Is medicine a craft or an industry?

So asks Atul Gawande in his most recent submission to The New Yorker, "The Score." It is about how Apgar scores changed the way obstetrics did business. If you haven't read it, you should.

The Apgar score, as it became known universally, allowed nurses to rate the condition of babies at birth on a scale from zero to ten. An infant got two points if it was pink all over, two for crying, two for taking good, vigorous breaths, two for moving all four limbs, and two if its heart rate was over a hundred. Ten points meant a child born in perfect condition. Four points or less meant a blue, limp baby.

The score was published in 1953, and it transformed child delivery. It turned an intangible and impressionistic clinical concept—the condition of a newly born baby—into a number that people could collect and compare. Using it required observation and documentation of the true condition of every baby. Moreover, even if only because doctors are competitive, it drove them to want to produce better scores—and therefore better outcomes—for the newborns they delivered.

This saved babies that were previously put aside to die because they weren't breathing at birth or were thought to be too small to survive. It also justified the expansion and use of various technological assessments and interventions.

Over the years, hundreds of adjustments in care were made, resulting in what’s sometimes called “the obstetrics package.” And that package has produced dramatic results. In the United States today, a full-term baby dies in just one out of five hundred childbirths, and a mother dies in one in ten thousand. If the statistics of 1940 had persisted, fifteen thousand mothers would have died last year (instead of fewer than five hundred)—and a hundred and twenty thousand newborns (instead of one-sixth that number).

But the rub? Improvements needed to be generally applicable. Never mind, as the article illustrates, that some physicians had outstanding outcomes using forceps. Their outcomes were better than those of Cesarean deliveries, in fact. Unfortunately, their results were not easily reproducible. Forceps technique takes up to two years to master. Even then not all doctors had the right touch.

By comparison, Cesarean deliveries are relatively easy to teach, learn and execute.

In answering the craft versus industry question, Gawande sides with the latter.

If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills—the Woods corkscrew maneuver for the baby with a shoulder stuck, the Lovset maneuver for the breech baby, the feel of a forceps for a baby whose head is too big. You do research to find new techniques. You accept that things will not always work out in everyone’s hands.

But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability...

After Apgar, obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section.

The rest of the article is given to one woman's story of a surgical birth, a description of Cesarean surgery itself, and the debate about rising C-section rates and elective surgical delivery.

The article ended sadly, with Gawande's acknowledging the "waning of the art of childbirth."

The skill required to bring a child in trouble safely through a vaginal delivery, however unevenly distributed, has been nurtured over centuries. In the medical mainstream, it will soon be lost.

Let's give thanks again for our midwives, who keep those skills alive and available to women today.