by Atul Gawande
50 The Web site www.polioeradication.orghas up-to-date information on the current number of polio cases and maps with the locations of outbreaks.
CASUALTIES OF WAR
51 The U.S. Department of Defense's weekly update on American military casualties can be found at http://www.defenselink.mil/news/casualty.pdf.
52 The study that first examined the relationship between homicide rates and medical care is A. R. Harris, S. H. Thomas, G. A. Fisher, and D. J. Hirsch, "Murder and Medicine: The Lethality of Criminal Assault, 1960-1999," Homicide Studies 6 (2002): 128-66.
52 The source for the historical casualty numbers is U.S. Department of Defense, "Principal Wars in which the United States Participated: U.S. Military Personnel Serving and Casualties," 2004 (http://web1.whs.osd.mil/mmid/casualty/WCPRINCIPAL.pdf). Some experts have argued that the DoD online data is inaccurate, because of changing definitions of who is wounded (see J. B. Holcomb, L. G. Stansbury, H. R. Champion, C. Wade, and R. F. Bellamy, Journal of Trauma 60 [2006]: 397-401). If figures are restricted to casualties known to have required at least some hospital care, the lethality rate for the American war wounded was 23 percent in World War II (using army-only data), 23 percent in the Korean War, and anywhere from 16 to 24 percent in the Vietnam War (the definitions for Vietnam remain contentious to this day). (These data are from G. Beebe and M. E. DeBakey, Battle Casualties: Incidence, Mortality, and Logistic Considerations [Springfield: Charles C. Thomas, 1952]; F. A. Reister, Battle Casualties and Medical Statistics: U.S. Army Experience in Korea [Washington: Department of the Army, 1973]; R. F. Bellamy, "Why Is Marine Combat Mortality Less Than That of the Army?" Military Medicine 165 [2000]: 362-67.) Using this definition of wounded, lethality of war wounds for American troops in the Persian Gulf War was 24 percent; in the current wars in Iraq and Afghanistan it has been no higher than 12 percent.
57 For more on Ronald Bellamy's concept of the "Golden Five Minutes," see his chapter on combat trauma in his Textbook of Military Medicine: Anesthesia and Pre-Operative Care of the Combat Casualty (Washington: Department of the Army, Office of the Surgeon General, Borden Institute, 1994), pp. 1-42.
NAKED
77 The U.K. standards on physical examination etiquette are described in the General Medical Council's report Intimate Examinations (London: General Medical Council Standards Committee, December 2001) and in the Royal College of Obstetricians and Gynaecologists' Gynaecological Examinations: Guidelines for Specialist Practice (London: Royal College of Obstetricians and Gynaecologists, July 2002).
78 I relied on three reports in particular in considering the etiquette of American examinations: The Ad Hoc Committee on Physician Impairment's Report on Sexual Boundary Issues (Dallas: Federation of State Medical Boards of the United States, April 1996); C. E. Dehlendorf and S. M. Wolfe, "Physicians Disciplined for Sex-Related Offenses," JAMA 279 (1998): 1883-88; and J. A. Enbom and C. D. Thomas, "Evaluation of Sexual Misconduct Complaints: The Oregon Board of Medical Examiners, 1991 to 1995," American Journal of Obstetrics and Gynecology 176 (1997): 1340-48.
79 Data on patient-initiated sexual behavior toward medical students comes from a report by H. M. Schulte and J. Kay in Academic Medicine 69 (1995): 842-46.
WHAT DOCTORS OWE
87 Much of the detail on the American medical malpractice system comes from research by my colleagues David Studdert, Michelle Mello, and Troy Brennan of the Harvard School of Public Health. See, for example, D. M. Studdert et al., "Negligent Care and Malpractice Claiming Behavior in Utah and Colorado," Medical Care 38 (2000): 250-60, and D. M. Studdert et al., "Claims, Errors, and Compensation Payments in Medical Malpractice Litigation," New England Journal of Medicine 354 (2006): 2024-33. Two excellent reviews of what we know about the American malpractice system are D. M. Studdert, M. M. Mello, T. A. Brennan, "Medical Malpractice," New England Journal of Medicine 350 (2004): 283-92 (that's a short one), and Tom Baker's The Medical Malpractice Myth (Chicago: University of Chicago Press, 2005) (that's a longer one).
108 For more on the National Vaccine Injury Compensation program, see D. Ridgway's description in the Journal of Health Politics, Policy, and Law 24 (1999): 59-90, and also the program's Web site, www.hrsa.gov/osp/vicp/.
109 The New Zealand malpractice system is detailed by M. Bismark and R. Paterson in "No-Fault Compensation in New Zealand," Health Affairs 25 (2000): 278-83.
PIECEWORK
116 William Hsiao outlined his evaluation of the relative amount of work involved in the different tasks physicians do--the relative value scale--in two principal articles: W. Hsiao et al., "Resource-Based Relative Values: An Overview," JAMA 260 (1988): 2347-53, and W. Hsiao et al., "Measurement and Analysis of Intraservice Work," JAMA 260 (1988): 2361-70.
120 William Weeks's studies of how much physicians work and earn and the comparison with other professions were published in W. Weeks and A. Wallace, "Time and Money: A Retrospective Evaluation of the Inputs, Outputs, Efficiency, and Incomes of Physicians," Archives of Internal Medicine 163 (2003): 944-48, and W. Weeks and A. Wallace, "The More Things Change: Revisiting a Comparison of Educational Costs and Incomes of Physicians and Other Professionals," Academic Medicine 77 (2002): 312-19.
126 The amount of money currently spent on health care in the United States is tracked by the government, and the figures are available from the Medicare Web site: www.cms.hhs.gov/NationalHealthExpendData/.
128 Information on doctors' incomes relative to average workers' incomes was found in Derek Bok's fascinating book The Cost of Talent (New York: Free Press, 1993) and in data from the Bertelsmann Foundation's International Reform Monitor (see www.reformmonitor.org).
128 Evidence on the health and financial consequences of lacking insurance can be found in Jack Hadley's "Sicker and Poorer," Medical Care Research and Review 60 (2003): 3S-75S.
THE DOCTORS OF THE DEATH CHAMBER
130 The full opinion of United States District Judge Jeremy Fogel in the case of Michael Angelo Morales v. Roderick Q. Hickman is a riveting and surprisingly readable document (No. C 06 219 JF; District Court, Northern District of California: February 14, 2006). Also see the appeals court's ruling specifying what participating anesthesiologists would be required to do to ensure a rapid, painless death for an inmate (Michael Angelo Morales v. Roderick Q. Hickman, No. CV 06 00926 JF; U.S. 9th Circuit of Appeals: February 20, 2006).
132 The history of lethal injection and other execution methods is told in Stephen Trombley's fine book The Execution Protocol: Inside America's Capital Punishment Industry (New York: Crown, 1992). Similarly intriguing is Ivan Solotaroff's The Last Face You'll Ever See: The Private Life of the American Death Penalty (New York: HarperCollins, 2001).
134 Ethics codes for participation in executions by different medical professions can be found as follows: The American Medical Association's position was published in JAMA 270 (1993): 365-68, and is available on the www.ama-assn.orgWeb site. The Society of Correctional Physicians puts its ethics code online at http://www.corrdocs.org/about/ethics.html.The American Nursing Association's position statement on nurses' participation in capital punishment is available at http://nursingworld.org/readroom/position/ethics/prtetcptl.htm. The American Pharmaceutical Association's current policies are found in its "policies related to the practice environment and quality of worklife issues," available at www.aphanet.org.
136 Current data on death penalty cases is available from the Death Penalty Information Center Execution Database at http://www.deathpenaltyinfo.org/executions.php.
137 The seminal study on physician participation in U.S. executions is Breach of Trust (Philadelphia: American College of Physicians and Physicians for Human Rights, 1994).
141 The survey I cite on the level of physician awareness of ethics guidelines on participation in executions was published by N. J. Farber et al. in Annals of Internal Medicine 135 (2001): 884-88.
152 On the U.S. government's recent willingness to use medical skills against individuals for state purposes, see Stephen
Miles's Oath Betrayed: Torture, Medical Complicity, and the War on Terror (New York: Random House, 2006).
ON FIGHTING
159 Watson Bowes Jr.'s study of aggressively resuscitating premature infants was published with his colleagues M. Halgrimson and M. A. Simmons in the Journal of Reproductive Medicine 23 (1979): 245.
THE SCORE
172 Information on the normal anatomy, physiology, and process of labor, as well as the abnormalities that can occur, is taken from F. G. Cunningham et al., eds., Williams Obstetrics, 22nd ed. (New York: McGraw-Hill, 2005).
176 The details of the history of obstetrical techniques and complications are from numerous sources, in particular: J. Drife, "The Start of Life: A History of Obstetrics," Postgraduate Medical Journal 78 (2002): 311-15; R. W. Wertz and D. C. Wertz, Lying-In: A History of Childbirth in America (New Haven: Yale University Press, 1989); and D. Trolle, The History of Caesarean Section (Copenhagen: University Library, 1982).
179 For more data on the modern experience of childbirth, including on how commonly laboring mothers turn to medical interventions such as electronic monitors, epidurals, and labor-stimulating medication, an excellent source is E. R. Declercq et al., Listening to Mothers: Report of the First National U.S. Survey of Women's Childbearing Experiences (New York: Maternity Center Association, 2002).
184 Historical data on perinatal mortality for mothers and newborns are from the U.S. Centers for Disease Control.
185 Shortly after Virginia Apgar's death, her friend and colleague L. Stanley James published his eulogy, "Fond Memories of Virginia Apgar," in Pediatrics 55 (1975): 1-4. Another key source of information on her life is A. A. Skolnick, "Apgar Quartet Plays Perinatologist's Instruments," JAMA 276 (1996): 1939-40. An excellent review of the development and importance of her score is M. Finster and M. Wood, "The Apgar Score Has Survived the Test of Time," Anesthesiology 102 (2005): 855-57.
188 The 1979 ranking of specialties' use of randomized trials was undertaken by the father of evidence-based medicine, Archie L. Cochrane, in his article "1931-1971: A Critical Review with Particular Reference to the Medical Profession," in G. Teeling-Smith and N. Wells, eds., Medicines for the Year 2000 (London: Office of Health Economics, 1979).
190 Watson Bowes Jr. and V. L. Katz published a 1994 review of studies of forceps deliveries, including a comparison with Cesarean sections, entitled "Operative Vaginal Delivery," in Current Problems in Obstetrics, Gynecology, and Fertility 17 (1994): 86. A 1979 Australian study, for example, compared 296 forceps deliveries with 101 Cesarean sections and 207 spontaneous vaginal deliveries. The children did equally well, including on IQ and motor tests at age five (W. G. McBride et al., "Method of Delivery and Developmental Outcome at Five Years of Age," Medical Journal of Australia 1, no. 8 [1979]: 301-4). A few studies showed some practitioners could achieve better results with forceps. A 1990 study, for example, compared 358 forceps deliveries with 486 Cesarean sections at UCLA and found that, while the infants had no differences in their Apgar scores or rates of birth trauma, the mothers had fewer complications and less blood loss with forceps (R. A. Bashore, W. H. Phillips Jr., C. R. Brinkman III, "A Comparison of the Morbidity of Midforceps and Cesarean Delivery," American Journal of Obstetrics & Gynecology 162, no. 6 [1990]: 1428-34).
197 A definitive review of the benefit and risks of elective Cesarean sections for pregnant mothers at full term was published in March 2006 by the National Institutes of Health and is available from their Web site, www.nih.gov.It is entitled "National Institutes of Health State-of-the-Science Conference Statement: Cesarean Delivery on Maternal Request." See also H. Minkoff and F. A. Chervenak, "Elective Primary Cesarean Delivery," New England Journal of Medicine 348 (2003): 946-50.
THE BELL CURVE
206 Information on bell curves in hernia repair is from data collected for a Veterans Administration study: R. J. Fitzgibbons et al., "Watchful Waiting vs. Repair of Inguinal Hernia in Minimally Symptomatic Men," JAMA 295 (2006): 285-92. Risk-adjusted neonatal ICU outcomes are from the Vermont Oxford Network Database (Health Affairs 23 [2004]: 89). In vitro fertilization center outcomes are available from the CDC at www.cdc.gov/ART.
208 An intriguing examination of the U.S. government's ill-fated Death List is S. T. Mennemeyer, M. A. Morrisey, and L. Z. Howard's "Death and Reputation: How Consumers Acted upon HCFA Mortality Information," Inquiry 34 (1997): 117-28.
209 For more on the superior performance of LeRoy Matthews's CF treatment program in Cleveland, see W. J. Warwick, "Cystic Fibrosis: Nature and Prognosis," Minnesota Medicine 50 (1967): 1049-53; L. W. Matthews and C. F. Doershuk, "Management-Comprehensive Treatment of Cystic Fibrosis," Minnesota Medicine 52 (1969): 1506-14; and American Thoracic Society, "The Treatment of Cystic Fibrosis: A Statement by the Committee on Therapy," American Review of Respiratory Disease 97 (1968): 730-34.
211 No one has done more to tease apart the relative contributions of genetics, sociodemographics, and differences in treatment programs in cystic fibrosis than Michael S. Schecter, a pediatric pulmonologist and CF expert at Hasbro Children's Hospital, Providence, Rhode Island. See in particular his article "Non-Genetic Influences on CF Lung Disease: The Role of Sociodemographic Characteristics, Environmental Exposures, and Healthcare Interventions," Pediatric Pulmonology 26 (2004): 82-85.
FOR PERFORMANCE
237 Data on the inadequacies of mammography screening in the United States come from two articles: K. A. Phillips et al., "Factors Associated with Women's Adherence to Mammography Screening Guidelines," Health Services Research 33 (1998): 29-53, and K. Blanchard et al., "Mammographic Screening: Patterns of Use and Estimated Impact on Breast Carcinoma Survival," Cancer 101 (2005): 495-507.
242 For more on the increasing longevity of much of the world's population and the resulting shift in patterns of disease, see the World Health Organization's The World Health Report 1999: Making a Difference (Geneva: World Health Organization, 1999), and J. A. Salomon and C. J. L. Murray, "The Epidemiologic Transition Revisited: Compositional Models for Causes of Death by Age and Sex," Population and Development Review 28 (2002): 205-28.
AFTERWORD: SUGGESTIONS FOR BECOMING A POSITIVE DEVIANT
251 That favorite essay of Paul Auster's is "Gotham Handbook," in Collected Prose (New York: Picador, 2003), and I owe to it not only the first rule but the structure of this chapter--and an understanding of the importance of talking about the weather.
255 The study of forgotten surgical tools was published in the New England Journal of Medicine 348 (2003): 229-35.
255 Lewis Thomas's quoting of John Ziman is in his essay "On Societies as Organisms," in Lives of a Cell (New York: Penguin, 1974).
Acknowledgments
Among several people indispensable to this book, my research assistant, Ami Karlage, comes foremost. She is whip smart and insanely resourceful and had better ways she could have spent three years of her life. But she helped research every chapter here and was essential to my making this book as rich and accurate as possible.
If Ami gave in breadth, my wife, Kathleen Hobson, gave in depth. She has made my successes and failures her own. She has pushed and encouraged this book and talked me through my uncertainties and confusions about it. And she made writing it possible alongside everything else in our life together.
I also owe particular thanks to my friends Burkhard Bilger, Henry Finder, Malcolm Gladwell, and David Segal. Four of the smartest people I know, they gave generously of their time and energy in thinking through my ideas for this book. I am lucky to have Henry as my editor at the New Yorker, as well--he not only midwifed the five chapters here that had begun as magazine pieces but has been my closest mentor for my writing career. The other essential person for that career has been David Remnick, who has let me continue as a New Yorker staff writer despite having to accommodate the demands of my surgical career. The opportunity to write for the magazine means more to me than I can possibly say.
The great Sara Bershtel of Metropolitan Books was my editor for B
etter, as she was for Complications. And she has proved to be the kind of book editor one hears no longer exists: she cares deeply about writing and ideas, and she edits. Her colleague Riva Hocherman also offered invaluable suggestions. Both made this book better in every way.
My longtime friend Tina Bennett has also been, for the past seven years, my agent, an arrangement that would ordinarily be considered dicey. But her judgment is impeccable. She is indefatigable. And she has proved as wise and loyal in her advocacy as an agent as she has in her devotion as a friend.
Several of the chapters began as articles I had written for the New England Journal of Medicine, and I am grateful to Debra Malina, Greg Curfman, Steve Morrissey, and Jeff Drazen of the Journal for their support, advice, and encouragement.
Finishing this book would not have been possible without the understanding and support of my surgical colleagues, in particular: Michael Zinner, the chief of surgery at Brigham and Women's Hospital; Stan Ashley, the chief of general surgery at Harvard Vanguard Medical Associates; and Francis "Chip" Moore, my surgical partner. Thank you also to Susan Cramer, Shilpa Rao, and Katy Thompson of Brigham and Women's Hospital, Arnie Epstein of the Harvard School of Public Health, and John Sterling of Henry Holt Publishing.
Finally, I want to give my deep thanks to the patients and colleagues who appear, named and unnamed, in this book. They gave me permission to try to tell their stories, and that is the most generous and vital gift of all.
