Book Review: What Atul Gawande's Newest Book Means for Breast Cancer Patients and Survivors

Patient Expert

On reading the title of the book, Better: A Surgeon's Notes on Performance, and glancing at its cover, which pictures a gowned-up surgeon, you'd expect it to be a graphic exploration of surgery, a "you are there" treatment of what goes on in a typical hospital operating room. But, by the time you get through the introduction, you realize that this book, though it includes scattered accounts of actual surgery, is much, much more. It's about what it takes -- besides a medical school diploma, brains, and a major amount of talent -- to be a truly good surgeon. And the characteristics author Atul Gawande outlines -- diligence, doing right, ingenuity, and the ability to change -- can be carried over into anyone's career, and certainly into life after breast cancer.

Gawande, the modern definition of a Renaissance man, combines science and art in equal measures. A surgeon at Brigham and Women's Hospital in Boston and a HarvardMedicalSchool professor, he's also a staff writer for The New Yorker magazine (where many of the essays in this book first appeared), and a 2006 MacArthur Fellow.

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Atul Gawande's debut book, the New York Times best-seller Complications: A Surgeon's Notes on an Imperfect Science, looked at surgery, revealing that this critical part of medicine, rather than being populated by the god-like figures we imagine our doctors to be, is after all only as good as its very human surgeons. In Better, Gawande goes a step further, detailing the inner attributes, rather than the outward abilities, which make someone a truly brilliant surgeon.

On the Shelves of a Breast Cancer Survivor's Personal Library

Since receiving a breast cancer diagnosis in 2001, my library has expanded to include numerous books touching on the subject: Dr. Susan Love's Breast Book, Hester Schnipper's After Breast Cancer, and other favorites now populate an entire section in my bookshelves. Atul   Gawande's Better, while it doesn't focus on breast cancer per se, is nevertheless a valuable addition to the collection of literature on the genre. While the primary focus of most cancer books is physical and practical, with perhaps a side trip into emotional issues, Better takes a whole new tack: looking at medicine in general (and breast cancer specifically, in a couple of instances) from a moral and ethical point of view, as it defines our personal standards of accountability.

The ethical issues Gawande examines aren't so much tied to law (though that's covered, too); but to the morals and ethics that become the personal compass by which we all live. Better isn't a book about breast cancer; nor is it directed toward the layman, as it speaks mainly to doctors. But the lessons it illustrates, through a fascinating peek inside the world beyond the waiting room, apply to all of us. And as such, Better is a book that can resonate way beyond the medical community it covers.

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?

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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 India: 41,000 healthcare volunteers in 2,000 vehicles, covering 50,000 miles to vaccinate 4.2 million Indian children--in three days. Diligence was the key factor at work there, and it did in fact prevent polio from spreading outside the region where it began.

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.

Doing Better By Doing Right

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.

Atul Gawande on Ingenuity

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."

How Gawande's Afterword Applies to the Rest of Us

Gawande concludes Better with "Suggestions for Becoming a Positive Deviant," a summary of a graduation speech he's given to students at Harvard Medical School. (A positive deviant is someone who acts in such a way that their achievements are at the top of the bell curve). And, while the examples he gives are based in medicine, the message they illustrate can apply to all of us. He urges doctors to step outside routine in their quest to become better than they are, advising the following: "Ask an unscripted question. Don't complain. Count something. Write something. Change."

He concludes, "The choices a doctor makes are necessarily imperfect but they alter people's lives. Because of that reality, it often seems safest to do what everyone else is doing-to be just another white-coated cog in the machine. But a doctor must not let that happen-nor should anyone who takes on risk and responsibility in society."

Hear that? Any of us who take on risk and responsibility in society-not just doctors, but parents, public servants, any of us with responsibilities to fulfill-should try to go beyond being "just one of the crowd." I read "Ask an unscripted question" as thinking outside the box. "Don't complain" needs no translation; as Gawande says, negativity drags all of us down needlessly. "Count something," I translate to "pay attention to the details; you'll learn something interesting."

In writing these SharePosts, it's often in out-of-the-way corners online that I find the most interesting writing about breast cancer: perhaps a blogger in India writes about a new vaccine being worked on there. Or some research on the connection between tamoxifen and depression, reported in a minor journal, strikes a chord with me: "Yeah-he nailed it, that's true." Keep your eyes open; you never know what's coming around the next bend.

"Write something." Over and over again, as I write about breast cancer, I experience the power of the written word. As I write, not only do I connect with my readers, I get in touch with a deeper part of myself, a part that's usually buried under the day-to-day struggle to simply exist in this complex world. Gawande writes, "An audience is a community. The published word is a declaration of membership in that community and also of a willingness to contribute something meaningful to it." Every one of us can contribute something to our community of sister survivors, if only in a sympathetic e-mail to someone beginning chemo. Write" it's advice I've been following all my life.

And finally, Gawande asks his students to "change." "Become the change you want to see" is a mantra for change at my workplace. If you're not happy with something, don't complain: model a solution. Change is a challenge" and change is good.

As a breast cancer patient or survivor, what can you take away from this book? Everything, if you're willing to step out of your comfort zone. After all, becoming better than you are-better than average-isn't a goal specific to surgeons; it's for all of us. And now, when cancer has given you the chance to make some wholesale life changes, is the perfect time to seek your better self.

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