As breast cancer patients, we face some fairly complex decisions. Each time we come to a major crossroads involving treatment, we must weigh our duty to survive -– for family, for friends, for ourselves –- vs. our ability and desire to withstand the extreme hardship of crippling drugs and disfiguring surgery. We look at each step the oncologist outlines in terms of our personal strength, and ability to take that step: can I do it? Will I make it? Do I even want to? How much of myself do I sacrifice to stay alive for someone else? Where do I draw the line between serving myself, and serving others? What’s the “right” decision?
Dr. Gawande discusses the most important ways patients can improve and safeguard their own medical care.
All of us, at one time or another, will face this type of medical decision. Even without being patients ourselves, we must sometimes make choices for family members: our children and, more commonly, aging parents. Complex decisions, life and death decisions, aren’t always governed by law. We’re given a lot of latitude in making healthcare choices, so it’s critical that we have some well-developed inner guidelines to inform those decisions. Better speaks to those personal guidelines, with its focus on four main themes: diligence, doing right, ingenuity, and the ability to change.
Atul Gawande on Diligence
Diligence is defined as the ability to perform a task over and over again; the attention to detail that seems insignificant, but can be the difference between success and failure (or life and death, in the case of medicine). Gawande illustrates this with the seemingly simple matter of healthcare professionals washing their hands frequently enough to avoid the spread of germs. It doesn’t routinely happen, due to a number of roadblocks (habit, forgetfulness, inaccessibility of facilities). And this lack of diligence, Gawande says, claims lives.
On the other hand, diligence, a long, relentless, daunting attention to detail, is present in the massive effort to eradicate polio worldwide. Gawande tells the tale of an incredible undertaking stemming from a 2003 isolated childhood polio case in
Diligence is also what takes us through breast cancer treatment, isn’t it? The everyday drudgery of radiation; the ability to get that shot of chemo in the arm, even though you KNOW it’s going to make you dreadfully sick; the physical therapy exercises after surgery, day after day after day… diligence is a hallmark of successful cancer treatment, even though we realize it’s no guarantee of success.
Gawande’s next key factor, something that distinguishes the great from the merely good, is “doing right.” He chooses to speak of it in rather uncomfortable terms: should doctors participate in prison executions? After all, aren’t doctors supposed to preserve life, not take it? Laws require medical personnel to be present, and if necessary, to assist with executions. As Gawande writes, “How, then, to reconcile the conflict between government efforts to provide a medical presence, and our [doctors’] ethical principles forbidding it?” The answer, as so often happens in real life, isn’t black and white. While Gawande comes down on the side of medical professionals NOT assisting at executions, he recognizes that those who do “took their moral duties seriously.” Gawande concludes that “…we have to be prepared to recognize when using our abilities skillfully comes into conflict with using them rightly.” Doing right: it may mean not following the law, and each doctor –- indeed, each of us, in our everyday lives –- must look into our hearts to find our own path.
As breast cancer patients or survivors, we have the ability to do the right thing, rather than the easy thing. While it’s not against any law to focus our often lagging energy on ourselves, how much better is it, in the long run, to reach outside your own misery and comfort the teary woman sitting next to you in the waiting room? Or to grab your IV pole and push it around the chemo area to see if anyone looks like they could use a friend? That’s right; that’s good.
Finally, Gawande examines ingenuity. He uses an account of a baby’s birth via Cesarean section to detail the ways doctors over the centuries have learned to deal with childbirth, a process that despite its worldwide ubiquity can go wrong “at almost any step.” From the seemingly barbaric ways “stuck” babies were taken from their mothers in ancient times, to the skillful use of forceps prior to the advent of surgery, Gawande shows ingenious responses to life-and-death situations.
He also examines strides in cystic fibrosis treatment by detailing the inventive ways doctors LeRoy Matthews and Warren Warwick have treated their patients over the years. And he uses their performance to riff on the meaning of average. “If the bell curve is a fact, then so is the reality that most doctors are going to be average. There is no shame in being one of them, right? Except, of course, there is. What is troubling is not just being average but settling for it... When the stakes are our lives and the lives of our children, we want no one to settle for average.” Ingenuity is one of the attributes that can take the average doctor to the next level.
And truly, ingenuity is second nature when you’re dealing with breast cancer treatment. How many of us have figured out a way to carry around those darned mastectomy drains without having them flop all over the place? Or how to fit a breast form into a favorite bra? Or how about pointing out to the overworked schedulers at the hospital that if you’re having radiation at 8 a.m. anyway, why not schedule that DEXA scan for 8:30, rather than 11? There are ways, both large and small, that you can use your imagination–your ingenuity–to make cancer treatment more “do-able.”
