Tuesday, June 1, 2010
Defining moments : when managers must choose between right and right
By Joseph Badaracco
This author who is a Harvard Professor has done a remarkable job discussing ethics in business world. I have been reading some his latest works and eventually ended up with this book (reverse chronology). To me, this is one of his best books. Pathos is that, he cites quite a number of stories from western mythology but did not present any examples from east missing out on equally evocative and elaborate choices.
When there are two choices which are equally “right” but points in opposite direction, taking a decision is discouragingly tricky and perhaps morally hazardous in certain cases. What I liked about his basic theme is that, ethics when it manifests as action, is anything but straight forward. I concur with him that real world problems seldom lend themselves for such direct shooting. The path is nebulous, methods may be at times questionable and yet we have to soldier on. This ethical dilemma has been debated for countless centuries and the answers don’t seem to converge at all as author quips “what cannot be resolved in theory has to be resolved in practice”.
Prof Badarcco has quoted Machiavelli, Aristotle, Nietzsche and host of other philosophers aptly to get his message across. He takes up 3 cases in the increasing order of complexity - how can a Harvard Prof do something without a case study?. He does not tell the entire story in one go, but pauses, explains a bit more on the nuances and later towards the end of the book, he really tells the final outcome of all the three cases. They are all well thought out.
Defining moments are the ones when you choose between one “right” over “other right paths”. But, he adds ruefully, they are the final and visible part of the complex political, psychological and administrative process. To think otherwise is to mistake an exclamation point for a sentence that precedes it. They are the crucibles of character.
He introduces the concept of “dirty hands” right at the beginning from the French Philosopher Jean Paul Sartre’s work. ( Ref: http://en.wikipedia.org/wiki/Dirty_Hands )
In that play Les Mains sales by Jean-Paul Sartre, the veteran communist party leader is harshly accused by a green horn youth that he has compromised on party ideals, values and so on. The leader responds thus:
“How do you cling to purity young man? How afraid are you to soil your hands? All right, stay pure. What good it will do? Purity is an idea for monk or yogi. To do nothing, to remain motionless, arms at your side, wearing kid gloves. Well I have dirty hands. I have plunged them in to filth and blood. But what do you hope? Do you think you can govern innocently?”
- That question alone would suffice to think deeply.
Also, he talks about a portion of brain that handles moral issues. He refers to an accident of a railroad worker (Circa: 1848), Phineas Gage. An explosion drove an iron rod in to his left cheek through the base of skull and out on the top of the head. Miraculously, he survived. His mental abilities were intact, but his character did not remain the same. Before accident he was a reputable, hard working family person, but after accident, he became undisciplined and foul mouthed. Apparently, the accident has destroyed the parts of brain that govern morality. For more details, please refer : http://en.wikipedia.org/wiki/Phineas_Gage
In Ethics courses in the business schools, it is difficult to find a course without J&J Tylenol case study.Now, the twitter version of the story (Poor packaging of Tyenol proved fatal and as result J&J withdrew it nationwide) For more details: http://en.wikipedia.org/wiki/Chicago_Tylenol_murders.
The way he looks at the entire episode is quite different and comments that to withdraw it from the market was a “no-brainier” - after all, customer didn’t want to play roulette just to cure a headache. Author cities other episodes in the same company (like Zomax) and concludes it is more an exception.
His analysis of “sleep test” is very incisive. Lady Macbeth could not sleep at night since she conspired with her husband to kill many political rivals and in that process murdered her own sleep. But then, responsible people lie awake precisely because they have done the right thing. He dramatically concludes if people like Mother Teresa sleep badly and people like Hitler sleep well, then we can place no faith on “sleep test”. He brings in the conditions where “sleep tests” can be counted on. I enjoyed both the views.
Author also cities Ernest Hemingway’s view, “I only know that moral is what you feel good after and immoral is what you feel bad after”. Trouble is that, it is essentially post event. Secondly, I think, if one is adept in self reconciliation, some kind of rationalization can be made almost for any action. The examples that come to my mind are: “this is what I get as a punishment when I try to defend myself” – One of the convict’s last statement before he was executed. He killed two police officers. Another Case: A boy murders his parents and pleads the court to be lenient because he is an orphan now! Very rarely, people are at fault in their own eyes.
In terms of number pages, it is a puny one (126pages), but it is a heavy duty book in the sense, it would force you to examine some of your past decisions, path taken so far, and also what path would you want to take?. In any case, as I reflected I concluded that it is simply NOT possible to govern or manage innocently – unless one gets extraordinarily lucky all through his/her life or be in that position for too small a period.
Oh God, then the loss of innocence is real if the job is well done .
Thanks for reading thus far.
Regards,
madhu
Saturday, May 1, 2010
Does IT matter by Nicholas Carr
Garr has a gift of articulating just about anything in a near zero sentimental way. He reminds me of a character in star trek episodes: DATA. The bye line of the title itself would make you sit up – “IT & the corrosion of competitive advantage” (IT as in Information Technology).
Garr declares “the transformation of IT from a source of advantage to a cost of doing business” raises a host of challenges for the business executive. If you think it is too presumptuous a remark to make, you would have read it with his examples to be convinced. Recall Mark Twain’s remark “Nothing is more annoying than a good example” - you may be annoyed mainly because it is more real than we would like.
At the heart of his sprawling argument is this: IT and Technology are means to do business. Now, they are commodity. Hence don’t look at them as differentiators but just as inevitable infrastructure items.
Let us take one of his stunning examples: Early in the 20th century, many large companies created a new management post called “Vice President – Electricity”. This is a clear acknowledgement of electrification transformation. But, in a short span of time, its strategic importance diminished so much that it quietly disappeared from the corporate hierarchy. Their work is done and hence they are out. He stops short of saying that for IT field. During its inception, when one or two manufactures used electricity to produce their products (whatever that is), they had a competitive advantage, but once everyone is into electricity, then it becomes a mere input to the business.
Like the Design guru, Donald Norman, Carr views computers and IT more as infrastructure, and remarks rightly that transformational power of new infrastructure technologies dissipates as they reaches the build out. After giving many examples (Machines Tools, Wi-Fi, Software, Web Services, SABRE system etc) he makes a profound statement: “When a resource becomes essential to the competition, but inconsequential to the strategy, then the risk it creates is more important than the advantage it provides.” How true! For example, take electricity in India. Certainly, it is nowhere near 99.xx % availability which perhaps can be taken for granted in certain advanced countries. In India, there would be power cuts, sudden surges and so on. Yet, the business has to run. So what is the solution?. In-house electricity generation when ever government supplied power goes kaput. Any firm that does not have in-house power generation will be very vulnerable and perhaps eventually earn the dissatisfaction of the customer. But, having them is no recipe for success; it is simply the cost of doing business.
His constant reference to the evolution of electricity is a bit unnerving if you belong to the IT field. At first, electricity was private; soon it became public and can be purchased as per your usage. It has become a utility. So would be data processing. Which computer processed your latest “Google search” he asks and adds that, “you don’t know and perhaps you don’t care” any more than which power plant generated the electricity that you home lights use.
Not long ago, when developing the information systems, companies would first decide how they wanted to do the business and then choose the software package that would support the process flow envisaged. Also, large efforts would be thrown in to customize it. This is true whether it is IT systems or technology side where each time around device drivers and other stuff would be written exclusively. Now, things stands reversed. Question is, how the enterprise systems which are available as packages should be modified to suit our business and also what are process editing which have to happen in-house to use these packages? Good news is that, standard process would be state-of-the-art. Bad news is that, everyone has access to it. As commodity wave hits, the plane of competition shifts. It is clear when it hits users stands to benefit but the sellers would have a nightmare unless they have something more as “value-adds”.
When Humans moved away from “hunting & gathering” to “centralized farming”, society and structures changed accordingly. It was essentially consolidation of physical powers. Per Garr, most of the society structures are temporary – without sounding philosophical, he states that they would be abandoned very easily depending on the spirit of times. Technology shapes economics and economics shapes society. He strongly thinks personal choices have no bearing on this, society is governed by economic trade-offs.
In the long run, it appears there is nothing “exclusive” about anything and eventually, law of gravity catches up. Celebrated sociologist Jane Jacobs observed that: “Invention of public libraries democratized the access to literature. Invention of public schools democratized the access to education. Invention of fashionable cloths democratized the access to personal appearance”. If she were around, maybe she would have added about Internet and so on to the list.
The telling lesson is that, when some stuff gets democratized or made available to a very large set of people, humanity as a whole would be benefited, but it does come at a cost of a small section of people who were selling those products and services when they were exclusive and fragmented. When “exotic” becomes “common” you better watch out. So, it is better to ask (say once in two years?) “Am I getting commoditized? Is my area getting democratized?” If so, you would should pull up your socks. Now I reminded myself, if I don’t come to the table at a good frequency, may be, I am already appearing on the menu!
Thank you for reading thus far.
Regards
madhu
l
Thursday, April 1, 2010
The Botany of Desire by Michael Pollan
Mike joyfully declares “Plants are Nature’s alchemists”. How true? They create a wide array of things. From sweet, nurturing and delicious to downright poison that could kill us. He starts with a paradigm shifting observation that, plants are remaking us as much as we are remaking them. He wonders, “Did I choose to plant potato or potato made me to do it?”Mike identifies four basic desires of humans, mapped to four plants which are taken as examples.
Desire: Sweetness. Plant: Apple.
Desire: Beauty Plant: Tulip.
Desire: Intoxication Plant: Marijuana
Desire: Control Plant: Potato
The examples and stories were as compelling as the ”The Napoleon Buttons”. http://jujubax.blogspot.com/2009/10/napoleons-buttons.html.
Now, some interesting stories that got my attention ….
I was surprised to find the Gene gun is not a metaphor, but a 0.22 shell used to fire stainless steel projectiles dipped in a DNA solution at a stem or a leaf of the target plant. If all goes well, some of the DNA would pierce the wall of the some of the cell’s nuclei and elbow its way in to double helix – a bully breaking in to line dance! If the new DNA happens to land at the right place, and no one yet knows what or where that place is, the plant grown from that cell will express the new gene. Wow, what a game of randomness!.
Brain itself has its own endogenous cannobinoid. It was discovered by Mecholam and Howlett. They have named it as “Anandamide” from the Sanskrit word for inner bliss. Mike foresees a clear case of Nobel Prize for this duo soon since it has opened great deal of avenues for our understanding of the brain. It would pave way for understanding the bio-chemistry of emotions.
Tulip according to Mike is nature’s eye-candy. (Psychiatrists even regard patient’s indifference to flowers is a clear sign of depression!). Tulip had its heyday during 1660-85 in Holland so much so, it can be called as tulip-mania. Turkey also had its share of whim, where sometimes tulip was paid in gold. In this context, instead of relying on wind and water alone to move gene around, a plant could enlist help from the animal by striking co-evolutionary deal: Nutrition in exchange for transportation. With advent of flowers there are more interdependency, more communication and more experimentation – a novel way to look at flowers!
Mike’s tracing how apple grew in many parts of the world along with history of Chapman is fascinating who systematically moved from one land to another land, plants apple trees, grow them for certain time and sell it for a handsome returns – only to move to next venture. Most of the time, care taking was done by the locals. It appears, in every era, there are some small set folks who really set out and make a difference, be it apple planting or telecom or search engine. The history of apple – I mean the fruit, is really good one, many chancy events have made it what it is now.
Donald Norman, lamented that, now a days, “It is important to be clever than correct. It is important to be profound than practical”. After reading this book, my view of the plants is…. “They are Profound, Practical, Clever and Correct”. Jai Ho to Plant’s kingdom!
Thanks for reading this far.
Regards, madhu
PS: You can also have a look @ http://mohansidlethoughts.blogspot.in/2010/06/botany-of-desire-plants-eye-view-of.html
Monday, March 1, 2010
Project Management - A Comedy of Errors
This 125 page is quite a “quote” and “mini story” intensive one. The story line may appear weak for a book, but it is worthwhile effort to go thru it for it contains many insightful view points. If you are in IT field, you can relate it even better. This book is of “In the wonderland of Indian managers” genre. I enjoyed it thoroughly.
Story outline in brief without ending:
Swaminathan (Sam) joins a Y2K Indian Software company, works very hard for about 5 years and gets an onsite assignment to USA. He meets his mysterious manager Bob who starts teaching all the way from Indian airport. He teaches him the seven habits of highly ineffective manager, types of bosses, courtship and belly dancing, baby sitting techniques (aka) people management, delivery pains, tricks after which he eventually attains “nirvana”. It is a full round trip: Trip to USA, bit of drama there and finally back here. The book is fully in dialogue mode which makes it even more an enjoyable read. The way author relates a story to IT scenario is really ingenious.
I will pick two stories and three quotes from this book – more than that, I would risk reproducing the entire book!
Chapter-9: Delivery Pains. Pharaoh, Priest and the Mason.
In ancient times, Egyptian priests loaded the Pharaoh’s mind an idea of building skyway to heaven (it is a promise) but what got delivered was a Pyramid which is nothing more than a tomb. Priest and Mason know that, once it is complete, they will not live another day. So, priest asks mason to build something that can never be completed, but they cannot fake the progress. Hence, when it reaches certain stage, additional changes in the form after life requirements keeps coming. Pharaoh will have no option but to fund further. Priest strengthens his portfolio and mason gets a life time employment. Now author concludes rather dramatically, “Any project that makes the team members job position irrelevant, in true spirit never gets completed”.
Now, some interesting excerpts or quotes from that book.
1. For every under estimation, there is an equal and opposite over estimation
2. Bugs once created cannot be destroyed. They can only be transferred from one module to another. (Deliver now and worry later)
3. Be content with what you have, but, be sure you have got plenty.
Kalahari Bushman Story: If unable to find water on their own, they apply salt on monkey’s tongue. The thirsty monkey runs to the water source. The bushman simply follow the monkey and the water.
I really liked the book since it explains serious stuff in a lighter vein.
Thanks for reading thus far.
Regards
madhu
Monday, February 1, 2010
Predictably Irrational
- The Hidden Forces that shape our decisions
DAN ARIELY
“Dad, don’t you think you are drinking too much?” asked the son.
“Come with me” says dad and takes him to his bar.
“Here, you see son” says dad takes out two glasses. In one glass he pours plain water and in another glass some whiskey. “Look carefully son” he says, as he drops two small worms in each one of them.
Poof - worm in the water continues to swim well and the worm inside the whiskey glass dies right away.
“Now, as you can see, I drink just to kill worms and at my age there are lots of worms inside my stomach!”. Son leaves the bar convinced that, if he ever he gets worms in his stomach when he gets old he would drink like his dad and thus drinking whiskey is not a bad idea after all.
No matter how apocryphal this story is, for me, it demonstrates a quirky point. You can devise some clever experiment to make a point or its counter point and convince some one – at least temporarily.
Now, here comes Prof Dan Ariely, an ultra smart Israeli M.I.T professor who does series of experiments with equally smart professors from similar campuses at Harvard, INSEAD, ULCA and all.
These experiments on human behavior are not like Michelson-Morley experiment, where you can eventually converge. For a moment, I visualized myself as President of MIT or dean or whatever so that I can pose this question: “Dan, I am awestruck! But to disprove all these points what are all the experiments you would come up with. Figuring that out is your assignment for this semester” (I will let you know when Dan comes back).
Dan starts with a personal incident at the age of 18, when he met with a fateful fire accident incurring about 70% burns. So, for the next few years, he was on a series of medical procedures and dressed as he says “as a crooked version of spider man”. During that period he had the luxury to observe lots of stuff pertinent to human behavior that perhaps shaped his career. Later, he would go on to study at Telaviv University and then move to MIT to conduct more and more experiments. In the introduction itself he sets the context well to make a neat claim: “We are not only irrational – but predictably so”. In the 13 chapters that would follow he does corroborate this idea well with experimental results. The style of writing is very lucid and appealing. Let us take 4 of 13 for the commentary purposes. Chapters are nearly independent and hence can be read in any order also.
The Chapter-9, “Keeping doors open” is indeed an eye-opener. He gives the historical example of 210B.C Chinese commander, who burnt all the boats and broke all the pots to cook which left no option but to win or die – of course, they did win 9 consecutive battles. Point is that, when options are limited, focus is so high, objective is achieved. However, I am sure the same Dan would is well aware of the siege of Massada, where, for lack of options to escape in the middle of fortified desert, all the rebellious Jews ended up committing mass suicide after killing their own families.
Be it dating or elective papers or choice of vehicle, as per Dan, we would prefer the options open as all long as possible and he says, “It is a fool’s game which we are remarkably adept in playing”. Even Dan had problems in deciding between MIT and Stanford.
The Chapters-11 & 12, “The context of Character Part 1 & 2” are quite interesting and troubling too. He conducts a series of experiments in MIT and concludes that “humans are honest to the extent it suits them”. In an experiment he had four batches tested with a question paper. First batch fully is controlled. Second batch, only self checks and claim money. Third batch self check + shredding & claim money. Forth batch self check + shredding + pick up from the money jar. Needless to add, the average correct answers increased upwards, but it did not increase beyond certain point albeit there no chance of being caught. It appears even when we have no chance of getting caught, we don’t become wildly dishonest.
To summarize:
CONTROL LEVEL Average
Condition # 1 Control (no chance to cheat) 32.6
Condition # 2 Self Check 36.2
Condition # 3 Self Check +Shredding 35.9
Condition # 4 Self Check + Shredding + Money Jar 36.1
“A measure of a man’s character is what he would do if he knew that, he would NOT be found out” says Macaulay. Dan has done a good deal of objective measurement – of course, results are troubling and his “take” on results are very convincing.
The Chapter-4, “The cost of social Norms” is insightful. We live in two worlds simultaneously. One is social and the other is business. In the social world, reciprocation need not be immediate, where as in business it has to be nearly real time and instantaneous. When the two worlds collide there is trouble.
He gives some dramatic examples. His “Day care” example: It imposed fine to the parents when they were late. Interestingly, parents construed it as they can chose to be late by paying fine (from social to market norm) hence late pick up increased. Palpably, that was not what the day care center intended to convey as the main message. So, they withdrew the penalty program. It did not help. Hence, once they collide and triumphed by market norms, social norms rarely returns.
After reading this book, for a moment, I felt it should have been titled “Design of experiments”.
Somehow, author has developed agreeable measurements for many of the hard to quantify stuff like honesty etc.
Distinguished French historian Emmanuel Le Roy Ladurie, once remarked there are two kinds of historians. One kind is parachutists and other is truffle hunters. Former kind observes history from afar, slowly floating down to earth while latter fascinated by the treasures of soil, keeps the nose close to the ground. It need not apply only to historians. This book indeed brought out many treasures-of-insight. Don’t miss this one.
Thanks for reading this far.
Regards,
madhu
Friday, January 1, 2010
The START UP Nation
Authors : Dan Senor and Saul Singer
“How do we get more out of people?.
Who can object to this? But it is a loaded question with industrial age thinking. Ironically, the management model encapsulated in this question virtually guarantees that company will never get the best out of its people. Vassals and conscripts may work very hard, but they do not do it willingly. This is a crucial difference when the prosperity depends on creativity and an enthusiastic workforce will consistently outperform a group which is merely industrious. Can you remember any instance when the assigned work brought more joy than the one which you choose to do?".
That was the management guru, Gary Hamel when he makes a passionate pitch that volition is better than assigned or forced or “draft” work. But, even he might have to change his mind seeing this country. Israel as a nation does know how to create lots of enthusiastic and ultra creative conscripts.
Let us quickly see how it does that.
Military service is compulsory and they have one of the toughest trainings. Entries in to elite programs like Air Force are even more demanding. The toughest being “Talpiot” which systematically garners the brightest of the bright and they go through longer and intense trainings. They invariably end up in creating some of the most promising startups to lift the industries in to the next plane of contributions. Real life battle hardened, intensely well trained on technology and strategy are ideal qualities for any company or startups and that is what this “draft” does to business.
This new book (released in November-2009) gives a good understanding of Israel as a nation from a startup stand point. It weaves quite a bit of perspectives in a story telling manner.
We will see two more stories, but before that, quick summary of key points.
1. Questioning status-quo approach is inculcated from childhood.
2. “Draft” training brings all strata of society folks to common ground and brings in a sense of identity and purpose in life very early. Many years of experience is compressed into handful of years.
3. Due to lack of resources, they are very resourceful. Runtime improvisations is something taken for granted.
4. Ownership of assignments is 100% - if not more (Example: Intel Israel case study )
5. Because of high interconnections, transparency is very high to the point of making a claim “everyone knows everyone” (being small, there is no place to run away).
6. Immigration as a policy is integrated at a constitutional level and processes & policies are geared toward enhancing the efficacy of it.
7. Israel seems to have a unique reserve system to address the military and safety needs of the country.
8. Inter disciplinary approaches are very common like Biology and Math, Rockets and Drug discovery and delivery.
Now two selected stories (because, I don’t want to rob the suspense of the remaining)
1. “Our Idea is quite simple. We believe the world is divided between good people and bad people and the trick to beating fraud is to distinguish between them on the web” – Imagine this elevator pitch to the e-bay Chief of operation who handles all the pay pal stuff - the largest internet payment service in the world. But, that is exactly what Shvat Shaked did. His small team developed an algorithm that detected fraud far more accurately than the much bigger team which e-bay had. Eventually, his company got acquired by e-bay. The story is fascinating.
2. The startup “Beta-O2” is working on bio-reactor for diabetes patients. Patients suffer from this disorder which causes their beta cells to cease the production of insulin. Transplanted beta cells would do but they need oxygen supply. Beta-O2's solution is to create micro eco system that has oxygen producing algae and a fiber optic light source. The beta cells consume oxygen and produce CO2 and algae do just the opposite thereby creating closed loop. The skin implantable reactor device can be replaced every year with a 15 minute outpatient procedure.
Some of the dialogues are very appealing. For example,
”What do you think of hybrid cars?”.
“A hybrid car is like mermaid; if you want a fish, you get a woman; if you want a woman, you get a fish”.
In this book, authors do ask a pertinent and a profound question “where is our Nokia?” – implying where are our big corporates. There is no explicit answer for that question. I think, it is very unlikely it would create a big corporation. I surmise it may be more out of conscious strategy and I see a lot of prudence in it. Centralized production may bring economy-of-scale, but I see the price of that as economy-in-innovation & economy-in-initiative - that may be a frightening prospect for Israel. Aside the culture “Why you are my boss and not the other way around” kind of attitude simply does not lend itself to building a corporate behemoth. May be, it is Shinkansen (Japan bullet train) approach – that is, there is no one big engine that pulls the train, but each coach has an engine “embedded” in to it. We all know it is one of the fastest and effective train system in the world since its inception. Add to that, any mammoth would have huge localized risk which is expensive to protect and oversee. Sum of parts would be always greater than the whole in this country.
Finally, the book contains so many inspiring stories on start up, if you are a cat-on-the-wall pondering about getting in to startup, this book can provide the final push in to the startup river.
Thanks for reading this far…..
Regards,
madhu
Tuesday, December 1, 2009
Complications – Notes from the life of a young surgeon by Atul Gawande
“Baala Joshiyam. Virudha vaidheedam” – says a Sanskrit lore.
It means if you have to consult an astrologer or a fortune-teller, find the youngest person possible. Logic is that, he is yet to learn the subtleties of psychology and owing to his inexperience he is likely to tell what is most probable that would happen no matter how unpleasant it may be, rather than saying what you want to hear. On the other hand, when you go to doctor, choose the eldest possible since he would have done many experiments with so many folks that his diagnosis is likely to be better than a younger one.
So, with that frame of mind, “young surgeon” was more a warning than a reassurance for me.
Add to that, from childhood, I am always used to the jokes on doctors in the vernacular magazines.
(For example, patient is asking the doctor, “Is this operation so difficult doctor?”. Doctor replies, “Oh, no, it is dead easy”). Well, I was in for a pleasant surprise. It is a serious and an impressive read.
This book contains three broad sections. (1) Fallibility (2) Mystery (3) Uncertainty, each containing four or five cases. The title “Complications” comes not just from unexpected turns that can result in medicine but also the underlying dilemmas in what we do. Author says “medicine, we have taken it to be both more perfect that it is and less extraordinary than it can be”.
Fallibility section has five good chapters. I am picking up “The computer and the Hernia factory” where he specifically talks about the Shouldice Hospital near Toronto. The recurring rate is an awesome 1% where as rest of country or anywhere in the world is way above that. Since this is a hospital that focuses one and only one on hernia operations, staffs are better trained; the infrastructure is designed very well to support this kind of surgery in large volumes and so on. A defining trait of experts is that, they move more and more problem solving in to an automatic mode.
In basket ball game, they call it as muscle memory - That is, you practice so much, instead of head, hand remembers how to pocket the ball.
Reading about this hospital makes me wonder, if doctors have to be trained very early for some specific super specialty. It also gels with the observation made by one of the very leading surgeon here at Bangalore- When he was interviewed as to why he assigns relatively very young personnel for such complicated surgeries, he responded with confidence that, “it is a question of experience, that is, number of exposures a person has had. Here, we do so many operations per day, such expertise comes much early in their lives than our counter parts elsewhere”.
Mystery section reminds me of the oft heard quote “just because your doctor has a name for your condition does not mean he knows what it is”. It has five neat stories and I am picking up “The pain perplex”. He talks about a person who was very physically fit, but after a fall in the construction site developed a kind of uncontrollable pain. It was so much that, he could not work for more than 2 or 3 hours a day. He would suddenly develop pain hence sustained working was impossible. After CT-scans, countless X-rays etc source and cause could not be figured out. After that, he was directed to meet Dr Ross who is a pain specialist. Dr Gawante makes a keen observation about Dr Ross’s waiting hall. Most of the testimonies he has put up hardly talks about the cure but they are testimonials of serious “Thank You Doctor” types for simply taking the patient’s pain seriously. It looks like recognition and acknowledgement of pain for an undetected cause is an issue. Dr Gawante talks about some interesting experiments we can do by ourselves in the pain area. He also talks about RSI rise and fall in Australia. It seems to me pain as a phenomenon is yet to be understood clearly even by medical fraternity, quite so because, it is complex concoction of physical, physiological, psychological and a bit a faking or ‘making up” by brain.
Uncertainty section has 4 stories. I would pick “whose body is it, anyway?” as a sample. He talks about a sober case of a patient called Lazaroff who had extensive cancer in liver, bowel and all the way to spine. The choice was to do nothing and have a peaceful death. The second option was to attempt a spine surgery which again had low probability of success and even so it would not cure him. Mae West would say, ”Whenever I'm caught between two evils, I take the one I've never tried”. Lazaroff has not tried both and the end is sure either way but a question of time. He chose surgery. 14 days past surgery, during which time he always had life system support, finally, Dr Gawande leans towards him at bedside and informs him (just in case if he can hear) that breath tube would be taken out of his mouth. 13 minutes later Larzaroff had died. Post that the case, author delves about patient’s autonomy which leaves you thinking deeply. While autonomy is fine, I also intuitively feel that, as he also says, patients prefer choices. Yet, when it comes to making decisions on critical medical choices, they prefer some near & dear and the doctor to take that decision rather than by themselves. He neatly says “Just as there is an art of being doctor, there is an art of being patient – You must choose wisely when to submit and when to assert”. I wonder when physical condition is in bad shape, weighing the alternatives would be an appropriate possibility at all. To me, it is an equation between difficulty-in-understanding versus the-danger-of-trust. When age crosses certain watermark which is of course individual specific, one is better off on the trust side!
One of Dr Gawante’s remarks caught my attention: “It is a reality in medicine that choosing to NOT do something – to not to order a test, to not to give antibiotic, to not to take the patient to the operating room – is far harder than choosing to do it”. I could not help recalling Software testing side. G.M.Weinberg, one of the software gurus, ask us to imagine having a buffet plate and load it the way you want – except that, the number of trips to the table is limited to two or three and so would be the number of plates and its size. In short, what you include in the plate would determine the sagacity as a test leader since there is so much to choose from. Is medicine is based on “exclusion” and software testing is based on “inclusion”?.
Nobel Physicist Murray Gell-Mann once proposed an interesting question.”Imagine how complex physics would be if atoms can think”. Well, the answer may be the practice of medicine from the complexity standpoint.
This is a must read for anyone who, like me, has no clue about the field of medicine yet want to story based start! Hats off to Doctors!
Thanks a lot for reading this far…..
Regards,
madhu