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Sunday, August 9, 2015

Post #42 A book review - Being Mortal: Medicine and What Matters in the End by Atul Gawande

In his breathtaking book, Being Mortal: Medicine and What Matters in the End, Atul Gawande (one of my favorite authors) elegantly describes three different modalities of patient counseling that doctors employ. 

The first is the oldest and most traditional approach, a paternalistic relationship.  The doctor not only has the knowledge to guide the patient, but also possesses the experience and wisdom to make decisions on their behalf. 

The second type of relationship is termed "informative."  Here the doctor informs you about the facts and figures related to your medical problem, along the lines of a talking Wikipedia page donning a white coat, but allows you to make your own decisions in regards to your health. 

And finally, the third type of relationship is called "interpretive."  Here the doctor asks a series of probing questions to discover your priorities and assists you in navigating the medical maze to achieve your goal. 

Methodically, Gawande utilizes a small gamut of actual patients he has encountered in real life, including his own father, and through their life stories he takes the reader step by step in his maturation process as he evolves from a mixture of initially employing the first two approaches - leaning heavily towards the informative style - to an actualization of becoming an "interpretive" doctor.
 
At times, along the way, Gawande has to remind himself of what he has learned from palliative experts and even Daniel Kahneman's research on kidney stones and colonoscopies (another favorite of mine! - the author not the procedure), to stay true to his new "interpretive" approach, which over time he recognizes as being a clear cut above the other two modalities. 

His most moving example is his own father, who is diagnosed with a  spinal tumor and begins losing first his grip in tennis and later his grip over day to day activities.  His father, also a physician (as is his mother - slacker family the Gawandes), seeks the counsel of two neurosurgeons, both of whom have excellent pedigrees and reputations. 

The first doctor goes into information overdrive overwhelming both Atul and his father, and despite being doctors themselves, they struggle with the tsunami of facts and statistics which leaves them feeling rudderless with no sense of direction; the neurosurgeon himself advocates operating right away.
 
The second doctor, takes the time to listen to the father's desires and goals in life, especially his optimal endgame, and helps the family to formulate a plan which will maximize his ability to achieve what is most important to him at the given moment in time.  The interpretive doctor exemplified. 

Rather than jumping at surgery which could lead to further complications - together, the neurosurgeon and the Gawandes arrive at the decision to wait on surgery, which although promises some relief of pain and restoration of function, also carries with it the risk of leaving the elder Gawande a quadriplegic. 

Although one of his hands is slowly becoming numb, in his time following the initial consultation where he decides to forgo surgery, Gawande's father throws himself into his role as newly elected Rotary district governor and precedes to follow through on a goal to speak at the meeting of each of his district's fifty-nine clubs, not just once but twice to each group.  (If the Gawandes make you feel insufficient, join the club.)

Over time, the tumor takes its toll and several years after the initial diagnosis, and several important life goals later, Gawande's father finally decides to submit to surgery.  The surgery goes well, but in 20/20 reflective hindsight, it becomes clear that had they followed the advice of the first surgeon, the scalpel would have been utilized several years prematurely and the hand of unnecessary risk would have been forced sooner than required. 

Even in pediatrics, although on a much less dire scale, I personally see how the interpretive doctor modality is superior to simply being informative or paternalistic. 

Although, I understand the natural history of an ear infection, and how 80% of ear infections in children over two years of age will improve without antibiotics, albeit with a slightly longer course of pain; I don't know the family's schedule (unless I ask).

Perhaps there is an important wedding they need to fly to over the weekend or maybe the family has a vacation coming up that has been in the works for several months.  While these are not life or death situations, I can fully appreciate the importance of preserving the quality time of a much needed break for the family, especially if it is a once-in-a-lifetime trip to Disney World which has received an immense amount of planning and a considerable portion of the family budget.

This would certainly push me to recommend antibiotics over watchful waiting.  Certainly, we should be judicious about antibiotic use when at all possible, but how can one weigh the risk of a 10 day course of amoxicillin and its small contribution to the scourge of antibiotic resistant bacteria vs. the preservation of a once-in-a-lifetime trip to Disney World. 

It is impossible to weigh in terms of any sort of risk assessment or even epidemiological probabilities.  Even my nerdy Pi-loving math professor brother would struggle with this.

And that is precisely the point.  I can't quantify the decision by myself, but by understanding the family's immediate goal and knowing the studies and treatment options for an ear infection, I can help a mom and dad to decide what is best for their family in the given situation.

These are ideas that have been floating around in my head for a while and as he so often does, Gawande's timely prose has helped sharpen thoughts that needed some coaching and fine-tuning.

Being Mortal is well worth reading for anyone who has grappled not just with medical decision making but is interested in a strategy for approaching the end of one's life and maximizing their personal goals with the assistance of the modern medical community who has hopefully read this insightful book.