How Malpractice Suits Are Damaging Health
Atul Gawande is a general surgeon at Brigham and Women’s Hospital and, since 1998, a staff writer for The New Yorker. In 2006, he received the MacArthur Award for his research and writing. His book "Complications: A Surgeon’s Notes On An Imperfect Science" was a finalist for the National Book Award in 2002 and is published in more than a hundred countries. His newest book, "The Checklist Manifesto," is one of Amazon’s best books of the month: December 2009. He and his wife, Kathleen Hobson, live outside Boston and have three children: Walker, Hattie, and Hunter.
Question: Does the fear of being sued ever affect a doctor's judgment?
Atul Gawande: I'm sure. I'm sure it does. Less so in the operating room. I think the place where it affects your decision-making is often in the office, where someone comes to you with a problem, it doesn't seem like a big deal, but then you get the what if? We had a meeting, for example, with -- a surgical meeting where I met a surgeon who was from Cedar Rapids, Iowa, and he was talking about some data they'd collected on how many CT scans they'd gotten in his hometown. This is a town of 300,000 people, and when they pulled out the numbers they found they'd done over 50,000 CT scans for the population in the previous year. The vast majority were normal scans that were probably unnecessary. On the other hand, what do we mean by unnecessary? So, 10,000 were largely for head scans, head CT scans, for people with headaches. Only a dozen found any abnormality. And most of those were unusual headaches. They probably could have followed guidelines that said that you don't need the head CT for nearly anything like the percentage of people who got them. But the fear of a lawsuit if you should miss something led to lots of scans. The irony here is, there is probably even more risk from the scans themselves. They have high doses of radiation. And the number of scans Americans are getting nowadays, we know they're generating hundreds if not potentially thousands of cancers down the road.
Question: How does it feel to make a mistake while operating on another person?
Atul Gawande: I still make them. You know, I operate on about 250 to 300 people in a year. I have a 3 percent major complication rate. At least half I can look back on and see that there were things we should have and could have done differently. And when you recognize that situation -- I wrote in my most recent book of a patient who nearly died on the operating table because I ended up making a wrong move that led to a tear in his vena cava, the major blood vessel going back to the heart, and he lost his entire blood volume into his belly in 60 seconds and arrested on the table. And it was just fabulous teamwork that saved him; that I got lucky. And what it feels like is shame. You know, there's guilt, which means you feel badly for what you've done; and then there's shame, where you feel that you are what was wrong. And because we are in a system where we want to convey to people that we are infallible, we have a hard time grappling with our own fallibility. And in a sense, I don't want that shame to go away. But we've got to use that sense of shame more productively. When that sense of shame leads us to clam up and not want to talk to even the patient about the situation, have a hard time being willing to let the public see our results because of fear of what the data might say about us, that's when it has paralyzed us and kept us from solving problems. Where it's good is **** feel responsible. And the culture of surgery has fundamental components that are driven in ways that make every surgeon recognize that they're fundamentally responsible, they're responsible for the results of their patients, even when it isn't necessarily their own hand that's slipping here. Things can go wrong in lots of ways.
Question: How can a person be a better patient?
Atul Gawande: It's a good question, because I think it is -- there are two things about it. Number one is there's no straightforward recipe. But there are things that we recognize we can do. I think number one is to understand that making the system work well is something that we're only starting to grapple with. Medicine has been about parts; it's been about having a great drug, a great doctor. It has only in the last few years started to become about making all of that fit together as well as possible. And the most important role, I think, that patients play is, they're the only ones that see when things are falling through the cracks. You see one specialist and then another specialist, but they don't talk to each other, and what they're telling you doesn't make sense or fit together. A third of patients by the end of their life have 10 or more specialists in their care. And we're not very good at knitting all of that together.
And so I think the most important part the patient plays is not being passive about their part on the team. They are -- we're not great at drawing out the patient; we've wanted the patient to be passive and not so involved, just do what we say. But the more we have different people involved, what we tell people is contradictory. It doesn't always help them the way it should. And as we get our act together, I think what we're learning is, the patients play a key role.
The fear of massive settlement fees has forced doctors to take a number of generally excessive precautions—including unnecessary CT scans that may cause cancer down the road.
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Research suggests that aging affects a brain circuit critical for learning and decision-making.
As people age, they often lose their motivation to learn new things or engage in everyday activities. In a study of mice, MIT neuroscientists have now identified a brain circuit that is critical for maintaining this kind of motivation.
Researchers develop the first objective tool for assessing the onset of cognitive decline through the measurement of white spots in the brain.
- MRI brain scans may show white spots that scientists believe are linked to cognitive decline.
- Experts have had no objective means of counting and measuring these lesions.
- A new tool counts white spots and also cleverly measures their volumes.
White spots and educated guesses<p>The white spots, or "hyperintensities," are brain lesions—fluid-filled holes in the brain believed to have been left behind by the breaking down of blood vessels that had previously provided nourishment to brain cells.</p><p>Prior to the new research, the quantity of white spots was assessed using an imprecise three-point scale indicating ascending likelihoods of dementia: A minimal number of spots was considered as level 1, a medium number of spots level 2, and a great number of them level 3.</p>
How the new measurements were derived<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDYwMTc1OS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYzNDQ1ODExNX0.vqhQJSvL99KjOe24TOs4E8R7c6-pprbXYSrGcIqbVps/img.jpg?width=980" id="c64d9" class="rm-shortcode" data-rm-shortcode-id="002d9b8ef47b5a86c3a387ad2cd90629" data-rm-shortcode-name="rebelmouse-image" />
Credit: sfam_photo/Shutterstock<p>The team of researchers from NYU's Langone's <a href="https://med.nyu.edu/departments-institutes/neurology/divisions-centers/center-cognitive-neurology" target="_blank">Center for Cognitive Neurology</a> and <a href="https://med.nyu.edu/departments-institutes/neurology/divisions-centers/center-cognitive-neurology/alzheimers-disease-research-center" target="_blank">Alzheimer's Disease Research Center</a> were led by <a href="https://med.nyu.edu/faculty/jingyun-chen" target="_blank">Jingyun "Josh" Chen</a>. They analyzed 72 MRI scans from a national database of older people taken as part of the <a href="http://adni.loni.usc.edu" target="_blank">Alzheimer's Disease Neuroimaging Initiative</a> (ADNI). The scans were mostly of white people over age 70, and there were a roughly equivalent number of men and women. Some had normal brain function, some were presenting moderate cognitive decline, and some had severe dementia.</p><p>Without knowing each individual's diagnosis, the researchers analyzed the white spots in their scans. While the team counted each scan's lesions, the innovation they introduced was the production of a 3D measurement for each lesion's fluid volume. The measurement was derived by measuring a lesion's distance from opposite sides of the brain.</p><p>Measurements of 0 milliliters (mL) were assessed for areas without white spots, with other white spots coming up as containing 60 mL of fluid. Chen's team predicted that volumes over 100 mL could signify severe dementia.</p><p>"Amounts of white matter lesions above the normal range should serve as an early warning sign for patients and physicians," Chen told <a href="https://nyulangone.org/news/white-matter-lesion-mapping-tool-identifies-early-signs-dementia" target="_blank">NYU Langone Health NewsHub</a>.</p><p>When the team compared the likely diagnoses derived from their calculations against the individuals' medical records, they found that their predictions were correct about 7 out of 10 times.</p><p>The researchers compiled their formulas into an online tool that's available to physicians for free via <a href="https://github.com/jingyunc/wmhs" target="_blank" rel="noopener noreferrer">GitHub</a>. The researchers plan to further refine and test it using an additional 1,495 brain scans representing a more diverse group of individuals from the ADNI database.</p>
The new tool and its limits<p>Chen notes that white spots alone may not tell the entire story of an individual's cognitive decline or the onset of dementia. Other factors must be considered as well, including memory loss, hypertension, and brain injuries.</p><p>Nonetheless, says senior investigator <a href="https://med.nyu.edu/faculty/yulin-ge" target="_blank">Yulin Ge</a>, "Our new calculator for properly sizing white matter hyperintensities, which we call 'bilateral distancing,' offers radiologists and other clinicians an additional standardized test for assessing these lesions in the brain, well before severe dementia or stroke damage."</p><p>Having an objective means of measuring white hyperintensities will allow physicians not only to get a better handle on the association between white spots and dementia, but also to track the spots alongside changes to a person's tau and beta-amyloid proteins, two chemicals implicated in Alzheimer's disease and dementia.</p>
A Mercury-bound spacecraft's noisy flyby of our home planet.
- There is no sound in space, but if there was, this is what it might sound like passing by Earth.
- A spacecraft bound for Mercury recorded data while swinging around our planet, and that data was converted into sound.
- Yes, in space no one can hear you scream, but this is still some chill stuff.
First off, let's be clear what we mean by "hear" here. (Here, here!)
Sound, as we know it, requires air. What our ears capture is actually oscillating waves of fluctuating air pressure. Cilia, fibers in our ears, respond to these fluctuations by firing off corresponding clusters of tones at different pitches to our brains. This is what we perceive as sound.
All of which is to say, sound requires air, and space is notoriously void of that. So, in terms of human-perceivable sound, it's silent out there. Nonetheless, there can be cyclical events in space — such as oscillating values in streams of captured data — that can be mapped to pitches, and thus made audible.
Image source: European Space Agency
The European Space Agency's BepiColombo spacecraft took off from Kourou, French Guyana on October 20, 2019, on its way to Mercury. To reduce its speed for the proper trajectory to Mercury, BepiColombo executed a "gravity-assist flyby," slinging itself around the Earth before leaving home. Over the course of its 34-minute flyby, its two data recorders captured five data sets that Italy's National Institute for Astrophysics (INAF) enhanced and converted into sound waves.
Into and out of Earth's shadow
In April, BepiColombo began its closest approach to Earth, ranging from 256,393 kilometers (159,315 miles) to 129,488 kilometers (80,460 miles) away. The audio above starts as BepiColombo begins to sneak into the Earth's shadow facing away from the sun.
The data was captured by BepiColombo's Italian Spring Accelerometer (ISA) instrument. Says Carmelo Magnafico of the ISA team, "When the spacecraft enters the shadow and the force of the Sun disappears, we can hear a slight vibration. The solar panels, previously flexed by the Sun, then find a new balance. Upon exiting the shadow, we can hear the effect again."
In addition to making for some cool sounds, the phenomenon allowed the ISA team to confirm just how sensitive their instrument is. "This is an extraordinary situation," says Carmelo. "Since we started the cruise, we have only been in direct sunshine, so we did not have the possibility to check effectively whether our instrument is measuring the variations of the force of the sunlight."
When the craft arrives at Mercury, the ISA will be tasked with studying the planets gravity.
The second clip is derived from data captured by BepiColombo's MPO-MAG magnetometer, AKA MERMAG, as the craft traveled through Earth's magnetosphere, the area surrounding the planet that's determined by the its magnetic field.
BepiColombo eventually entered the hellish mangentosheath, the region battered by cosmic plasma from the sun before the craft passed into the relatively peaceful magentopause that marks the transition between the magnetosphere and Earth's own magnetic field.
MERMAG will map Mercury's magnetosphere, as well as the magnetic state of the planet's interior. As a secondary objective, it will assess the interaction of the solar wind, Mercury's magnetic field, and the planet, analyzing the dynamics of the magnetosphere and its interaction with Mercury.
Recording session over, BepiColombo is now slipping through space silently with its arrival at Mercury planned for 2025.
Why not just divide the United States in slices of equal population?
- Slicing up the country in 10 strips of equal population produces two bizarre maps.
- Seattle is the biggest city in the emptiest longitudinal band, San Antonio rules the largest north-south slice.
- Curiously, six cities are the 'capitals' of both their horizontal and vertical deciles.
Sweeping re-alignments<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDYwMTAwOC9vcmlnaW4ucG5nIiwiZXhwaXJlc19hdCI6MTYyMzU3ODA1NH0.u_5xakBvkYwgPtiwLU3z-1e082hBeqwS4Rl1uiJqdF4/img.png?width=980" id="23ff1" class="rm-shortcode" data-rm-shortcode-id="24a5b6ec251a11f3ed7aaefc205dde17" data-rm-shortcode-name="rebelmouse-image" alt="Printed in March 1812, this political cartoon was drawn in reaction to the newly drawn state senate election district of South Essex created by the Massachusetts legislature to favor the Democratic-Republican Party candidates of Governor Elbridge Gerry over the Federalists. The caricature satirizes the bizarre shape of a district in Essex County, Massachusetts, as a dragon-like "monster". Federalist newspaper editors and others at the time likened the district shape to a salamander, and the word gerrymander was a portmanteau of that word and Governor Gerry's last name." />
The original cartoon of the 'Gerry-Mander', published in 1812 in the Boston Centinel.
Image: Elkanah Tisdale (1771-1835), Public Domain.<p>One way for a political party to manipulate the outcome of elections is to 'gerrymander' electoral districts: manipulate their boundaries to increase the likelihood of a favorable outcome (see also #<a href="https://bigthink.com/strange-maps/53-ever-been-ger..." target="_blank">53</a>).</p><p><span></span>The term is almost as old as the United States itself, and the practice continues to disfigure the electoral map to this day. Perhaps these maps can serve as the inspiration for a radical solution. </p><p><span></span>They show the contiguous United States (i.e. without Alaska and Hawaii) sliced latitudinally and longitudinally into ten straight-bordered bands of varying size, so that each contains exactly 10 percent of the population. </p><p><span></span>Although certainly not intended as a reflection on electoral redistricting, it's tempting to see these sweeping re-alignments of the U.S. as a suggestion with some potential in that direction. </p>
United Strips of America<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDYwMTA4MS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY0NzE1MjQ1MX0.WpISo-g15B5O3qXbHXHf-7lQtAainpO7zPuizXWFOGs/img.jpg?width=980" id="d6656" class="rm-shortcode" data-rm-shortcode-id="72ed7c905283f9979ec0f82d451ad261" data-rm-shortcode-name="rebelmouse-image" alt="Reddit user curiouskip used U.S. Census population data to divide the 'Lower 48' into deciles (ten equal parts), each representing about 30.8 million people. Each decile is consigned its most populous city as 'capital'." />
The contiguous United States, divided into horizontal and vertical deciles.
Image: u/curiouskip, reproduced with kind permission.<p>Reddit user curiouskip used U.S. Census population data to divide the 'Lower 48' into deciles (ten equal parts), each representing about 30.8 million people. Each decile is consigned its most populous city as 'capital'.</p><p><span></span>Looking at the top map, which divides the U.S. into 10 longitudinal strips, we see</p><ul><li>Seattle rules the northernmost slice of territory. It is the broadest, and therefore also the emptiest one.</li><li>The Chicago, Omaha, New York City and Indianapolis strips complete the northern half of the country. And indeed: 50 percent of the population occupies roughly one half of the country, from north to south.</li><li>The dividing line between the top and bottom halves of the country runs from just north of the San Francisco Bay to halfway across the Delmarva Peninsula.</li><li>Capital cities of the southern strips are San Jose, Charlotte, Los Angeles, San Diego, and Houston.</li><li>The Houston Strip is divided into two non-contiguous areas. Florida maintains its panhandle, albeit much reduced. </li></ul><p>The bottom map shows the U.S. divided latitudinally into 10 bands of equal population. </p><ul><li>San Jose and Los Angeles both retain their capital status, this time of the two westernmost strips.</li><li>San Antonio is the main city of the Big Empty, more than twice as wide as the second-broadest band.</li><li>The dividing line between America's eastern and western half, population-wise, is far off-center: it skirts the eastern edge of Chicago, making the western half much bigger than the eastern one.</li><li>Houston, Chicago, and Indianapolis also remain the largest cities in their respective bands.</li><li>Further east, Jacksonville and Philadelphia get to rule over their strip of America, while Charlotte and New York City keep winning, both vertically and horizontally.</li></ul><p>Redistricting a country into zones of equal population – and that being your only criterium – will create districts that are randomly diverse, and perhaps also, at least in this case, unmanageably large. </p><p>However, mixing up the political map with a bunch of straight lines as the only instrument is something that has been considered before. Usually, the objective is the wholesale removal of age-old divisions. <br></p>
Perfectly square departments<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDYwMTEzOS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYwOTQyMzIwOH0.kYuf58g0bjsPL9DGPq5PycZ7PDJMnItT0rfrPonOP3k/img.jpg?width=980" id="89a68" class="rm-shortcode" data-rm-shortcode-id="5b81a43e785997bb1f11f72548659a9f" data-rm-shortcode-name="rebelmouse-image" alt="\u200bCh\u00e2ssis figuratif du territoire de la France partag\u00e9 en divisions \u00e9gales entre elles, proposition annex\u00e9e au rapport du 29 septembre 1789 \u00e0 l'Assembl\u00e9e nationale de la commission dite Siey\u00e8s-Thouret" />
France divided into 80-odd geometrical departments: failed proposal by Jacques-Guillaume Thouret (1790).
Image: Centre historique des Archives nationales – Atelier de photographie; public domain.
European Pie<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDYwMTQ0Ny9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYxNTE5NDE3OX0.dPcY1tkO7nwkx6IX98Sleh7AmBpDnwlcJLfC_Z-WBlY/img.jpg?width=980" id="b35d7" class="rm-shortcode" data-rm-shortcode-id="84509a9425e13c0dd8fbe00df28a197e" data-rm-shortcode-name="rebelmouse-image" />
In this rather outlandish proposal, continental Europe's 24 cantons center on Vienna.
Image: PJ Mode Collection of Persuasive Maps, Cornell University.<p>And in 1920, an anonymous author – possibly the Austrian P.A. Maas – proposed slicing up Post-World-War-I Europe as a pie, into 24 slices that would center on Vienna's St. Stephen's Cathedral. Each of those slices would be made up of a wide and random variety of linguistic, ethnic, and religious groups – and that would be the point: the better to unite them all into one massive superstate (see also #<a href="https://bigthink.com/strange-maps/a-bizarre-peace-proposal-slice-europe-up-like-a-pie" target="_blank">851</a>).</p><p>Needless to say, both plans never left the drawing board. Would a proposal for the longitudinal and/or latitudinal redistricting of the U.S. have more traction? <br></p>
Coast-to-coast precedents<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNDYwMTIwOS9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY1MDM2OTE0OX0.52UjcA_YD9Y9UB9_hoSctI_xBrRDALZ2DRLkIo9a8RM/img.jpg?width=980" id="10784" class="rm-shortcode" data-rm-shortcode-id="1999808ea21e11162fdb9181c3912753" data-rm-shortcode-name="rebelmouse-image" alt="Illustration of the Connecticut Charter boundary, 1662" />
Putting the 'connect' into Connecticut: the Nutmeg State extending from the Pacific to the Atlantic.
Image: Connecticuthistory.org<p>Well, for one, coast-to-coast polities have some pedigree in America's past: some of the first colonies had claims that extended from the Atlantic all the way to the Pacific. </p><p>If history had gone entirely the way Connecticut would have wanted, the state would include such inland cities as Detroit, Chicago, and Salt Lake City, and extended to what is now the northern part of California.</p><p>Is such geopolitical weirdness reasonable or feasible today? Absolutely not. But in its randomness, would it be it as unfair as gerrymandering? </p><p><em><br></em></p><p><em>Decile maps of the contiguous United States reproduced with kind permission by u/curiouskip; found <a href="https://www.reddit.com/r/dataisbeautiful/comments/ijyn7p/oc_us_population_deciles_by_latitude_and_longitude/" target="_blank">here</a> on <a href="https://www.reddit.com/" target="_blank">Reddit</a>.<br></em></p><p><strong>Strange Maps #1054</strong></p><p><em>Got a strange map? Let me know at </em><a href="mailto:firstname.lastname@example.org">email@example.com</a><em>.</em></p>