Better : Summary
Non-technical books by doctors are rare , and amongst them, “hard to put down” books , are extremely rare.
A view on performance by a doctor is always a nice read, for you would want to know, the variables that a doc attributes to the success. For whatever I have known about doctors, mainly anecdotal, I have the following impression :
- Doctors need to have excellent PR to succeed , besides the skill sets which are kind of default in any doc
- Its more touchy feely thing that makes you choose a specific doctor. You need not always judge a doc by the medicine he/she gives.
- Doctors need to constantly update their knowledge about whatever domain they are working in.
- Doctors make a ton of money, at least in US.They slog till early 30’s , establish a practice by late 30’s and early 40’s and then its heaven
- Doctors in US have to deal with a truck load of insurance problems . One of my friend who is a doc in US thinks that insurance knowledge is sometimes the key between a successful and an ordinary doc
- Doctors are usually health conscious , cleanliness focused people .
What’s this book about ? This book is by Dr. Atul Gawande, a endocrine tumor surgeon , who talks about performance. Well, to begin with, I imagined this book to fall in either of the following categories, A book which cribs and brings out the darker aspects of medicine OR A book which would talks as though docs are next to god etc.
THANKFULLY, this book did not fall in to any of those categories and it was a pleasant surprise to read
3 paragraphs in the introduction made the connection while I was browsing in book section at a crossword store in Mumbai.
Author , in the intro says the following :
**The three core requirements for success in medicine are :
**
1. Diligence , the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles. It seems easy and minor virtue( just pay attention!!) But it is most central to performance and fiendishly hard.
2. To do Right : Medicine is fundamentally human profession. It is therefore , forever troubled with human failings, failings like avarice, arrogance, insecurity , misunderstanding. So , the solutions / problems / issues are interwoven with human traits
3. Ingenuity : It is not a matter of superior intelligence , but of character. It demands more than anything, a willingness to recognize failure, to not paper over the cracks , and to change it. It arises from deliberate , even obsessive reflection on failure and a constant searching for new solutions.
If one thinks about the three requirements mentioned above, one can apply this to trading too. Ask a successful trader the reason behind his most successful trades, most often, he attributes it some personal characteristic and not to intellectual technical prowess or some PR skills. Reread the three characteristics mentioned above by the author again and you will agree that the three traits are infact the traits for a successful trader too.
Actually the mention of errors in various parts of the books is what pulled me to read this book. The author highlights various facets of errors, like error causality, error quantification and error reduction. The author clearly has a statistical bent of mind and is definitely a numbers guy . Obviously I can never recreate the experience of reading the book, but I will attempt to summarize this book so that it might motivate a reader who likes numbers to read this book and find his/her aha moments
As mentioned earlier, there are 3 themes in the book which are
_Diligence : The constant and earnest effort to accomplish what is undertaken
_
A story about “Washing Hands” brings out the devilish difficulty of compliance to a simple rule. There is a story is about Ignac Semmelweis, who was vociferous in his opinion about hand washing in hospitals , which he rightly believed to be the cause of maternal deaths. Though everyone came to realize this after 150 years , story till this day is that doctors do not strictly adhere to this policy. Who says, ensuring compliance is easy ?
Diligence , as defined above seems simple. You just keep doing things. However there are tons of things that resist / deviate you from the diligent efforts that you would like to put in. Think of any task which you wanted to do on a regular basis but couldn’t and you will see why diligence which seems so easy is SO DIFFICULT. A story about polio eradication in India brings to light the extraordinary achievement of doctors whose diligent efforts can perform things which WHO finds it difficult to execute.
The story of US Military doctors is probably my favorite in this part of the book. This story brings out the importance of hidden variable, a well known concept in stats. When Iraq war casualties were rising, there was a realization that it was the trauma care that was the hidden variable behind these numbers. Improve the trauma care and you drastically reduce casualties. Not waiting for the new technologies to develop, diligent efforts in injury quantification, injury data analysis resulted in wonderful and effective solutions in trauma care. All these improvements came from the doctors focus on quantification of the patient condition, patient progress etc. This story is my personal favorite because the improvements came from studying the system carefully and making improvements. I tend to believe that most of the problems of any domain can be solved by studying the system and quantifying it. Well, my thinking has been shaped more from my black belt experience at GE , many years ago where I learn ways to solve system related issues by error quantification and analysis. That’s exactly, in a grand scale,is what I see in this story of medical doctors . A story of quantification of the problem, trauma care , brought down the casualty rate in the IRAQ war.
Author talks about one of the most sensitive and costly aspects of medical profession, Mal practice suits. Some of the numbers mentioned in here brings out the severity of the problem. In US, about 55000 patients sue the doctors and out of which 1 in 100 get money and usually the money is a windfall amount. Malpractice lawyers charge a ton of money . Look at these numbers. There is a mention of Barry Lang, an independent malpractice suit lawyer who manages to get 5 cases to trial ever year out of which 4 cases are given compensation. Attorneys get about 40% for <$150k, 33% for>$150K and <$500k and 25 % for >$500K. So, on a average the lawyer makes about $50K per case , earning him a total of about $200K . We are talking about an independent lawyer with no attachment to a specific branded agency. So you see that system is similar to a lottery , of course the outcomes involve human lives in this case..Nevertheless, the system is highly skewed. A doc gets sued atleast once in 6 years and pays about 1/2 million to 1 million as insurance premium in his life( may be I am underestimating here, but definitely not overestimating). So, the whole system is designed not to provide relief to a majority of people . Docs are humans after all, they make mistakes too . Operating under uncertainty is almost a daily exercise. However when things go wrong, inspite of the docs reputation, one mistake could cost his/ her license. Strange are the ways in which the whole system is designed. After going through the numbers and sad story of the system, the author presents a remarkable case of a system which works, “Vaccines” . Vaccines are given to children and obviously any mistake by the manufacturer led to law suits. This had a great effect on the availability of vaccines, shortages , artificial price hikes etc. To deal with this situation , American vaccine association came up with a nice idea. Price the vaccines in such a way that a part of the price goes to a fund which then allocates money to the cases where vaccines have caused harmful effects. Well ,vaccines carry 75% surcharge (15% of the total costs) , the money generated is then used to deal with cases. Well, it is not a windfall amount but at the same time the affected parties are usually satisfied with the amount. A great case which shows tinkering with crucial elements of the system make the system efficient. It reminds me of Critical Chain , a Goldratt’s book which talks about the same thing . A few critical elements and tinkering with them changes the whole game!!. A project management principle, however, has a wide range of applications to a lot of systems!
Author then goes about writing things more specific to medical domain like the hazy compensation structure, the ethical dilemmas of the doctors who are sought help to give lethal doses to criminals in prisons, etc.
Docs are elevated to the status of gods and we like docs who fight and fight for patient’s illness . From the perspective of most of the successful docs, the element of fight is a little differently viewed. It is very easy to let the ego do the talking / working. When you bring your egos to the surgery table , then there is a huge danger of putting the patient at risk. I cannot equate a noble field of medicine to rather mundane domain of arbitrage trading. But in a way, a novice trader can learn that it is sensible to know when to let go of the egos for the various trading situations. When stoploss / risk limits are breached, it is always better to get out rather than let the ego do the talking. It is similar to the host of examples mentioned in this essay. When to fight and When to let go is a crucial decision that doctors take . These decisions are taken keeping in mind the patient. It is not about doctor’s expertise, doctor’s credentials or past performance..Its always always about the patient in front of them. Most of the successful docs stop when they realize that it is not worth trying or when they realize that it is better to let the patient die.
It is a stretch to find this situation analogous to trading but I tend to think it is. In the world of fin modeling, you cant be wedded to models. They are just a form of representing reality. If a trade goes right, good for you. But if the trade starts going wrong, its time to cut the losses, tweak the parameters etc than thinking that you have power over every trade. Sometimes the best of best trading signals turn out be phantom signals. As a trader, you have got to be sensible enough to keep things in perspective. It should never ever be EGO thing . Every trade is specific, time bound and needs action. You diagnose the numbers, check for signals , get in or get out based on the patterns that evolve. I have a looooooong way to go in terms of understanding these things in a detailed way….
This is the best part of the book as it reveals the quant thinking that lead to solutions for some of the vexing problems in the medical domain.
Till late 1930’s childbirth was considered to be one of the most dangerous events in a woman’s life as the mortality rates of woman was very high. Most of the solutions sought were aimed at stricter rules, technological improvements, smart techniques etc. However there was one Ms. Virginia Apgar who attacked the problem from a numbers perspective. A Columbia grad who , while working as an anesthesiologist came up with a score to measure the child health immediately after the birth. Apgar score had a few critical variables, which could be easily measured and reported at the end of the child birth. This metric was a great contribution from her that became instrumental in looking at the whole delivery process. Thousands of improvements like prenatal care, obstetrics techniques and post natal care were developing by focusing on the apgar scores across a lot of operations. In this context, I remember the words of Dr.Robert Almgren at NYU, who, in his talk on volatility said , " I don’t know whether volatility is good or bad in financial markets. All I want is to measure it". This approach is a killer approach as some of the finest high frequency algorithms and related work has been done by Robert Almgren at NYU.
Quantifying changes the way you look at things and there could be totally surprising and pleasant consequences of the quantification!
There is also a story about Don Berwick who uses quant and diligent care to fight Cystic Fibrosis, a deadly genetic disease. I guess one needs to always keep in mind , the bell curve in our work. There will be times when we end up doing average work and there will be times when we do brilliant work. One needs to carefully introspect at the kinds of work that brings out the best in oneself and keep at it. I guess that’s the central message from Cystic Fibrosis Story.
Author’s final thoughts are from his experiences from a visit to India. He sees the range of operations and procedures being conducted by doctors using textbook knowledge, shared knowledge . He is totally stunned by the sheer amount of people being handled by doctors. He concludes by saying , “Arriving at Meaningful solutions is an inevitably slow and difficult process. Nonetheless, what I saw was: better is possible. It does not take a genius . It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try”
Author’s Suggestions for becoming a Positive Deviant:
- Ask an Unscripted Question. Ours is a job of talking to stranger, Why not learn something from them ?
- Don’t complain. Its boring. It doesn’t solve anything and it will get you down.
- Count something. If you count something you find interesting, you will learn something interesting
- Write something. Published word is a declaration of membership to a community and also a willingness to contribute something meaningful to it.
- Change.Find something new to try and something to change
Betterment is Perpetual labor
Diligence , Doing the right thing and Ingenuity are the critical elements that will make you better