Atul Gawande Quotes

There was a succession of roommates, never chosen with her input and all with cognitive impairments. Some were quiet. One kept her up at night. She felt incarcerated, like she was in prison for being old.

Human birth...is a solution to an evolutionary problem: how a mammal can walk upright, which requires a small, fixed, bony pelvis, and also possess a large brain, which entails a baby whose head is too big to fit through that small pelvis...in a sense, all human mothers give birth prematurely. Other mammals are born mature enough to walk and seek food within hours; our newborns are small and helpless for months.

we usually have only vague indicators to rely upon.

Human beings have an ability to simply recognize the right thing to do sometimes. Judgment, Klein points out, is rarely a calculated weighing of all options, which we are not good at anyway, but instead an unconscious form of pattern recognition.

IN THE PAST, when dying was typically a more precipitous process, we did not have to think about a question like this. Though some diseases and conditions had a drawn-out natural history — tuberculosis is the classic example — without the intervention of modern medicine, with its scans to diagnose problems early and its treatments to extend life, the interval between recognizing that you had a life-threatening ailment and dying was commonly a matter of days or weeks. Consider how our presidents died before the modern era. George Washington developed a throat infection at home on December 13, 1799, that killed him by the next evening. John Quincy Adams, Millard Fillmore, and Andrew Johnson all succumbed to strokes and died within two days. Rutherford Hayes had a heart attack and died three days later. Others did have a longer course: James Monroe and Andrew Jackson died from progressive and far longer-lasting (and highly dreaded) tubercular consumption. Ulysses Grant’s oral cancer took a year to kill him. But, as end-of-life researcher Joanne Lynn has observed, people generally experienced life-threatening illness the way they experienced bad weather — as something that struck with little warning. And you either got through it or you didn’t.

In one of her most influential studies, she and her team tracked the emotional experiences of nearly two hundred people over years of their lives. The subjects spanned a broad range of backgrounds and ages. (They were from eighteen to ninety-four years old when they entered the study.) At the beginning of the study and then every five years, the subjects were given a beeper to carry around twenty-four hours a day for one week. They were randomly paged thirty-five times over the course of that week and asked to choose from a list all the emotions they were experiencing at that exact moment.
If Maslow’s hierarchy was right, then the narrowing of life runs against people’s greatest sources of fulfillment and you would expect people to grow unhappier as they age. But Carstensen’s research found exactly the opposite. The results were unequivocal. Far from growing unhappier, people reported more positive emotions as they aged. They became less prone to anxiety, depression, and anger. They experienced trials, to be sure, and more moments of poignancy — that is, of positive and negative emotion mixed together. But overall, they found living to be a more emotionally satisfying and stable experience as time passed, even as old age narrowed the lives they led.
The findings raised a further question. If we shift as we age toward appreciating everyday pleasures and relationships rather than toward achieving, having, and getting, and if we find this more fulfilling, then why do we take so long to do it? Why do we wait until we’re old? The common view was that these lessons are hard to learn. Living is a kind of skill. The calm and wisdom of old age are achieved over time.
Carstensen was attracted to a different explanation. What if the change in needs and desires has nothing to do with age per se? Suppose it merely has to do with perspective — your personal sense of how finite your time in this world is. This idea was regarded in scientific circles as somewhat odd. But Carstensen

Your chances of avoiding the nursing home are directly related to the number of children you have, and, according to what little research has been done, having at least one daughter seems to be crucial to the amount of help you will receive.

No matter what measures are taken, doctors will sometimes falter, and it isn’t reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.

human beings fail the way all complex systems fail: randomly and gradually.

Skill, surgeons believe, can be taught; tenacity cannot.

Loyalty, said Royce, “solves the paradox of our ordinary existence by showing us outside of ourselves the cause which is to be served, and inside of ourselves the will which delights to do this service, and which is not thwarted but enriched and expressed in such service.

I felt a sense of shame like a burning ulcer. This was not guilt: guilt is what you feel when you have done something wrong. What I felt was shame: I was what was wrong.

attending surgeons say that what’s most important to them is finding people who are conscientious, industrious, and boneheaded enough to stick at practicing this one difficult thing day and night for years on end. As one professor of surgery put it to me, given a choice between a Ph.D. who had painstakingly cloned a gene and a talented sculptor, he’d pick the Ph.D. every time. Sure, he said, he’d bet on the sculptor being more physically talented; but he’d bet on the Ph.D. being less “flaky.” And in the end that matters more. Skill, surgeons believe, can be taught; tenacity cannot. It’s an odd approach to recruitment, but it continues all the way up the ranks, even in top surgery departments. They take minions with no experience in surgery, spend years training them, and then take most of their faculty from these same homegrown ranks.
And it works.

Expertise is the mantra of modern medicine. In the early twentieth century, you needed only a high school diploma and a one-year medical degree to practice medicine. By the century’s end, all doctors had to have a college degree, a four-year medical degree, and an additional three to seven years of residency training in an individual field of practice — pediatrics, surgery, neurology, or the like. In recent years, though, even this level of preparation has not been enough for the new complexity of medicine.

When, as the researchers put it, “life’s fragility is primed,” people’s goals and motives in their everyday lives shift completely. It’s perspective, not age, that matters most.