Doctor Write

What does one do when faced with the reality of imperfection or human error,when surgeons snip the wrong nerve or spread infections by not washing their hands,when systems fail and lives are lost? These questions have interested and stimulated 46-year-old Gawande in his writing career of over 13 years. His first book Complications (2002) was an account of his experiences as a resident surgeon at a Boston hospital. It revealed the world of medicine as one of imperfect striving,peopled not by flawless medical professionals,but of overworked experts making split-second decisions despite not being sure,shaky novices learning how to hold a knife,of good doctors who turn bad ― and of ingenuity and courage in the face of it. I was not writing to say,Look at these terrible people. I was saying look at these human people trying to do these very difficult things. I was interested in how you become good at something when you are an imperfect creature, he says,when he meets us at a Delhi hotel on a Sunday morning. He is 6 ft 2 inches tall,dressed in jeans; his round glasses give him the air of an earnest student and he has the large,assuring hands of a surgeon.

Failure is the premise from which Gawande begins. One of the fundamental things I am interested in is failure,why people fail,why society fails, he says. It is not a theoretical interest,but one that arose because he came into medicine and felt like a fool. But its the title of his second book Better (2007) ― that explains the arc of his career,from endocrine surgeon to a thinker on American public health policy and a checklist evangelist. He is engaged,at all times,with the possibility of action and wisdom,of bettering lives,despite the debris of failure that always surrounds all human effort. Why does surgery claim 1,50,000 lives a year in America? How does one ensure that crucial steps are not left out during surgeries? How can old people have better lives?

In seeking the answers to these questions,Gawande looks not for technological wizardry but the most ordinary details,the dumb stuff. As he wrote in Better,one of the simplest ways to cut down on hospital infections,which claim 90,000 lives a year in the US,was to get doctors to wash their hands. A hundred and fifty years ago,we learnt that washing hands could save lives,and yet why dont we do it? You could say doctors are bad people. But 150 years of bad people,that cant be…it must be something human. I am very convinced that ordinary experiences tell us things that we are not noticing. In these little moments,something fundamental turns up,and means we may have misunderstood the world, he says. His last book,The Checklist Manifesto (2011),takes these insights further,arguing that if doctors follow the cognitive net of a simple checklist before complicated surgeries,they could save lives,by eliminating flaws of memory and attention and thoroughness. The idea was tested in eight hospitals across the world,including St Stephens Hospital,Delhi,and the results showed a reduction in death rates by 50 per cent.

With the WHO and the Gates Foundation,he has been trying to convince authorities to implement a checklist in surgery and childbirth in government hospitals in Uttar Pradesh as well as the high-end Fortis and Apollo chains. The checklist intervenes at three stages: when the mother arrives in the labour room,when she starts to push,when the child is born and then discharged. And you are checking things like if she should receive antibiotics,if everybody has washed their hands. If,immediately after the baby is born,the child has been put skin-to-skin against the mothers abdomen,and then to the breast to start its feed, he says. In UP,he found the conditions tough,he says with a chuckle,though he managed to get nurses and government officials interested.

When he heard of the fire at Kolkatas AMRI Hospital,he was reminded of a blaze at Hartford Hospital,Connecticut,50 years ago,that forced changes across hospitals in the US. There had been many fires before but this one was different because people were not interested in shaming doctors or sending people to jail. They focussed on why the fires kept happening. An inquiry found that a cigarette had started off the fire,the paint used in the hospital was flammable,ceiling tiles were made of sugarcane fibre,and evacuation procedures were faulty, he says. The results led to changes in hospital building norms across the US. Smoking was banned in all hospitals,as they should be in India. I am interested in knowing if this fire will be the one that changes everything?

Gawande grew up in Ohio,Texas,the son of a paediatrician mother and a urologist father,familiar with the language and sights of emergencies and OR. It was a while before he decided to study medicine,though,taking a detour at Oxford University,where he studied philosophy and politics,and working as a public health policy adviser for the Clinton administration.

When he became a resident surgeon,he also became a writer,prodded by his friend and Slate founder Jacob Weisberg to write about his experiences. He was commissioned to write for The New Yorker,and became a staff writer in 1998. Writing was not something that came very easily. When I turned in my first piece for The New Yorker,they said,nice start. It took nine months and 22 revisions for it to be published. Though he never expected it,writing has become the most important thing that he does. Its my way of understanding my world and medicine,my way of thinking. I get to see the patterns in my work,and how it connects to other things,and other worlds, he says. As a writer,he joins the dots between these disparate worlds,scooping ideas from skyscraper construction and the aviation industry,for example,and applying them to medicine. Because he believes that peoples experiences,and not statistics,tell you what really happen,his books are full of quirky,moving characters,who humanise the world of medicine. Details matter in writing,as it does in surgery. Even the way you stand when you are operating can make a difference to the patient. Similarly,the way you describe a nose,the way the line of your story unfolds,makes a difference: can the reader see what you want them to see,smell what you want them to smell? he says.

For a person who once described himself as indecisive,was surgery an odd choice? Part of my attraction towards surgery was not just the blood and the guts or that I liked to use my hands,part of it was the character of the surgeon. Here were people who believed in action even in the midst of uncertainty,believed that acting was more important than imperfection, he says. Its a belief that makes Atul Gawandes writing resonate beyond medicine,and makes him relevant and inspiring to ordinary lives. Over time,(you learn to) become comfortable with uncertainty and imperfection. No one writes about this in textbooks,no professor teaches you how. But it is in a sense the real education of a doctor,or of anyone trying to do something difficult in life.