Human beings are social creatures. We are social not just in the trivial sense that we like company, and not just in the obvious sense that we each depend on others. We are social in a more elemental way: simply to exist as a normal human being requires interaction with other people.
I think we are faced in medicine with the reality that we have to be willing to talk about our failures and think hard about them, even despite the malpractice system. I mean, there are things that we can do to make that system better.
Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination.
To become a doctor, you spend so much time in the tunnels of preparation – head down, trying not to screw up, trying to make it from one day to the next – that it is a shock to find yourself at the other end, with someone shaking your hand and asking how much money you want to make.
As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.
I believe that one version of the good in life can be defined by the moments I sometimes had playing tennis as a sixteen-year-old. You’d be out on the court and for an hour, two hours, sometimes an entire roasting hot day, and every single thing you hit would go in. Hit that ball as hard as you wanted, wherever you wanted, and it went in.
I have always believed that there is nothing greater than a life in rock n’ roll – it has to be good rock n’ roll – and I still think it is true.
I was never born to write. I was taught to write. And I am still being taught to write.
I write because it’s my way of finding cool ideas, thinking through hard problems and things I don’t understand, and getting better at something.
When I do an operation, it’s half a dozen people. When it goes beautifully, it’s like a symphony, with everybody playing their part.
People say that the most expensive piece of medical equipment is the doctor’s pen. It’s not that we make all the money. It’s that we order all the money.
My vantage point on the world is the operating room where I see my patients.
The vast majority of doctors really do try to take the money out of their minds. But to provide the best possible care requires using resources in a way that keeps you viable but improves the quality of care.
I think the extreme complexity of medicine has become more than an individual clinician can handle. But not more than teams of clinicians can handle.
Our great struggle in medicine these days is not just with ignorance and uncertainty. It’s also with complexity: how much you have to make sure you have in your head and think about. There are a thousand ways things can go wrong.
You know, 97 percent of the time, if you come into a hospital, everything goes well. But three percent of the time, we have major complications.
I’m floating between multiple media. I really wish you could buy the hardcover book and it would come with the digital download and audible version. I spend stupid amounts of money because I’m usually buying my books in at least two formats.
Oliver Sacks remains my hero to this day. He was one of the first medical writers I read. The other was Lewis Thomas, who is no longer alive but is just heroic to me.
George Orwell is a pinnacle writer, for his combination of moral insight and literary writing.
The writing I love has something memorable in it – an image, a smell. It’s the connection between the moment and the whole concept, weaving the micro together with the macro so that it has a hold on people – that’s writing.
No one looks at your hands to see how much they shake when you are interviewed to be a surgeon. The physical skills required are no greater than for writing cursive script. If an operation requires so much skill only a few surgeons can do it, you modify the operation to make it simpler.
You want to ensure people can do it right 99 percent of time. When we have to fire one of our surgical trainees, it is never because they don’t have the physical skills but because they don’t have the moral skills – to practise and admit failure.
If I get hit by a bus tomorrow, my patients will not even be postponed. Another surgeon would step in and take over. The reason to do research and writing is that it at least makes me feel not entirely replaceable. If I didn’t write, I don’t know if I would do surgery.
Every country in the world is battling the rising cost of health care. No community anywhere has demonstrably lowered its health-care costs (not just slowed their rate of increase) by improving medical services. They’ve lowered costs only by cutting or rationing them.
Outsiders tend to be the first to recognize the inadequacies of our social institutions. But, precisely because they are outsiders, they are usually in a poor position to fix them.
Cost is the spectre haunting health reform. For many decades, the great flaw in the American health-care system was its unconscionable gaps in coverage.
The health-care sector certainly employs more people and more machines than it did. But there have been no great strides in service. In Western Europe, most primary-care practices now use electronic health records and offer after-hours care; in the United States, most don’t.
There are, in human affairs, two kinds of problems: those which are amenable to a technical solution and those which are not. Universal health-care coverage belongs to the first category: you can pick one of several possible solutions, pass a bill, and (allowing for some tinkering around the edges) it will happen.
The history of American agriculture suggests that you can have transformation without a master plan, without knowing all the answers up front.
No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it. You must consider what is covered for a patient and what is not.
In every industrialized nation, the movement to reform health care has begun with stories about cruelty.
The damage that the human body can survive these days is as awesome as it is horrible: crushing, burning, bombing, a burst blood vessel in the brain, a ruptured colon, a massive heart attack, rampaging infection. These conditions had once been uniformly fatal.
This is the reality of intensive care: at any point, we are as apt to harm as we are to heal.
Expertise is the mantra of modern medicine.
We now live in the era of the super-specialist – of clinicians who have taken the time to practice at one narrow thing until they can do it better than anyone who hasn’t.
Health care confronts us with a difficult test. We have never corrected failure in something so deeply embedded in people’s lives and in the economy without the pressure of an outright crisis.
Our health-care morass is like the problems of global warming and the national debt – the kind of vast policy failure that is far easier to get into than to get out of. Americans say that they want leaders who will take on these problems.
Most people are squeamish about saying how much they earn, but in medicine the situation seems especially fraught. Doctors aren’t supposed to be in it for the money, and the more concerned a doctor seems to be about making money the more suspicious people become about the care being provided.
Doctors quickly learn that how much they make has little to do with how good they are. It largely depends on how they handle the business side of their practice.