Better: A Surgeon's Notes on Performance

Atul is not only a great doctor, but a very gifted story-teller. His stories are interesting, quirky, surprising and filled with feeling.

From my perspective the selection of essays in this second volume feels a little uneven compared to Atul's first book, "Complications". Some of the essays in this second volume are a tad dry.

Still I'd have to say that Atul's books are very accessible and absorbing and will help you gain useful insights on the complexity and pressures faced by the world of medicine and medical professionals.

Good book with good advice. Dr. Gawande is an engaging, entertaining, candid writer. Better is nice for a general crowd, but Complications, his earlier book, is excellent for people interested in the medical sciences, especially surgery. I'd recommend both, but if I had to choose just one, Complications gets my vote.

Atul Gawende's "Better" should be mandatory reading for anyone engaged in providing, regulating, or legislating health services. Gawende, a general surgeon who specializes in endocrine surgery at Boston's Brigham and Women's Hospital, has written a provocative and insightful book on how we can improve healthcare today. He is quick to admit that true success in medicine is not easy. It requires will, attention to detail, and creativity.

"Better" shows, however, that it is possible anywhere and by anyone. The author illustrates this with case studies showing how diligence, doing it right, and ingenuity can make a big difference.

Gawende argues that once we've made a science of "performance" - as he shows with simple examples of hand washing, a polio "mop-up,"wounded soldiers, child delivery - thousands of lives can be saved. Today, the scientific effort to improve performance gets only a miniscule portion of scientific budgets. Yet it can arguably save more lives in the next decade than bench science, more lives than research on the genome, stem cell therapy, cancer vaccines, and all the other laboratory work we see in the press. The stakes are high.

Gawende is arguable the best nonfiction doctor-writer around today.

Dr Gawande may have written this book specifically about improved practice in medicine, but many of the points he makes are valid in other fields of human endeavour. Dr Atul has provided eleven essays around the themes of Diligence, Doing Right and Ingenuity. The question posed in the introduction, and explored throughout the book, is ` ..having accepted the responsibility, how one does such work well.'

The topics of the essays are:

Under the heading of `Diligence', Dr Gawande writes about the importance of handwashing, attempting to eradicate poliomyelitis, and the treatment of casualties of war.

Under `Doing Right', Dr Gawande addresses the use of chaperones during medical examinations, medical malpractice, income earned by doctors, the roles of doctors in capital punishment, and issues around aggressive medical treatment.

Under `Ingenuity', Dr Gawande covers medical intervention in the process of birth, excellence in treatment for cystic fibrosis, and medical care in India.

Finally, Dr Gawande offers suggestions to medical students (and others) about making a difference by becoming `positive deviants'.

In summary, the answer to the question posed by Dr Gawande could well be the following `Do what is right and do it now' (Dr Virginia Apgar, as quoted on Page 186).

This is well written book which, while it draws on examples in the field of medicine, contains lessons for each of us who strive to make a difference. Technology provides many solutions and enables advances in areas previously thought impossible. But it is human ingenuity that underpins technological advance, and sometimes it is simple human practices that have the biggest impact.

I recommend this book to those who are interested in striving for excellence more generally.

Jennifer Cameron-Smith

Atul Gawande, in "Better: A Surgeon's Notes on Performance," asks, "What does it take to be good at something in which failure is so easy?" When someone's well-being is at stake, is mere competence enough? The author maintains that a great deal more is needed "to enable every human being to lead a life as long and free of frailty as science will allow." With so much on the line, knowledge is not enough. To do their best, doctors should be conscientious, technically proficient, morally scrupulous, resourceful, and compassionate. The author examines "three core requirements for success in medicine": diligence (attention to detail and avoidance of errors), "to do right," and ingenuity ("thinking anew"). Is a doctor willing to look at a difficult situation in a new light? Can she confront her failures, learn from them, and change? Dr. Gawande presents specific examples of medical professionals meeting a variety of challenges and, in the process, transforming medical care and saving lives.

In this elegantly written book, the author makes the abstract real. He does not merely focus on dramatic events; he also demonstrates how the seemingly mundane can be crucial. One example centers on infection control. Deborah Yokoe, an infectious disease specialist and Susan Marino, a microbiologist, have done their utmost to reduce the spread of infection in their Boston-based hospital. Two million Americans acquire infections every year during their hospital stays and thousands die as a result. One way to cut down on infection in hospitals is for clinicians to carefully and consistently wash their hands. Yokoe and Marino have tried everything to get doctors and nurses to wash. They have posted warning signs, installed new sinks in convenient locations, given rewards to the units with the best rates of compliance, and even issued hygiene report cards. Nothing has worked. Doctors and nurses simply do not take the time to wash their hands as much as they should. As a result, the rates of infection in the hospital remain higher than they should be.

Two other individuals in Pennsylvania, however, came up with innovations that actually made a difference. Peter Perreiah, an industrial engineer, devised an ingenious system that made each hospital room function like a mini-operating room. Jon Lloyd, a surgeon and colleague of Perreiah, promoted the idea of "positive deviance--the idea of building on capabilities people already had rather than telling them how they had to change." By inviting the staff to come up with their own solutions rather than imposing rules from above, "the norms began to shift." One year into the experiment, infection rates dropped precipitously.

Gawande demonstrates time and again that when people rack their brains to come up with answers, they can solve seemingly intractable medical problems. The author's account of the Herculean efforts expended to eradicate polio in India and to save the lives of wounded soldiers in Iraq are fascinating and impressive. Equally engrossing are the sections dealing with best practices in obstetrics and effective treatments for cystic fibrosis. Dr. Gawande's remarks concerning how far physicians should go to keep their patients alive raise intriguing questions without offering facile answers. "In the face of uncertainty, wisdom is to err on the side of pushing, to not give up. But you have to be ready to recognize when pushing is only ego....You have to be ready to recognize when the pushing can turn to harm." The author believes that medical decisions should always be based on the best interests of the patient, and fruitless suffering should be avoided. This is a tough call and wise doctors will not hesitate to consult with their colleagues to get other opinions. My one quibble is that Gawande's segments focusing on doctors' income, malpractice, and the ethics of physician-assisted executions do not fit comfortably in a work about enhancing medical performance.

The bottom line is that "arriving at meaningful solutions is an inevitably slow and difficult process." Common to all successful initiatives is the willingness to face challenges with a determination to do whatever it takes to find remedies. Atul Gawande is a thoughtful and intelligent writer; his graceful prose makes "Better" an absolute pleasure to read. We can only hope that Dr. Gawande's colleagues will pick up on his admirable enthusiasm for behaving more responsibly, creatively, and diligently.