FACE TO FACE
Lives on the line all the time
SAMANTH SUBRAMANIAN
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Dr. Atul Gawande on the world of medicine and how he began to write on it.
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PHOTO: HARVARD UNIVERSITY NEWS OFFICE
HIGH DRAMA: Dr. Atul Gawande.
DR. ATUL GAWANDE'S writing happened in the midst of a hectic life. At 26, he was one of President Bill Clinton's health policy advisors and he has been writing for publications such as the New Yorker, Slate and the New England Journal of Medicine for a decade.
He is also a staff member at the Brigham and Women's Hospital and the Dana Farber Cancer Institute, as well as Assistant Professor of Surgery at Harvard Medical School and the director of the World Health Organisation's Global Challenge for Safer Surgical Care.
In 2006, he received the MacArthur Award for his research and writing.
Excerpts from an interview with Gawande ahead of the U.S. release of Better:
How did you originally begin to write about your profession? What set you on that track?
Well, I'd never written anything professionally before I was a surgical resident. What started me on it was grappling with questions that I didn't find good answers to in textbooks — questions about the mistakes we make, and the responsibility for uncertainty in medicine.
That started me writing essays on policy questions first and later on deeper issues. I wrote a column for a couple of years for Slate and then moved on to the New Yorker and essays for the New England Journal of Medicine. The Slate columns started in 1997, so it's exactly 10 years now.
What is the hardest part about writing about something that you do every day?
Finding the time!
That's understandable! But is there ever a problem of being so immersed in the field that you never know what might appear interesting to a lay reader?
There's actually the exact opposite challenge. Medicine is so dramatic, and there are so many interesting things going on that you can persuade yourself that every story is worth telling.
The usual mistake is to think that it is all worth telling; the harder part is to recognise which ideas are different.
I don't go through my day thinking: "Ah, there's a story!" I stumble upon ideas or puzzles, and then I think back to cases that have come up as solutions to those ideas or puzzles.
There's a theme to both Complications and Better, in which you explore the fundamental humanity of medical practitioners and the benefits and drawbacks of that humanity. When did that begin to manifest itself to you when you began working?
It began from the moment I walked into a hospital and put on my white coat as a doctor. The responsibility you inherit, in many ways, is like any other job. You have to get the details right, meet production quotas, and so on.
If you're a teacher, you're responsible for the education of human beings. If you're a taxi driver, you're responsible for the safe transport for human beings.
The only difference in medicine is that there are lives on the line all the time.
Was it incidental that Better is broader in scope than Complications?
It's true. I did venture a little further with Better looking more at the edges of what we do. I was trying to understand the moral dimensions of success in medicine, and talking to medical consultants at executions or war doctors at Walter Reed Hospital was one way of trying to grasp that.
Often, going out of the usual lets you see something in an entirely new way.
Do you see an irony in the fact that the humanity and fallibility of doctors is more emphasised now than ever, even as so many medical processes get automated or computerised?
The irony is that it is the product of our success. Fifty years ago, it didn't matter what doctors did, because a lot of it was not successful. Now there are thousands of ways to diagnose and treat ailments, even when there is no specific cure. So even the smallest choices matter. Ironically, as technological and scientific as medicine has become, it has also become more human. That science is not delivered until a human being sits down and does it.
What about in a country like India, where science and technology have not necessarily caught up with American standards?
The absolutely fascinating thing about my travels in India is, first, how incredibly talented the surgeons are.
I tell the story of how a surgeon in my father's village operates on everything from the brain to the prostate. When he asked me what my preferred approach was to remove bladder stones, I could only say: "To call a urologist."
The striking thing is that life expectancy in India has increased from 40 to 65 years in one generation. So diarrhoeal and respiratory illnesses are no longer a problem; instead cardiac problems and cancer are killing people. How India will cope with that on $20 a person a year is the driving dilemma.
I saw that physicians felt duty-bound to not abandon their patients, but I also saw where the simplest things could be utter failures. It's that mix of talent and systemic failure that drives a lot of Indian patients to feel at their wit's end.
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