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April 3, 2007
Atul Gawande Rocks in the O.R.
By CHARLES McGRATH
BOSTON — Just as precious to Dr. Atul Gawande as his loupes — magnifying glasses he wears during surgery — is his iPod, which he carries with him into the operating room and plugs into a little speaker there. On a recent day, when he took out a gallbladder, two thyroids and what was supposed to be a parathyroid gland but maybe wasn’t, the playlist included David Bowie, Arcade Fire, Regina Spektor, Aimee Mann, Bruce Springsteen, Elvis Costello, the Decemberists and the Killers.
The music wasn’t turned up high, but it rocked sufficiently that the anesthesiologist bobbed his head, the O.R. nurse tapped her toe, and the member of the team in charge of all the clamps and retractors drummed his fingers on the instrument tray. “It all depends on who’s in the room,” Dr. Gawande said of his selections. “You can’t play anything hard-hitting if there’s anyone over 45.”
Dr. Gawande is 41, and it might be said that that’s a little old for the Killers. In every other respect, however, he is almost annoyingly admirable. He is tall, handsome, brilliant (a former Rhodes scholar and currently the recipient of a MacArthur “genius” grant); he has three children and a wife with musical interests so eclectic that when they pooled their vinyl record collections, his 800 and her 600, there were only 10 overlaps; he’s an accomplished surgeon and an equally accomplished writer, whose second book, “Better: A Surgeon’s Notes on Performance” (Metropolitan Books), comes out this week.
Like his first, “Complications,” it consists mostly of essays he has published in The New Yorker — pieces whose common theme is both the complexity and the imperfection of modern medicine and the need for doctors to strive to do better. “For me to improve, I have to depend on a whole bunch of people,” he said recently, sitting in his office at Brigham and Women’s Hospital in Boston, where he keeps a copy of Sylvia Plath’s poem “The Surgeon at 2 a.m.” next to his desk. “That’s something you don’t understand at first — that in some ways the surgeon is the least important part of the team. That’s just part of the modern system. Some people want to blow up the machine. Medicine is successful because of the machine, but the machine is pretty inhuman. It can be like a factory around here.”
Actually, in the early morning, with patients stacked up, waiting to get into an operating room, it’s more like an airport, and the O.R. itself is like a high-tech garage, with computer screens everywhere (including a stand-up terminal where doctors can check their e-mail) and lots of fancy equipment with a tendency to go on the fritz.
On that recent day of surgery Dr. Gawande needed three cauterizing machines and two nerve stimulators. The two flat-screen monitors worked perfectly, on the other hand, affording a full-color, high-definition view of the first patient’s gallbladder, which Dr. Gawande and a surgical resident, Siva Raja, proceeded to remove laparoscopically, after first inserting a fiber-optic camera through a tiny incision in the patient’s abdomen. Various wands and clippers and cauterizers went into other little holes, and while watching the screens, the two doctors moved them around as if working joysticks on a video game.
When the gallbladder was finally loose from the liver bed and detached from all the little vascular tentacles, they snagged it in a little plastic bag, the way you’d net a goldfish in a bowl, and pulled it out through an incision in the navel. The whole business took less than two hours.
The two thyroidectomies also went off without a hitch, though the second thyroid was so big Dr. Gawande said later that he had felt he was delivering a grapefruit. These operations were mostly performed the old-fashioned way, with a slit across the throat and then the deployment of nasty-looking spreaders and retractors to keep the wound open while the surgeons sliced and snipped, occasionally employing some ultrasonic scissors, and tied off dozens of tiny blood vessels, dabbing and mopping now and then with a little gauze pad.
The whole business is suprisingly unmessy. The really tricky part, Dr. Gawande explained, is to keep from nicking the nerves that control the vocal chords, and he had the anesthesiologist stick a camera down the patient’s throat for a better view.
In the case of the parathyroidectomy, however, Dr. Gawande from the start had trouble finding what he was looking for. The parathyroid, which has no relation, really, to the thyroid, is a gland the size of a rice grain that regulates the production of calcium. Everyone has four of them, but they’re not always where they’re supposed to be.
Dr. Gawande was pretty sure that, in this patient, the problematic gland, which had been causing her to leach calcium from her bones and send it into the bloodstream, was on the right side of the neck. When that parathyroid turned out to be healthy, he started looking on the left, and he peered and probed for the better part of an hour — or the length of an entire Aimee Mann album on the iPod — before finally extracting a brownish, pea-size gobbet. “I’m not sure what this is,” he said after rolling it around with a gloved finger. “Paraganglioma maybe?”
He sent it to the lab, along with a blood sample to see if the parathyroid hormone levels had started to come down, and while waiting for the results he took out a marking pen and drew a game of Hangman on the surgical drapes covering the unconscious patient. His word was “velvet,” which stumped everyone. A few minutes later, the phone rang with an old-fashioned ring (to distinguish it from the beeping on the anesthesiologist’s monitor); Dr. Gawande picked up, listened for a moment, and then smiled and said “Whoo!” The hormone was down 98 percent, he explained. “We don’t know what that tissue was, but it was the cause of the problem.”
Back in his office, where he usually retreats between surgeries to check e-mail and, if he can, snatch a bit of writing time, Dr. Gawande said surgery appealed to him, in part, because he does not have the typical surgeon’s personality. “When I got in the O.R. as a resident, I found that I really liked it,” he said. “No. 1, I was attracted by the blood and guts. No. 2 was the sense of decision-making: there is uncertainty, but you have to make choices. I’ve always had a tendency to indecision. In the rest of my life I’m sort of a ditherer.”
Both his parents are physicians, he added — his father a urologist and his mother a pediatrician — and growing up in Athens, Ohio, he tried hard not to follow in their footsteps. “This idea that a bright Indian kid is supposed to be a doctor — I resisted that,” he said. “I wanted to be a rock star. I played guitar and wrote songs and even had a couple of club shows. I was just terrible.”
At Oxford he toyed with the idea of becoming a philosopher until he realized he didn’t have the knack for asking the right sort of philosophical questions, and so he wound up in medical school after all. “It turns out you can be a doctor and be almost anything,” he said. “Even a writer.”
He began contributing little pieces to Slate about 10 years ago, while still a resident, he said, even though he thought he had no particular aptitude and had never written for publication before. He took one writing course in college, and the instructor told him that he could write a sentence but had nothing to say. “Slate was perfect for me,” he explained, “because it enabled me to fly under the radar. It was just like going through surgical residency. I did 30 columns for them, and it was like doing 30 gallbladders. Then I had to learn how to get comfortable with 4,000-word and then 8,000-word essays for The New Yorker.”
He added: “I now feel like writing is the most important thing I do. In some ways, it’s harder than surgery. But I do think I’ve found a theme in trying to understand failure and what it means in the world we live in, and how we can improve at what we do.”
Pulling out his Blackberry, he said, “It seems like there’s a story in every nook and cranny of medicine,” and scrolling down a list of 106 ideas he’d saved, he picked a few. “Itching,” he said. “Nobody really understands what it is. Chernobyl. Twenty years on, what really happened there? Why weren’t there as many cancer cases as we predicted? And here’s a good one: why, if we have so many health-policy experts in this country, do we have such bad health policy?”