of satire, the book captured the excruciating contradictions of its era’s medical moment–the promise of life-saving treatments for pneumonia and plague mixed with the consuming pressures of business–and won its author a Pulitzer Prize. Lewis turned down the award–as a satirist and social critic, he felt he could not in good conscience (or any conscience, really) accept a prize intended to honor the book that best presented “the wholesome atmosphere of American life, and the highest standard of American manners and manhood.” But he left a lingering portrait of an era in which the Gospel of Ford, with its tenets of commerce and competition, first began to overtake the sacred disciplines of science and medicine.
Eight decades later, a group of prominent doctor-writers–among them Sherwin Nuland, Jerome Groopman and Atul Gawande–has resurrected Lewis’s fascination with the truth-seeking physician and ushered in a new era of medical criticism. Today’s doctor-authors tell vivid stories of the contradiction between the doctors they had once dreamed of being and the ones they have since become–the very contradiction that plagued Lewis’s hero. But unlike Arrowsmith, their stories touch only lightly on the themes of greed and commercialism, and speak not at all of issues like HMOs or universal healthcare (subjects Lewis might have spun into glistening satirical threads). Instead, they focus on the threat posed to medicine by the modern medical industry’s cult of technology, emphasis on action and obsession with quick-fix procedures. In the face of a fast-paced, algorithm-obsessed medical culture, they ask how a doctor can go about the business–or is it the art?–of doctoring. How does a physician heal rather than just treat?
Atul Gawande, the Harvard-trained surgeon, writer and medical golden boy, thinks he has the answer. He certainly has the résumé, and media savvy, to make other people think he has the answer. At 41, Gawande is a general surgeon at the respected Brigham and Women’s Hospital in Boston, an assistant professor at Harvard Medical School, a staff writer for The New Yorker and a regular contributor to The New England Journal of Medicine. He is also a former Rhodes scholar and 2006 MacArthur fellow–or “genius”–who, like his colleague Malcolm Gladwell, has managed to parlay his success and savoir-faire into demi-celebrity status. His books and articles have a tendency to feel less like dialogues between peers or with interested patients than guides for other MDs, how-to tracts advising them on how they too “might make a worthy difference.”
His latest thoughts on making a difference–which he also refers to as achieving “success in medicine”–are laid out in his new book, Better: A Surgeon’s Notes on Performance. As the title suggests, Better is about what it takes to become a “better” clinician–to go beyond the purely doctorly skills that make a physician competent (skills like “canny diagnosis, technical prowess, and some ability to empathize”) to the skills that make a physician outstanding. Gawande has identified three of these magical skills, or the “core requirements” necessary “for success in medicine–or in any endeavor that involves risk and responsibility.” They are “diligence,” “doing right” and “ingenuity,” and he dedicates his book to teasing them apart in chapters on everything from the life-saving importance of hand-washing (vigilance) to the ethics of participating in prison executions (doing right–or, in this case, not doing right) to the creation of the Apgar score for assessing the health of newborn babies (ingenuity).
In a world in which doctors are called upon to do ever more in ever shorter periods of time; in which radiologists read slides for as many as 25,000 cases a year and a surgeon like Gawande cuts into as many as 350 patients; in which it’s easy even for someone of Gawande’s stature to feel like a “white-coated cog in a machine,” a doctor’s best chances for “success,” he argues, come from obsessively honing these three “core” traits–or, quite simply, from “the drive to do better.”
“Betterment is a perpetual labor,” he writes in his introduction, sounding something like a Protestant schoolmarm or, perhaps, an inspirational business guru. This message gets additional plugs throughout the book from the introduction to the afterword, as when Gawande urges his readers to “make a science of performance” and when he cites five recommendations for how medical students can themselves become “positive deviants.” They are: Ask an unscripted question, don’t complain, count something, write something and, vaguely yet boldly, “change” (by becoming an “early adopter,” as the business buffs might say).
If all of this sounds a bit pat or corporate, a bit like a self-help manual for the aspirational MD, that’s because it is. Like the author’s friend Gladwell, who receives a “thank you” in the acknowledgments for his contributions to the book, Gawande has perfected the art of couching business-management-style messages in compelling, vigorous prose. He has loaded his book with lofty-sounding ambitions, but no matter how sharp the writing, the ultimate result is banal, a plea not to make a better system but to make better selves to fit the system.
This is not to say that the book does not have its moments, even its merits. Gawande explores some fascinating subjects in his attempt to understand how doctors “succeed”–subjects that include an exploration of how an understaffed band of military doctors has managed to save a greater percentage of soldiers’ lives than in any previous US war. And he calls attention to some of the mixed-up funding priorities of today’s medical culture, in which pharmaceutical companies pump streams of money into developing dazzling new cancer vaccines and decoding the genome but hospitals scrimp on efforts that could save tens of thousands of lives a year simply by forcing doctors and nurses to wash their hands more frequently. (Hospital infections, which are often transported by poorly washed hands, kill some 90,000 patients a year in this country, far more than the number of people who die from breast and prostate cancer combined.)
Still, the chapters of Gawande’s book don’t quite add up to a larger whole. The project seems ad hoc, as if he’d simply strung the pieces of Better together by using a convenient motivational theme. This is not altogether surprising, since, in a sense, Gawande did string the book together–or at least large chunks of it–molding articles he had already written for The New Yorker and The New England Journal of Medicine into a bound product. This product is proficient, as is everything Gawande does. But for all his awards and plaudits, perhaps he could have done better than writing a how-to primer for the high-performing physician.
Pauline Chen does do better. A 42-year-old transplant surgeon who most recently held a faculty position at UCLA, she is, at first blush, Gawande’s West Coast female double. Like Gawande, she has won her share of awards and accolades–she was named Outstanding Physician of the Year by UCLA in 1999 and was a finalist for a 2006 National Magazine Award for a piece in the Virginia Quarterly Review called “Dead Enough? The Paradox of Brain Death”–and she too has recently published a treatise on doctoring, Final Exam: A Surgeon’s Reflections on Mortality. But while Gawande’s book feels meandering and at times thin, Chen’s elegant medical memoir offers a series of extended meditations on mortality–and by extension humanity–that stay with you long after you’ve finished the book. Like the story of little Max, for example.
When Chen was still a young surgeon rising through the ranks of elite fellowships, she became obsessed for a time with a hapless patient named Max. Max was just a baby, but he was a sickly little thing, born with a horrific birth defect that seemed to have been dreamed up by a deeply disturbed soul–a “gaping” hole in his abdominal wall that required pediatric surgeons to remove nearly all of his bowels within hours of his birth. When, after four months, his overburdened teenage mother gave up custody of him, Chen and colleagues became his de facto medical guardians–and torturers.
They never meant to be. Like all good doctors, they had made a vow to do no harm, to avoid “those twin traps of overtreatment and therapeutic nihilism,” as the modern Hippocratic oath puts it. But along the way they had become “bound” to their technology, as Chen later reflected, and “despite inklings of self-doubt” felt compelled to make use of the tools science had provided them. So they kept at it, poking, prodding and transplanting through half a dozen surgeries that left the surface of Max’s belly raw and gangrenous, his body invaded by infection. When he finally died, a nurse told Chen, “Maybe it was a good thing, huh? I mean, how much can you do to a person?”
The story of baby Max haunts the pages of Final Exam. In a book full of distressing tales, it is among the most disturbing, an object lesson in the seductive dangers of practicing medicine for medicine’s sake–and of the occasional, unspeakable cruelty of trying to stave off death.
For Chen, death is medicine’s primary socializing force, the thing that repeatedly tests the humanity of physicians. While she went into medicine with dreams of saving lives and presiding over a clinic of “grateful, cured, modern-day Lazarus equivalents,” she quickly learned that death, not life, is medicine’s lingua franca. And since few doctors ever learn to cope with death–since medical training is, in fact, a series of “lessons in denial and depersonalization”–many physicians end up being “unable to care humanely for the dying.”
Chen’s own initiation into this culture of denial began within her first few days in medical school, with her human anatomy class. Anatomy is the notoriously grisly course during which first-year students learn the intricacies of the human body by dissecting a cadaver, one formaldehyde-soaked muscle at a time. Chen paints this process with a writer’s sense of poetry and a doctor’s precision; she describes how the back muscles of one group’s cadaver reminded her of the “big chunks of meat” she had seen in the butcher section of her supermarket, while her own cadaver’s legs were “turning outward like those of a dancer in the first position” after a classmate sawed apart its pelvis.
Despite (or perhaps because of) her eloquence, however, this section of Final Exam is almost impossible to get through–a series of descriptions of brutal acts that a reader can barely read, let alone imagine performing. And that’s the point. The process of taking apart another human is a violent undertaking, a violation that contradicts all our notions of the body’s sanctity. Not surprisingly, students in human anatomy resort to all kinds of distancing and dehumanizing strategies–suppressing their fear of death, sublimating the horror of slicing up another human being, turning them into “cadavers” rather than people, even, perhaps, hiding in literary language–something their professors encourage by example and by withholding all personal information about the bodies except their age. That the students receive scarcely any psychological support only compounds the problem. By the time they put down their scalpels at the end of the course, they have stripped their first “patients” of any and all humanity.
“We learned to suppress our instincts of fear and even of repulsion,” writes Chen. “We pushed those emotions out of our consciousness in order to further medical knowledge. We had become initiated.”
Initiation was only the first step, however. With anatomy class behind them, Chen and her peers moved on to participating in messy “code blues,” bloody surgery deaths and slow, painful expirations in lonely hospital rooms. Final Exam describes many of these episodes and, with them, the various dysfunctional (but rather understandable) responses that Chen and her peers perfected. We watch her absorb the bureaucratic nonchalance of older residents who have reduced death to a pile of paperwork they need to fill out. We see her puzzle over the behavior of a team of physicians who all but abandon an elderly patient once it becomes clear they cannot save her. And we observe how the chronic pressures of residency–the long hours, the intricate operations she must learn, the constant risk of killing a patient–turn her into an operating machine with little time to reflect on the loss of the patients who don’t make it.
“I forgot their humanity,” she says of the patients who died on her watch. “I forgot that they had families and friends, likes and dislikes, and hopes probably not that dissimilar from my own. For me, these dead were just another middle-of-the-night operation.”
Chen’s turning point came during an operation to remove the organs of a 35-year-old Asian woman who had been irremediably injured in a car accident several days earlier. The procurement, as these organ-harvesting operations are known, was Chen’s eighty-third, and might have been as routine as all the previous ones. But as she prepared to slice into the woman’s breastbone, the sterile drape covering her chest fell away and she noticed that the woman’s breasts resembled her own. The “thinness” of her chest, the “texture” of her skin–it all reminded Chen of her own 35-year-old body. “I felt as if I were pulling apart my own flesh,” she writes.
Chen began writing shortly after this incident, spewing forth “fictional stories” that were “almost always thinly veiled narratives” about her patients. Along the way, she rediscovered her patients’ mortality, as well as her own, and with it the good old-fashioned humanism at the heart of medicine. It’s the kind of positive ending that could easily fall into cliché, were it not for the fact that Chen’s thesis–that doctors who can’t confront their mortality make poorer clinicians–is supported by so many terrifying anecdotes and statistics. With more than 90 percent of us destined to die from a “prolonged illness,” with one out of four oncologists failing to tell their patients they have terminal cancer, often because they are too busy or because they simply don’t know how to break the news, it would be reassuring to know that our doctors have spent enough time confronting their own mortality to take care of our failing bodies when the time comes.
In her chapter on Max, Chen traces the birth of today’s dysfunctional medical culture to the scientist-physician of the late nineteenth century, whose various medical innovations–standardizing training and procedures, introducing anesthesia and sterile practices, and giving up archaic treatments like bloodletting–had turned the body from some “mysterious repository of disease” into “a rational, potentially reparable biological machine.” It was an evolution that has saved many lives but that also, when taken to its extreme, has stripped doctors of their humanism, their patients of their humanity. No doubt Sinclair Lewis would have recognized the paradox.
“We battle away until the last precious hours of life, believing that cure is the only goal,” Chen writes. “We inflict misguided treatments on not just others but also ourselves. During these final, tortured moments it is as if the promise of the nineteenth century has become the curse of the twenty-first.”