Authors: Atul Gawande
153 The Göteborg surgeons’ results with ETS for blushing were published in Drott, C., et al., “Successful treatment of facial blushing by endoscopic transthoracic sympathicotomy,”
British Journal of Dermatology
138 (1998), pp. 639–43. For chary view of the surgery, see Drummond, P. D., “A caution about surgical treatment for facial blushing,” in
British Journal of Dermatology
142 (2000), pp. 195–96.
160 The Web site for Christine Drury’s organization is
www.redmask.org
.
162 The statistics on the number of gastric-bypass operations being done comes from Blackburn, G., “Surgery for obesity,”
Harvard Health Letter
(2001), no. 884.
169 The National Institutes of Health’s depressing findings on the longterm, almost universal failure of dieting is in its publication “Methods for voluntary weight loss and control,”
Annals of Internal Medicine
119 (1993), pp. 764–70
A fairly comprehensive listing of the various surgical treatments that obese people have been subjected to, and their results, can be found in Kral, J. G., “Surgical treatment of obesity,” in Bray, G. A., Bouchard, C., and James, W. P. T., eds.,
Handbook of Obesity
(New York: M. Decker, 1998); together with Munro, J. F., et al., “Mechanical treatment for obesity,”
Annals of the New York Academy of Sciences
499 (1987), pp. 305–11.
170 The research on dieting for obese children described is in Epstein, L. H., et al., “Ten-year outcomes of behavioral family-based treatment for childhood obesity,”
Health Psychology
13 (1994), pp. 373–83.
Information on Prader-Willi syndrome comes from Lindgren, A. C., et al., “Eating behavior in Prader-Willi syndrome, normal weight, and obese control groups,”
Journal of Pediatrics
137 (2000), pp. 50–55; and Cassidy, S. B., and Schwartz, S., “Prader-Willi and Angelman syndromes,”
Medicine
77 (1998), pp. 140–51.
The “fat paradox” is explained in Blundell, J. E., “The control of appetite,”
Schweizerische
129 (1999), p. 182.
171 One study demonstrating the “appetizer effect” is Yeomans, M. R., “Rating changes over the course of meals: What do they tell us about motivation to eat?”
Neuroscience and Biobehavioral Reviews
24 (2000), pp. 249–59.
The French chewing study is published in Bellisle, F., et al., “Chewing and swallowing as indices of the stimulation to eat during meals in humans,”
Neuroscience and Biobehavioral Reviews
24 (2000), pp. 223–28.
171 The study of eating in densely amnesiac people is published in Rozin, P., et al., “What causes humans to begin and end a meal?”
Psychological Science
9 (1998), pp. 392–96.
173 Information on the long-term failure of just stomach stapling surgery to maintain weight loss is from Blackburn’s 2001 article, cited above, and Nightengale, M. L., et al., “Prospective evaluation of vertical banded gastroplasty as the primary operation for morbid obesity,”
Mayo Clinic Proceedings
67 (1992), pp. 304–5.
174 For information on the psychological and social experiences of obesity surgery, see Hsu, L. K. G., et al., “Nonsurgical factors that influence the outcome of bariatric surgery: a review,”
Psychosomatic Medicine
60 (1998), pp. 338–46.
Two excellent summaries of the research on the sustained longterm weight loss from obesity surgery are Kral’s 1998 article and Blackburn’s 2001 article, both cited above.
181 For data on the high prevalence of morbid obesity, see Kuczmarski, R. J., et al., “Varying body mass index cutoff points to describe overweight prevalence among U.S. adults: NHANES III (1988 to 1994),”
Obesity Research
5 (1997), pp. 542–48.
191 The faltering war on the nonautopsy is recounted in Lundberg, G. D., “Low-tech autopsies in the era of high-tech medicine,”
Journal of the American Medical Association
280 (1998), pp. 1273–74.
192 Information on the history of autopsy comes from two sources: Iserson, K. V.,
Death to Dust: What Happens to Dead Bodies
(Tucson, Ariz.: Galen Press, 1994); and King, L. S., and Meehan, M. C., “The history of the autopsy,”
American Journal of Pathology
73 (1973), 514–44.
197 The three recent studies evaluating autopsy are Burton, E. C., Troxclair, D. A., and Newman III, W. P., “Autopsy diagnoses and malignant neoplasms: How often are clinical diagnoses incorrect?”
Journal of the American Medical Association
280 (1998), pp. 1245–48; Nichols, L., Aronica, P., and Babe, C., “Are autopsies obsolete?”
American Journal of Clinical Pathology
110 (1996), pp. 210–18; and Zarbo, R. J., Baker, P. B., and Howanitz, P. J., “The autopsy as a performance measurement tool,”
Archives of Pathology and Laboratory Medicine
123 (1999), pp. 191–98.
The review of autopsy studies described is from Hill, R. B., and Anderson, R. E.,
The Autopsy: Medical Practice and Public Policy
(Newton, Mass.: Butterworth-Heinemann, 1988), pp. 34–35.
The classic comparison of autopsies over the decades is Goldman, L., et al., “The value of the autopsy in three medical eras,”
New England Journal of Medicine
308 (1983), pp. 1000–5.
198 Gorovitz and Maclntyre’s explanation of necessary fallibility is in their article “Toward a theory of medical fallibility,”
Journal of Medicine and Philosophy
1 (1976), pp. 51–71.
201 The disappearance of data on the autopsy is described in Burton, E., “Medical error and outcome measures: Where have all the autopsies gone?”
Medscape General Medicine
, 28 May 2000.
202 The details of the case come mainly from two sources: the affidavit for Marie Noe’s arrest and Stephen Fried’s disturbing article, “Cradle to Grave,”
Philadelphia Magazine
, April 1998.
203 On the reduction of sudden infant deaths associated with the national “Back to Sleep” campaign, see Willingner, M., et al., “Factors associated with the transition to nonprone sleep positions of infants in the United States,”
Journal of the American Medical Association
280 (1998), pp 329–35.
204 A comprehensive source for information on patterns of child abuse is Sedlak, A. J., and Broadhurst, D. D.,
The Third National Incident Study of Child Abuse and Neglect
(Washington: U.S. Department of Health and Human Services, 1996).
210 Katz, J.,
The Silent World of Doctor and Patient
(New York: Free Press, 1984).
220 The study of what cancer patients prefer is Degner, L. F., and Sloan, J. A., “Decision making during serious illness: What role do patients really want to play?”
Journal of Clinical Epidemiology
45 (1992), pp. 941–50.
222 Schneider, C. E.,
The Practice of Autonomy
(New York: Oxford University Press, 1998).
233 Information on necrotizing fasciitis comes from Chapnick, E. K., and Abter, E. I., “Necrotizing soft-tissue infections,”
Infectious Disease Clinics
10 (1996), pp. 835–55; and Stone, D. R., and Gorbach, S. L., “Necrotizing fasciitis: the changing spectrum,”
Infectious Disease in Dermatology
15 (1997), pp. 213–20. A useful source of information for patients is also the National Necrotizing Fasciitis Foundation Web site,
www.nnff.org
.
236 For a comprehensive summary of research on the quality of health care (including the heart attack studies described), see Institute of Medicine,
Crossing the Quality Chasm
(Washington, D.C.: National Academy of Sciences Press, 2001).
Naylor, C. D., “Grey zones of clinical practices: some limits to evidence-based medicine,”
Lancet
345 (1995), pp. 840–42.
238 The Medical College of Virginia study: Poses, R. M., and Anthony, M., “Availability, wishful thinking, and physicians’ diagnostic judgments
for patients with suspected bacteremia,”
Medical Decision Making
11 (1991), pp. 159–68.
The University of Wisconsin study: Detmer, D. E., Fryback, D. G., and Gassner, K., “Heuristics and biases in medical decision making,”
Journal of Medical lEducation
53 (1978), pp. 682–83.
The Ohio study: Dawson, N. V., et al., “Hemodynamic assessment in managing the critically ill: Is physician confidence warranted?”
Medical Decision Making
13 (1993), pp. 258–66.
239 The first installment of David Eddy’s startling series on the problems with decision making in medicine is “The challenge,”
Journal of the American Medical Association
263 (1990), pp. 287–90.
247 Gary Klein’s magnificent book on his research into intuitive decision making is
Sources of Power
(Cambridge: M.I.T. Press, 1998).
248 One can look up information about the patterns of what doctors in one’s own area do relative to doctors in other areas in Jack Wennberg and his research team’s publication,
Dartmouth Atlas of Health Care
(Chicago: American Hospital Publishing, Inc., 1999). Their findings are also available online at
www.dartmouthatlas.org
.
B
eing the child of two doctors, I have been familiar with medicine since I was small. The dinner talk at home was as often about local doctor gossip and cases (the badly asthmatic boy my mom was taking care of, for instance, whose parents were not giving him his medication; my dad’s first successfully reversed vasectomy; the guy who’d gone to bed drunk and shot his penis off thinking there was a snake under the covers) as about school and politics. As soon as we were old enough, my sister and I were taught to field phone calls from patients. “Is this an emergency?” we learned to ask. If callers said yes, that was easy. We were to tell them to go to the emergency room. And if they said no, that was easy, too. We were to take a message. Only one time did I get an “I don’t know.” It was from a man with a rather strained voice calling for my father because he’d “injured himself” while shoveling. I told him to go to the emergency room.
Once in a while, I’d be out with my mom or dad when an emergency page would come through. We’d go to the hospital together, and I’d be put in a chair in the ER hallway to wait. I’d sit watching the sick children crying, the men bleeding into rags, the old ladies
breathing funny, and the nurses scurrying everywhere. I got more used to the place than I realized. Years later, as a medical student entering a Boston hospital for my first time, I realized I already knew the smell.
I came to writing, however, only much later and with the help of a lot of people whom I owe a deep debt of gratitude. My friend Jacob Weisberg was the one who first encouraged me to write seriously. He is the chief political correspondent for the Internet magazine
Slate
, and during my second year of surgical residency he pushed me to give a try at some medical writing for his publication. I agreed. He helped me through multiple drafts of that first piece. And then, over the next two years, he and Michael Kinsley,
Slate’s
editor-in-chief, along with my editors Jack Shafer and Jodie Allen, gave me both space and guidance to create what became a regular column on medicine and science. The opportunity changed everything for me. Residency is a grueling experience, and in the midst of all the paperwork and pages and sleep deprivation, you can forget why what you do matters. The writing let me step back and, for a few hours each week, remember.
In my third year of residency, another friend, the
New Yorker
writer Malcolm Gladwell, introduced me to his editor Henry Finder. And for this I consider myself one of the luckiest writers there could be. A mumbling, astonishingly widely read boy genius who at the age of thirty-two was already editor to several of the writers I most admired, Henry took me under his wing. He had the patience and persistence and optimism to pull me through seven complete rewrites of the first article I submitted to
The New Yorker
. He pushed me to think harder than I had ever thought I could. He showed me which of my instincts in writing I could have confidence in and which ones I should not. More than that, he has always believed that I had stories worth telling. Since 1998,
The
New
Yorker
has engaged me as a staff writer. Many of the chapters in this book originated as articles I published there. In addition, Henry has read and provided
invaluable advice on everything written here. This book would not have been possible without him.
There is a third person at
The New Yorker
besides Henry and Malcolm to whom I owe particular thanks: David Remnick. Despite my unpredictable schedule as a resident, and the reality that my patient responsibilities must come first, he has stuck with me. He has built a great and special magazine. And most of all, he has made me feel part of it
In writing this book, I have found two new kinds of people in my life. One is an agent, which seems like something everyone should have—especially if you can have one like Tina Bennett, who has looked after both me and the book with dedication, unshakable good cheer, and eminently sound judgment in everything (even as she carried and gave birth to a child in the midst of the project). The other is a book editor, which turns out to be a species as different from magazine editors as surgeons are from internists. With an uncommon combination of tenacity and gentleness, Sara Bershtel at Metropolitan Books got me to find the broader frame that caught what it is I write and think about, showed me how a book could be more than I imagined it to be, and somehow kept me going though at times the task seemed overwhelming. I am immensely fortunate to have her. My thanks, too, to her colleague Riva Hocher-mann, for her careful reading of the manuscript and invaluable suggestions.
Trying to write as a surgical resident is a sensitive and tricky matter, particularly when one is as interested, as I am, in writing about how things go wrong as how things go right. Doctors and hospitals are usually suspicious of efforts to discuss these matters in public. But to my surprise I have found only encouragement where I am. Two people in particular have been instrumental in this. Dr. Troy Brennan, a professor of medicine, law, and almost anything else you can think of, has been a mentor, a sounding board, a collaborator in
research, and an unstinting advocate for what I have attempted to do. He even gave me the office space, computer, and phone that let me get this work done.