HIV and ID Observations

I was an English major in college, so when my acceptance to medical school (miraculously) arrived, several people gave me books written by doctors about their experience in the medical profession.

“See,” these gifts implied, “Just because you’re going to medical school doesn’t mean you need to become a science drone. Doctors can write too!”

Sure, doctors can write — but can they write well?

Debatable — confess I’m not a big fan of most books or articles written by doctors. First, the tone in many of them is the very definition of sanctimonious. Second, I often note this strange sameness to the depiction of clinical care. It goes something like this:

1. A patient is [choose one or more of the following] doing poorly/unhappy with their care/suffering from a mysterious illness/critically ill/dismissed as a hypochondriac/tired of seeing so many doctors/ready to give up.
2. Everyone else in the medical profession is messing up.
3. Doctor author comes in and saves the day.

Atul Gawande, a staff writer at the New Yorker, is a wonderful exception to the rule that doctor writers are big show-offs.

He also happens to be a general surgeon at the Brigham, hence the “Brush with Greatness” claim in the title — I get to see him periodically on the inpatient wards.

I’m thinking of him because he wrote a fascinating piece in this week’s New Yorker on how hospitals could learn a thing or two from the Cheesecake Factory, of all places. (Note it’s not an Olive Garden — phew.) The major point is that there’s potentially real value in standardization — better care, lower costs — but that it won’t be easy for individualist doctors and isolated health care systems to adapt.

As usual in one of Atul’s pieces, the tone is just right. It’s been a revelation to read a doctor who writes about clinical medicine in a style that 1) avoids sanctimony and, 2) does not feature a “saved-the-day” story starring MD Superstar.

In fact, when Atul does involve himself in his pieces, it’s usually either as interested observer (such as this wonderful and truly heartbreaking description of modern aging), or to describe his own failings as an MD  — trouble with an operation, an erroneous diagnosis, a sense of feeling overwhelmed. These disclosures are inevitably followed by reflections on how he might improve — how very human and appealing.

My favorite part of the current New Yorker piece juxtaposes the precision and lack of waste on the food prep lines of the restaurant with the chaos of a brief hospitalization for an elderly woman after a fall. The woman, who has Alzheimer’s, is the mother of the Regional Manager of the Cheesecake Factory branches here in Boston:

The doctors ordered a series of tests and scans, and kept her overnight. They never figured out what the problem was. Luz [the Regional Manager] understood that sometimes explanations prove elusive. But the clinicians didn’t seem to be following any coordinated plan of action. The emergency doctor told the family one plan, the admitting internist described another, and the consulting specialist a third. Thousands of dollars had been spent on tests, but nobody ever told Luz the results….

Luz’s family seemed to encounter this kind of disorganization, imprecision, and waste wherever his mother went for help. “It is unbelievable to me that they would not manage this better,” Luz said.

If you do any inpatient medicine at all, this is all too recognizable a scenario, and frankly quite painful. And, as usual in Atul’s pieces, a real motivator for us to get better at what we do.

Hey, that would make a good name for a book!