開刀房裡的沉思: 一位外科醫師的精進 Better: A Surgeon's Notes on Performance by Atul Gawande,第一章
"禍手" 序
1. 禍手
2. 一個都不能漏
3. 浴血
4. 裸
5. 纏訟
6. 薪事誰人知
7. 死刑室醫師
8. 戰到最後
9. 艾卜佳評分表
10. 醫師的成績單
11. 我的印度之旅
後記
出版社：天下文化
出版日：2007-04-25
這 本書的十一個故事大都圍繞著一個主題：要創造醫療佳績，醫學知識和技能固然重要，但有「心」、且勇於改變，才能更上層樓。譬如艾卜佳醫師，因為有 心，想出前所未有的評量表，來評估嬰兒的健康狀況，使產科的表現立刻有如脫胎換骨；又如渥偉克醫師，因為全心希望提昇囊腫纖維症的療效，不斷研究改進，他 所屬的費爾維大學兒童醫院在這方面的表現，始終領先全美所有醫院。其他如戮力消滅小兒麻痺、減少前線士兵死亡率、爭取每個早產兒的生存機會……莫不是本於 用心和勇於改變。
特別值得一提的是，此書觸及兩個醫界非常關切、但少有人談得如此深入而精采的話題：「薪事誰人知」和「纏訟」。難怪《時代雜誌》（TIME）讚美葛文德「文筆犀利如手術刀，目光如X光，能見人所不能見者」。
薪事誰人知
為 了當醫師，不知有多少年，你像在黑暗的隧道中摸索——全神貫注，每一天都戰戰兢兢，不容自己有半點閃失——終於走到盡頭，重見天日，有人跟你握手，給你一 份工作，你不禁覺得激動。我在波士頓一家醫院的外科做了八年住院醫師，最後一年即將完成訓練之時，終於等到這一天了。那家醫院有外科主治醫師的職缺，除了 一般外科，也還能在我感興趣的腫瘤外科某些領域發揮所長，真是千載難逢的機會。我第一次面試過關了。第二次面試那天，我西裝筆挺，坐在外科主任那間牆面全 部鑲嵌木板的豪華辦公室裡。主任坐在我對面，告訴我不久就可以上任。「你能來吧？」我受寵若驚地答道：「這是我的榮幸。」他說，新科主治醫師前三年有保障 薪，第四年開始，我親自執行的業務都可向病人收取費用，但也必須負擔成本。他接下來問我，你認為我們該付你多少保障薪？
過去這麼多年來，都是別人告訴我該付多少錢（如醫學院一年的學費約四萬美元）或會付多少錢給我（住院醫師一年薪資也大約是四萬美元）。那主任一問，我一時不知道該怎麼回答，於是問他：「外科主治醫師一般賺多少？」
他搖搖頭，說道：「你還是先告訴我，你希望的保障薪是多少。如果合理，就照這個數目，三年後就做多少算多少了。」他給我幾天的時間想想。
大 多數的人都是先看同樣的工作別人拿多少，來評估自己應得的薪資，於是我向科裡的同事探聽。收入這種敏感的話題，不免教人尷尬。我不經意地丟出這個小小的問 題，原本伶牙俐齒的同事突然變得口齒不清，好像嘴巴塞滿了餅乾似的。我絞盡腦汁，想了各種方法，希望從他們那兒套出答案。我問，如果一個禮拜開八檯刀，可 以拿到多少？或是，我該跟主任說多少才好？沒有人願意告訴我。
很多人都不想跟別人講自己賺多少，尤其是當醫生的。行醫不是以賺錢為目的， 似乎愈在意收入多少，愈會被人懷疑醫術不佳。（你看，電視影集裡的好醫師都是開老車、住破爛公寓，壞醫師則是一身名牌。）我們在當住院醫師的時候，每週工 作時數破百，薪水僅及最低標準，然而，我們都喜歡裝出一副大義凜然的樣子，暗示別人我們工作多辛苦，收入多微薄。等到可以獨當一面，自行開業，或幹了幾年 主治醫師下來，就守口如瓶，絕口不提自己賺了多少錢。自從二十世紀八○年代初期，已有多篇調查報告指出，三分之二的美國民眾認為醫師「太愛賺錢」。我不久 就發現，醫師動不動就想到錢，實在是現行醫療制度造成的。 |
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紐約時報的"書評"?和親臨現場之介紹
Atul Gawande Rocks in the O.R.
Erik Jacobs for The New York Times
Dr. Atul Gawande, center, at Brigham and Women’s Hospital in Boston, is a Rhodes scholar who has written his second book. More Photos >
By CHARLES McGRATH
Published: April 3, 2007
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.猶疑不決者”
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?”
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