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Book reviews

The challenge for primary care. Nigel Starey. Radcliffe Medical Press, 2003. ISBN 1-85775-569-3. 240 pp £35 (www-radcliffe-oxford.com).
Gawande A. Complications - A surgeon’s notes on an imperfect science. London: Profile, 2002. £12.99

The challenge for primary care. Nigel Starey. Radcliffe Medical Press, 2003. ISBN 1-85775-569-3. 240 pp £35 (www-radcliffe-oxford.com).

Many people in primary care might look at the title of this book and feel their eyes glaze over. Simply seeing “challenge” in the singular is likely to demand the riposte of which particular challenge of the many Nigel Starey wants to write about. They can be reassured that Starey, himself a GP with many years experience in primary care, is wise enough to know that there are times when the use of the singular is more emphatic than the use of the plural.

This book is about “management”, but not the sterile management that makes us groan because it is obtuse and unhelpful, but which too often is the norm inside large organisations. Rather it is about clever thinking, about avoiding problems before they occur, about being ahead of the curve. It is about how to make the best of what we have inside the structure that we have now, or whatever other structure someone might impose, usually without any clear evidence that it will work better than what we have now.

In healthcare we often forget what management is really all about. Dictionary definitions iinclude "to succeed in achieving", and "to succeed with limited resources". To give him his due, Starey uses the "m" word sparingly, but the emphasis is on succeeding to achieve with limited resources.

Many examples throughout the book make excellent thinkpieces. Those concerned with repeat prescribing struck home. In one box the system is described as inefficient, time and energy consuming, designed to ensure that everyone will be unhappy most of the time. Later, a description of the pills needed by an 80-year old relate a need for five repeat prescriptions, ten trips to the surgery and five to the pharmacy. Nor is the human side overlooked, with patient and organisational perspectives balanced throughout.

The book has been written with knowledge, care, understanding, and with a degree of humanity not usually seen in a treatise on management. While its focus is on UK primary care structures, it is a worthwhile read in any healthcare context. In UK primary care, almost a must read.


Gawande A. Complications - A surgeon’s notes on an imperfect science. London: Profile, 2002. £12.99

This is an intelligent and entertaining book by a trainee surgeon. Its provenance is probably Samuel Shem’s House of God through ER, with the waspish insight of Asher. Just as ER uses cross-cutting plots here the chapters take in for example how a surgeon learns manual skills, and the problems of burn-out, obesity and even chronic pain.

Each chapter in the best American journalistic tradition tells a human interest story, and they are all credible, identifiable and accurate. The net result is that you romp through the book like a thriller with multiple plots, but behind most of the stories lie important thoughts, which linger intriguingly. No more perhaps than you would expect from a Rhodes Scholar with a Balliol PPE and Clinton administration background.

The book has three sections, fallibility, mystery, and uncertainty, and the structure hangs together. Early on he mentions the saying about surgeons “Sometimes wrong; never in doubt”. He goes on to say that this is a strength, not a weakness, because uncertainties are part of the surgeon’s life, with inadequate information, ambiguous science and imperfect knowledge and abilities. Yet the surgeon has to act. The best surgeons also know when not to act.

The public importance of uncertainty in medicine is that we rarely discuss it. In a culture of “I want it, I will go and get it”, the very idea that you might suffer from a disease for which there is no fix is hard to swallow. In a scientifically illiterate media there is no room for critical appraisal of evidence. Gawande tackles the decision making at an individual level in the final chapter, the decision tree laced with unknowns when treating a woman with necrotising fasciitis, and I would love to read him on the public health aspects. He quotes David Eddy on the arbitrary nature of medical decision-making, but this is just one side of the coin. When the vociferous call is for patients to be involved in the decision-making little thought is given as to just how they are to be empowered to make the decisions. The reality for all of us is that the crucial decision when you need help is to choose the right professional.

The chapter “Education of a knife” tells the story of how he learnt to put in a central venous line, which involves sticking a big needle into a big vein, guessing where that vein is running beneath the skin. He writes beautifully about the anxiety and the politics of learning the manoeuvre. In a training culture of “see one, do one, teach one” he captures the anti-machismo of admitting defeat, sweat on brow and unwilling to stab the patient victim with ever increasing odds of failure. There is now an ultrasound technology to identify the target vein. Perhaps unsurprisingly there is a Luddite (and machismo?) tendency to damn the technology. Real men don’t need the machine.

The burn-out chapter bears reading. In teaching, just as in medicine, we make little allowance for waning or changing interest, aptitude or even capability. There are rare individuals who want to carry on teaching or operating in the same way past fifty, and some have to, but we give little thought to the recognition of the waning appetite, and even less to how we change their commitments to everyone’s benefit. This is a marvellous read, thought-provoking and entertaining.

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