Atul Gawande is a doctor specializing in endocrine surgery. This book
is a collection of loosely related chapters that comprise his thoughts
on the subjects related to his profession. As he describes in the
afterword, surgery is more of a physical than an intellectual
pursuit. So he picked up this writing as a way to balance this
and to not get burned out with long hours of hard meticulous work
where a small error may cause human suffering or death.

Gawande writes with surety of a person accustomed to using a
scalpel. In some stories, this self-assuredness is a bit grating. This
may in part be due to the actor who narrates the stories in the audio
version of the book. Moreso, Gawande is somewhat of a technocrat and a
right-winger, and occasional dose of skepticism may be what the good
doctor should have ordered. Another one of his afterword's credos is a
positive outlook. So, Gawande often takes the state of affairs for
granted and avoids critically examining the systemic failures of the
health care in the US. That said, Gawande often reserves his judgment
and tries to present both sides of the issue.

The book has come out relatively recently -- in 2008 -- yet a few of
the facts that Gawande uses are already dated. He claims regular
mammograms to be necessary for fighting breast cancer while more
recent studies contest that.  In one of the chapters, Gawande
describes how C-section leads to better and more predictable delivery
outcomes than vaginal delivery in complicated pregnancies.  It is
interesting to read about various maneuvers, some of them are
difficult to master, to help with complications during vaginal
delivery. The obstetrics opted for simpler C-section, effectively
de-skilling doctors, so as to ensure this improvement and
predictability of deliveries.  After the book was published, new
studies show the risk of respiratory problems, struggle with
breastfeeding and higher rates of obesity for children delivered
through C-section.

Oh, and Gawande loves the thoroughly discredited "The Bell Curve" by
Charles Murray.

The first part of the book (Diligence) contains three chapters. The
first deals with the necessity of controlling hospital infection rates
and a major role that simple disciplined hand washing plays in it, and
how important this mundane procedure is, and how difficult it is to
enforce. Gawande describes how hospital officials responsible for
lowering infection rates tried everything from pestering doctors to
enlisting proactive staff participation and rewards. I remember how
doctors are occasionally hesitant to shake hands with patients. Next
time I'll just node. 

This chapter starts with Gawande describing how modern medicine is a
complicated machine of delivering health care where everything should
go exactly right.  It is then amusing how later in the book Gawande
focuses on his own individual betterment as a way of improving his
patient's care.

The "mop-up" chapter describes a worldwide polio-elimination
campaign. Specifically, the mission of mass vaccinations in India in
and around areas where recent polio cases had been found. The mission
relies on local doctors and volunteers and has to deal with patients'
illiteracy, ignorance and ethnic hostility.  Gawande personally
participates in one such mopup and ponders the difficulty of the
mission, the amount of resources spent and the worthiness of the goal.

The next chapter is on the revolution of the treatment of
battlefield casualties which allowed to bring the death rate from 41%
in the Civil War, 30% in WWII, 25% in Viet Nam and First Gulf War to
about 10% during the war in Iraq and Afghanistan. Gawande's interest
in this is purely technocratic: he is proud of the surgical
advances. It never crosses his mind that these advances enable further
US military adventures.

The next chapter "Naked" is silly prudishness about social taboos and
having to see patients naked and examine their private parts. 

"What Doctors Owe" examines medical malpractice cases. Gawande shows
how seriously broken the system is. He claims that doctors, as all
humans, make mistakes. Their mistakes cause injury and death. However,
punishing the doctors for them, especially through courts, is hardly
constructive. This results in a few patients getting financial
windfalls while most of them get nothing.  He suggests that a fairer
system would set up a fund that would try to offset the financial loss
(to the patient to the family) due to medical mistakes. He gives an
example of a similar system set up for vaccine manufacturers.

"Piecework" discusses the business side of running a medical practice:
dealing with insurances, setting rates, making sure payments are
coming in on time and so on. This time Gawande is not at all critical
of hospitals and insurance companies that make US health care ever
more expensive and unwieldy, Gawande just wants to get paid.

In "The Doctors of the Death Chamber", Gawande describes how American
Medical and Nurse Associations prohibit doctors and nurses from taking
part in executions, especially the executions by lethal injection. And
for good reason: the medical professionals start from just stating the
fact of death but eventually get dragged into the process such that
they actually become executioners.  He then interviews a few doctors
and nurses who do participate in executions in various capacities and
describes their stories and reasoning: somebody worked in a prison
hospital and felt like he had to do it, Somebody else just could not
hold back when they were mucking up the procedure and making it
painful for the "patient". Gawande does not state his opinion, he just
covers both sides of the story.

In one of the chapters, I forget which, Gawande describes his
experiences on sort of a field trip through Indian medicine with
attendant third-world problems: overcrowded hospitals, shortage of
supplies, complicated cases, long stressful work hours, lack of
diagnostic facilities, graft and ignorance. It was interesting how
Gawande, then an experienced surgeon thought he could teach his Indian
colleagues. As it turned out, his American training was often of
little use as it relied on tests and equipment that were not available
there. Moreover, Indian doctors learned to cope with this state of
affairs and become adept at successfully diagnosing and treating
patients without little more than physical examinations and basic
tests. In fact it was an artistry of experience and calculated risk.
I remember how russians were proud of such artisan doctors as
authentic achievement of Russian medicine. Oh, well.

The last three chapters is where Gawande's right-wing comes out to
shine.  He considers giving numerical score to the performance of
individual doctors and hospitals as a way to evaluate them and improve
their work. The first examples he gives are the Apgar score (the
health of a newborn) and the number of successful implantations in
in-vitro fertilization.

He then focuses on percentage of lung function and average life
expectancy of patients with Cystic Fibrosis. The better results tend
to be achieved if patients meticulously follow treatment regiment
throughout their lives. So doctors and clinics need to make sure they
do. Gawande talks about how patients may or may not want to go to the
clinics that achieve the best results. The whole discussion starts to
sound like the recent test-based evaluations of teachers with
attendant school closings, managers running schools as business,
firing "underperforming" teachings teaching to the test and similar
silliness.

It then gets worse as Gawande starts to sound like a self-help guru:
how to get ahead of the curve of doctors, how to stay positive and
other nonsense.

Overall, a good read, with interesting questions raised, warts and
all.