Part I. Diligence 恪尽职守
On washing hands 勤洗手
Each year, according to the U.S. Centers for Disease Control, two million Americans acquire an infection while they are in the hospital. Ninety thousand die of that infection.
Bacterial counts on the hands range from five thousand to five million colony-forming units per square centimeter. The hair, underarms, and groin harbor greater concentrations. On the hands, deep skin crevices trap 10 to 20 percent of the flora, making removal difficult, even with scrubbing, and sterilization impossible. The worst place is under the fingernails.
Even with the right soap, however, proper hand washing requires a strict procedure. First, you must remove your watch, rings, and other jewelry (which are notorious for trapping bacteria). Next, you wet your hands in warm tap water. Dispense the soap and lather all surfaces, including the lower one-third of the arms, for the full duration recommended by the manufacturer (usually fifteen to thirty seconds). Rinse off for thirty full seconds. Dry completely with a clean, disposable towel. Then use the towel to turn the tap off.
Alcohol rinses…at alcohol concentration of 50 to 95 percent, they are more effective at killing organisms, too. (Interestingly, pure alcohol is not as effective—at least some water is required to denature microbial proteins.)
People underestimate the importance of diligence as a virtue. No doubt this has something to do with how supremely mundane it seems. It is defined as “the constant and earnest effort to accomplish what is undertaken.” There is a flavor of simplistic relentlessness to it. And if it were an individual’s primary goal in life, that life would indeed seem narrow and unambitious.
Jonas Salk’s vaccine, made from killed poliovirus, was given to 440,000 children; 210,000 received a placebo injection, and more than a million served as unvaccinated controls.
In India, it seems, half the doctors who work in public health smoke.
Beneath that ideal is the gruelingly unglamorous and uncertain work… it is a monument to the perfection of performance—to showing what can be achieved by diligent attention to detail coupled with great ambition.
Casualties of war
“Trust no one” is the mantra we all learn to live by in surgical training.
Soldiers had been directed to wear eye protection, but they evidently found the issued goggles too ugly… So the military bowed to fashion and switched to cooler-looking Wiley-brand ballistic eyewear. The rate of eye injuries decreased markedly.
II. Doing right
The fact that all medical professional have blushed or found their thoughts straying in unwanted directions during a patient visit reveals the potential for impropriety.
The social dimension turns out to be as essential as the scientific—matters of how casual you should be, how formal, how reticent, how forthright. Also: how apologetic, how self-confident, how money-minded.
What doctors owe
Substandard care or outright mistake
It’s precisely because of our enormous success that people are bound to wonder what went wrong when we fail.
We are tainted by the harm we cause.
Nobody, though, would see him in quite the same light again. And nobody would be happy to have the game go on as if nothing had happened. We’d want him to show sorrow, to take responsibility. We’d want the people he injured to be helped in a meaningful way.
Not just compensation but the satisfaction of a resounding punishment, fair or not.
For the moment, we must make do with what we have.
Most people gauge what they deserve to be paid by what others are paid for doing the same work.
Work was a function of time spent, mental effort and judgment, technical skill and physical effort, and stress.
How much they make has little to do with how good they are.
Willingness and ability to work the long hours wane
We can count ourselves lucky that we don’t have to choose.
The reason has to be that doctors remain at least partly motivated by the hope of doing meaningful and respected work for people and society… If we fail ordinary people, then the notion that we do something special is gone.
In the beginning, we were all committed. We worked hard—long hours, a lot of dedication, young and hungry.
This is where money-mindedness becomes inescapable—and likewise the struggle between doing right and doing well.
The prospect of my new responsibilities filled me with both exhilaration and dread.
The doctors of the death chamber
2,500 to 5,000 milligrams of sodium thiopental… can produce death all by itself by causing complete cessation of the brain’s electrical activity, followed by respiratory arrest and circulatory collapse. Death, however, can take fifteen minutes or longer with thiopental alone, and the prisoner may appear to gasp, struggle, or convulse. So 60 to 100 milligrams of pancuronium is injected one minute or so after the thiopental to paralyze the prisoner’s muscles. Finally, 120 to 240 milliequavalents of potassium is given to produce rapid cardiac arrest.
There are vital but sometimes murky differences between acting skillfully, acting lawfully, and acting ethically.
Death by firing squad came to be regarded as too bloody and uncontrolled.
Hanging… the cervical spine is broken at the second vertebra, the diaphragm is paralyzed, and the prisoner suffocates to death, a minute-long process.
Asphyxiation from cyanide gas, which prevents cell from using oxygen by inactivating a vital enzyme known as cytochrome oxidase, took even longer than death by hanging
“I do not have a very strong conviction about the death penalty, but I don’t’ feel anything negative about it for such people either.”
When someone has come to you for your expertise and your expertise has failed, what do you have left? You have only your character to fall back upon—and sometimes it’s only your pride that comes through. You may simply deny your plan has failed, deny that more can’t be done. You may become angry. You may blame the person. You may dread just seeing that person again.
In the face of uncertainty, wisdom is to err on the side of pushing, to not give up. But you have to be ready to recognize when pushing is only ego, only weakness. You have to be ready to recognize when the pushing can turn to harm.
The mother’s pelvis may be too small, as was frequently the case when the lack of vitamin D and calcium made rickets common…
The bell curve
Untidy, human, but practiced carefully and conscientiously—as well as anyone could ask for.
Excellence came from seeing, on a daily basis, the difference between being 99.5 percent successful and being 99.95 percent successful.
It’s important to acknowledge when we’ve failed.
What the best may have, above all, is a capacity to learn and change—and to do so faster than everyone else.
Yet we all feel uneasy about being judged by such grades. They never seem to measure the right things. They don’t take into account circumstances beyond our control. They are misused; they are unfair. Still, the simple facts remain: there is a bell curve in all human activities, and the differences you measure usually matter.
The hardest question for anyone who takes responsibility for what he or she does is, What if I turn out to be average?... But what if I were a B-?.. I could tell myself, Someone’s got to be average. If the bell curve is a fact, then so is the reality that most doctors are going to be average. There is no shame in being one of them, right?
Except, of course, there is. What is troubling is not just being average but settling for it. everyone knows that averageness is, for most of us, our fate. And in certain matters, we would do well to accept this… When the stakes are our lives and the lives of our children, we want no one to settle for average.
Arriving at meaningful solutions is an inevitably slow and difficult process. Nonetheless, what I saw was: better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.
Afterword: Suggestions for becoming a positive deviant
None of us is irreplaceable. So not surprisingly, in this work one begins to wonder: How do I really matter?
Paul Auster: ask a unscripted question
Ours is a job of talking to strangers. Why not learn something about them?
You don’t have to come up with a deep or important question, just one that lets you make a human connection. Some people won’t be interested in making that connection.
You will find, however, that many respond—because they’re polite, or friendly, or perhaps in need of that human contact. When this happens, see if you can keep the conversation going for more than two sentences. Listen. Make note of what you learn.
computer system crashes, pre-dawn pages, insurance companies, work getting dumped on us at six o’clock on a Friday night. We all know what it feels like to be tired and beaten down.
Doctors are supposed to coach themselves. We have no one but ourselves to buck us up. But we’re not good at it. Wherever you find doctors—sitting with fellow residents in the hospital cafeteria, waiting in a conference hall for grand rounds to start—you will find the natural pull of conversational gravity is toward the litany of woes all around us.
Resist it. It’s boring, and it will get you down. You don’t have to be sunny about everything. Just be prepared with something else to talk about: an interesting patient you saw, an idea you read about, even the weather if that’s all you’ve got.
It needs only to add some small observation about our world.
You can lose your larger sense of purpose.
by offering your writing to an audience, even a small one, you connect yourself to something larger than yourself.
people respond to new ideas in one of three ways. A few become early adopters, as the business-types call them. Most become late adopters. And some remain persistent skeptics, who never stop resisting.
Nonetheless, make yourself an early adopter. Look for the opportunity to change.
She is whip smart and insanely resourceful and had better ways she could have spent three years of her life.
They gave me permission to try to tell their stories, and that is the most generous and vital gift of all.