Wash up!

>>Dr. Atul Gawande explores the mundane
tasks that can save lives in Better:
A Surgeon’s Notes on Performance

by Juliet Waters

No matter how entertaining Canadians are finding Michael Moore’s Sicko, we all know universal Medicare won’t solve all, or even most, of the worst health care problems. Deep down, we know there’s something even more important than medical insurance in keeping us healthy, and that this “something” is harder to document than tragic stories about mercenary insurance companies.

As Dr. Atul Gawande makes clear in his riveting book of essays, Better: A Surgeon’s Notes on Performance, the good news is that quality of health care is far less dependent on innovative technology, abundant resources and relentless, well-funded research than we tend to believe. The bad news is that it’s dependent on something probably more difficult to achieve, the common will to maintain high standards of care.

That said, innovation, abundance and relentlessness don’t hurt. Take one significant change in recent medicine, one that could save countless lives if it were properly implemented, but rarely is: adequate hand-washing.

I balked at the title and cover of Gawande’s book, implying, as it does, a catalogue of miraculous operations. Isn’t there enough of this on basic cable? What drew me in was Gawande’s first essay, a fascinating study of the historical and contemporary challenges of keeping hands washed and germ free. Remarkable diligence and commitment to essential mundane tasks is, Gawande believes, as responsible for life and death as a high level of skill.

Each year, two million Americans acquire infections in hospitals and 90,000 die. Meanwhile, “we doctors and nurses wash our hands one-third to one-half as often as we are supposed to. Having shaken hands with a sniffling patient, pulled a sticky dressing off someone’s wound, pressed a stethoscope against a sweating chest, most of us do little more than wipe our hands on our white coats and move on—to see the next patient, to scribble a note in the chart, to grab some lunch.” Clearly, Gawande has not written this book to bolster our faith in the health care system. But neither has he written it to shock or outrage. He’s written it with the clear intention of locating the essential problems and improving the system.

Gawande (a surgeon who specializes in endocrinal tumours) unearths problems in the system that are like gnawing cancers, and weaves suspenseful, unpredictable stories around how well the system has grappled or failed to grapple with them. These stories include first-hand, highly perceptive accounts of fighting to eradicate polio in the third world; dealing with the “success” rate on the front line of Iraq and Afghanistan (more survivors than previous wars, meaning more disabled and more traumatized individuals); the ethics of doctors being involved in lethal injections; and the difficulty and absolute necessity of getting hospitals to open up the records of their success and failure rates (and stomaching their fear of malpractice suits) if medicine is going to have any substantial chance of improving.

But back to hand-washing; Medicare, it turns out, is not the only thing Americans have been slow in adopting. “Alcohol rinses and gels have been in use in Europe for almost two decades but for some reason only recently caught on in the United States.” Easier to use, faster, less irritating than soap and far, far superior in the killing of germs, gels increased the compliance rate in Gawande’s hospital from 40 to 70 per cent.

And yet, the infection rates remained the same. A 30 per cent failure rate is still too high. So Gawande sets out to find a hospital in Pittsburgh that has managed to get its wound-infection rate down to zero. The magic recipe? An idea called “positive deviance.” Organizing regular small meetings of health care workers across the spectrum, from janitors to food service staff to doctors to patients, in order to brainstorm ways to make relentless “gelling up” feel standard instead of neurotic. Kind of like what AIDS activists did for condoms.

If we could get half as many people talking about Better as they are about Sicko, who knows what kinds of “deviant” standards of health we could set.

Better by Atul Gawande,
Metropolitan, hc, 273pp, $30