Better (27 page)

This situation is not unique to India, and that is what makes it a core conundrum for our time. Throughout the East, demographics are changing swiftly. In Pakistan, Mongolia, and Papua New Guinea, the average life expectancy has risen to over sixty years. In Sri Lanka, Vietnam, Indonesia, and China, it is more than seventy years. (By contrast, because of AIDS, the expected life span in much of Africa remains under fifty years.) As a result, rates of cancer, traffic accidents, and problems like diabetes and gallstones are exploding worldwide. Cardiac disease has become the globe's leading killer. New laboratory science is not the key to saving lives. The infant science of improving performance--of implementing our
existing know-how--is. Nowhere, though, have governments recognized this. A surgeon in much of the world therefore stands on his own, with little more than a pen, his fine fingers, and his wits, to cope with a system that barely works and an ever-growing sea of patients.

These realities are without question demoralizing. The medical community in India has mostly resigned itself to current conditions. All the surgical residents I met hoped to go into the cash-only private sector (where patients with the means increasingly seek care, given the failure of the public system) or abroad when they finished their training--as I think I would, in their shoes. Many attending surgeons were plotting their escape, too. Meanwhile, all live with compromises in the care they give that they cannot bear to tolerate.

Y
ET, DESPITE THE
conditions, the surgeons have persisted in developing abilities that were a marvel to witness. I had gone there thinking that, as an American-trained surgeon, I might have a thing or two I could teach them. But the abilities of an average Indian surgeon outstripped those of any Western surgeon I know.

"What is your preferred technique for removing bladder stones?" one surgeon in the city of Nagpur asked me.

"My technique is to call a urologist," I said.

On rounds in Nanded with a staff surgeon one afternoon, I saw patients he'd successfully treated for prostate obstruction, diverticulitis of the colon, a tubercular abscess of the chest, a groin hernia, a thyroid goiter, gallbladder disease,
a liver cyst, appendicitis, a staghorn stone in the kidney, and a cancer of the right hand--as well as an infant boy born without an anus in whom he'd done a perfect reconstruction. Using just textbooks and advice from one another, the surgeons at this ordinary district hospital in India had developed an astonishing range of expertise.

What explains this? There was much the surgeons had no control over: the overwhelming flow of patients, the poverty, the lack of supplies. But where they had control--their skills, for example--these doctors sought betterment. They understood themselves to be part of a larger world of medical knowledge and accomplishment. Moreover, they believed they could measure up in it. This was partly, I think, a function of the Nanded surgeons' camaraderie as a group. Each day I was there, the surgeons found time between cases to take a brief late-afternoon break at a cafe across the street from the hospital. For fifteen or thirty minutes, they drank chai and swapped stories about their cases of the day--what they had done and how. Just this interaction seemed to prod them to aim higher than merely getting through the day. They came to feel they could do anything they set their minds to. Indeed, they believed not only that they were part of the larger world but also that they could contribute to it.

Among the many distressing things I saw in Nanded, one was the incredible numbers of patients with perforated ulcers. In my eight years of surgical training, I had seen only one patient with an ulcer so severe that the stomach's acid had eroded a hole in the intestine. But Nanded is in a part of the country where people eat intensely hot chili peppers, and patients arrived almost nightly with the condition, usually in
severe pain and going into shock after the hours of delay involved in traveling from their villages. The only treatment at that point is surgical. A surgeon must take the patient to the operating room urgently, make a slash down the middle of the abdomen, wash out all the bilious and infected fluid, find the hole in the duodenum, and repair it. This is a big and traumatic operation, and often these patients were in no condition to survive it. So Motewar did a remarkable thing. He invented a new operation: a laparoscopic repair of the ulcerous perforation, using quarter-inch incisions and taking an average of forty-five minutes. When I later told colleagues at home about the operation, they were incredulous. It did not seem possible.

Motewar, however, had mulled over the ulcer problem off and on for years and became convinced he could devise a better treatment. His department was able to obtain some older laparoscopic equipment inexpensively. An assistant was made personally responsible for keeping it clean and in working order. And over time, Motewar carefully worked out his technique. I saw him do the operation, and it was elegant and swift. He even did a randomized trial, which he presented at a conference and which revealed the operation to have fewer complications and a far more rapid recovery than the standard procedure. In that remote, dust-covered town in Maharashtra, Motewar and his colleagues had become among the most proficient ulcer surgeons in the world.

True success in medicine is not easy. It requires will, attention to detail, and creativity. But the lesson I took from India was that it is possible anywhere and by anyone. I can imagine few places with more difficult conditions. Yet
astonishing successes could be found. And each one began, I noticed, remarkably simply: with a readiness to recognize problems and a determination to remedy them.

Arriving at meaningful solutions is an inevitably slow and difficult process. Nonetheless, what I saw was: better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.

T
HERE WAS A
one-year-old boy I saw brought into the teeming Nanded surgery clinic by his parents, their faces wearing that distressing look of fear, helplessness, and fervent hope I'd come to recognize in poor, overcrowded hospitals. The child lay in the cradle of his mother's arms disturbingly quiet, his eyes open but without interest or reaction. His breathing was steady and unlabored yet unnaturally fast--as if a pump inside him were set at the wrong speed. The mother described repeated bouts of frighteningly violent vomiting--the emesis could burst out of him across a table. A doctor in the pediatric clinic had noted his head to be enlarged, with a circumference distinctly out of proportion to his small body, and made a provisional diagnosis that was confirmed on a skull X-ray: the boy had a severe hydrocephalus--a congenital disease in which the normal drainage of the brain is blocked. The cerebral fluid slowly accumulates, gradually expanding the skull but also compressing the brain to relieve the pressure. Unless surgery is performed to provide a new route out of the brain and skull for the fluid, the resulting brain damage becomes severe, advancing from vomiting to visual loss to sleepiness, coma, and
finally death. But if surgery were successfully done, the child could live completely normally. The pediatricians had therefore sent the child and his parents to the surgery clinic.

The surgery department had no neurosurgeon, though. Nor did it have the equipment a neurosurgeon would need--no drill to burr a hole through the skull, no shunt device with its sterile, one-way-flow tubing to channel the fluid out of the brain, under the skin, and down into the abdominal cavity. The surgeons did not want to just let the child die, however. They gave the father instructions about the sort of device his son needed, and he managed to find a facsimile of one in the local market for 1,500 rupees (about thirty dollars). It was not perfect--the tubing was too long and it wasn't sterile. But P. T. Jamdade, the chief of surgery, agreed to take the case.

The child was brought to the operating room the next day, my last in Nanded, and I watched the surgical team perform. The tubing was trimmed to size and put in a steam autoclave. The anesthetist put the boy to sleep with an injection of ketamine, a cheap and effective anesthetic. A nurse shaved the hair from the right side of his head with a razor and cleansed his skin from head to hips with an iodine antiseptic. A surgical resident laid sterile cloth drapes down to frame the operative field. On a little tray under a lone operating light, a nurse lined up the surgical instruments--silvery, gleaming, and, it seemed to me, wholly inadequate to the task. Jamdade had little more to work with than I would use to sew a minor laceration closed. But he took the scalpel and made a one-inch incision through the skin and thin muscle an inch above the boy's ear. He took a hemostat--an ordinary scissors-shaped metal clamp that surgeons normally use to grasp a small blood vessel or a
suture thread--and began slowly grinding its tip into the child's exposed white skull.

At first, nothing happened. The tip kept sliding off the hard, bony surface. But it began to find purchase, and over the next fifteen painstaking minutes he ground and scraped until a tiny hole through the skull appeared. He worked to widen the aperture, taking care not to slip and puncture the now exposed brain. When the opening was large enough, he slid an end of the tubing through into the space between the brain and the skull. He took the other end of the tubing and snaked it under the skin of the neck and chest down to the abdomen. Before popping the tubing into the open space of the abdominal cavity, though, he stopped momentarily to watch the fluid of the brain flowing out of its new channel. It was clear and lovely, like water. Like perfection. He had not given up. And as a result, at least this one child would live.

I
n October 2003, upon my return from India, I officially began my life as a general and endocrine surgeon in Boston. Mondays, I saw patients in a third-floor surgical clinic at my hospital. Tuesdays and some weekends, I took emergency call. Wednesdays, I saw patients at an outpatient clinic across the street from Fenway Park. Thursdays and Fridays, I spent in the operating room doing surgery. It has proved to be an orderly life, and I am grateful for that. Nonetheless, there was much I wasn't prepared for, including how small one's place in the world inevitably proves to be. Most of us, most of the time, are far removed from planning a polio mop-up for 4.2 million children in southern India or inventing new ways to save the lives of frontline soldiers. Our enterprise is more
modest. In my clinic on a Monday afternoon, I need to think about Mrs. X and her gallstones; Mr. Y and his painful hernia; Ms. Z and her breast lump. Medicine is retail. We can tend to only one person at a time.

No doctor wants to believe that he or she is a bit player, though. After all, doctors are given the power to prescribe more than 6,600 potentially dangerous drugs. We are permitted to open human beings up like melons. Soon we will even be allowed to manipulate their DNA. People depend on us personally for their lives. And yet, as a doctor each of us is just one of 819,000 physicians and surgeons in this country tasked with helping people live lives as long and healthy as possible. And even that overestimates the size of our contributions. In on this work are also 2.4 million nurses, 388,000 medical assistants, 232,000 pharmacists, 294,000 lab technicians, 121,000 paramedics, 94,000 respiratory therapists, 85,000 nutritionists.

It can be hard not to feel that one is just a white-coated cog in a machine--an extraordinarily successful machine, but a machine nonetheless. How could it be otherwise? The average American can expect to live at least seventy-eight years. But reaching, and surpassing, that age depends more on this system of millions of people than on any one individual within it. None of us is irreplaceable. So not surprisingly, in this work one begins to wonder: How do I really matter?

I get to lecture to the students at our medical school on occasion. For one lecture, I decided to try to figure out an answer to this question, both for them and for myself. I came up with five--five suggestions for how one might make a worthy difference, for how one might become, in other words, a positive deviant. This is what I told them.

M
Y FIRST SUGGESTION
came from a favorite essay by Paul Auster:
Ask an unscripted question.
Ours is a job of talking to strangers. Why not learn something about them?

On the surface, this seems easy enough. Then your new patient arrives. You still have three others to see and two pages to return, and the hour is getting late. In that instant, all you want is to proceed with the matter at hand. Where's the pain, the lump, whatever the trouble is? How long has it been there? Does anything make it better or worse? What are the person's past medical problems? Everyone knows the drill.

But consider, at an appropriate point, taking a moment with your patient. Make yourself ask an unscripted question: "Where did you grow up?" Or: "What made you move to Boston?" Even: "Did you watch last night's Red Sox game?" You don't have to come up with a deep or important question, just one that lets you make a human connection. Some people won't be interested in making that connection. They'll just want you to look at the lump. That's OK. In that case, look at the lump. Do your job.