“Count something.”

This keen piece of advice comes from Dr. Atul Gawande, as espoused in his most recent book, Better: A Surgeon’s Notes on Performance. Gawande is a general and endocrine surgeon at the Brigham and Women’s Hospital in Boston, MA. Although he is a surgical fledgling, completing his residency in 2003, Dr. Gawande’s insights blossom from his experience in public health issues, at one point serving as a senior health policy adviser for the Clinton administration.1

The thesis of Better is that, while advances in medical technology, new drugs, and the like can lead to an overall healthier humanity, the most effective — and commonly overlooked — way to improve well-being is to make better use of what we already have. When he proposes that everyone in the healthcare community ‘count something,’ he means that evaluation and reevaluation of current methodology and practice are the true keys to success. We must measure ourselves, and then use those measurements to understand where shortcomings occur. He also makes it gravely clear that all doctors are not created equal in their ability to treat patients.

In the medical world, Gawande reports that many fields have no metric by which to measure their relative success. In those cases, we must create one. For example, the simple (but not-at-all trivial) invention of the Apgar Score by Dr. Virginia Apgar in the 1950’s for measuring neonate health led to incredible progress in childbirth success. Contrarily, the technological breakthrough of childbirth forceps did not lead to an appreciable increase in overall neonate outcome.2 The point is that, if you can measure it, you can make it better.

No where does this theme prove more true than in situations where efficacy is paramount. Gawande’s global background in health policy made this particular suggestion exquisitely compelling. He talked of WHO initiatives in India to abolish polio. Upon news of a single case of polio, the WHO would mobilize a veritable army of health workers to “mop-up” the radial population, vaccinating every child in the vicinity. Numbers were everything, and the doctors in India were obsessive about not missing a single person. A failure would set back the whole program, because eradication is about totality, and diseases — like the germs from which they arise — spread on an exponential scale.

In the military, as well, army surgeons would stay up late into the night recording data on the day’s trauma cases, knowing that record-keeping is the cheapest, most effective way to keep more soldiers alive. One example was that, while all soldiers were issued kevlar vests during the Persian Gulf War, many soldiers came to the clinics with severe injuries to their core … the very region the vests are purported to protect. The simple revelation was that the soldiers were not wearing the hot, heavy jackets. After a mandate to keep the vests on at all times, the mortality rate on the front lines dropped precipitously.

As simple as it may sound, the adage to ‘count something’ is an unassumingly brilliant suggestion. For Dr. Gawande, it was tracking the number of sponges and instruments during surgical operations to ensure that none were left in the patient (a scarily realistic problem). For one’s personal health, this might translate to keeping a sum of daily saturated fat and sugar intake. For the nation, counting would show that 25,000 female deaths could be prevented each year if women simply attended annual mammography screening.3

So go ahead, count something, and get better.

Footnotes:
(1) Dr. Atul Gawande’s website.
(2) There were various reasons for this observation, among which were the difficulty of properly implementing the technique, and shrouding the procedure in secrecy for the purpose of self-aggrandizement; the latter of which raises serious ethical concerns.
(3) I do research in breast cancer mortality modeling, and our group has unearthed this very relevant fact. We are currently in the process of developing and deploying an automated mammography reminder system to help increase mammography attendance.