Better: A Surgeon's Notes on Performance

Gawande's essays contain honest observations of the conflicting roles that the medical profession play in the life and death of individuals and populations. He also asks seemingly obvious questions about why things are done in medicine and public health despite clear evidence that there are simple changes that can radically improve patients' health outcomes. There are no clear answers naturally, but the narratives provoke much thought.

What is really striking is the humility in his advice about being a positive deviance through simple principles of diligence, doing right, and ingenuity. His suggestions to fellow doctors and medical students to ask an unexpected questions, not complaining, measure and write about one's experience, and adopting best practices continually are underpinned by the recognition of medicine more as art than science. That there is always uncertainty in how human beings respond to the best of care in the medical setting. That much is unknown, and even more is unknown about what the profession does not yet know. Perhaps a healthy dose of scepticisim, coupled with a dash of irreverence for sacred cows, and continually asking "Why not?" in medicine, may be what is needed to "do right".

In Better, the anecdotes show just how unpredictable and irrational human behaviour can be despite the best of intentions. How surgeons who are obsessively sterile in the confines of an operating field ironically seem to blatantly disregard their own obsession once they are out of the OT. Stories about communities who reject the life-saving (and tragedy-preventing) public health measures to ring-fence polio outbreaks with vaccinations.

A fascinating (and fast) read.

Atul Gawande's collection of essays reflect on medicine in an amazingly even-handed way, considering the author is a surgeon. Rather than a defense of medical care, the author explores several controversial issues affecting health care and manages to not only see the various aspects of each issue, but to examine them in such a way the reader's mind is opened.
Divided into 3 main sections, each a virtue that contributes to the development of modern medicine: diligence, doing right, and ingenuity.
I was grabbed immediately by the first chapter regarding hand washing. Yes, hand washing! As an obsessive hand washer myself, I found the statistics regarding health care professionals and hand washing to be astonishing! And in the face of overwhelming evidence favoring hand washing, its pretty amazing that everyone is not donning exam gloves for everyday tasks. On the contrary, the cavalier attitude demonstrated by doctors and nurses towards hand washing would make a great psychology study. But luckily for us, there are people out there that not only appreciate the value of frequent washing, but took the extra step to figure out how to make it happen.
I must apologize for not making this sound more interesting, because it truly is.
While I found every chapter fascinating, I was particularly intrigued by the study of cystic fibrosis centers, and the description of medical care in India. In each chapter, we meet people who use their knowledge and skills to BE better.
I especially appreciate Gawande's advice on becoming better, a 5 step program for improvement, or how to be a positive deviant. 1. Ask an unscripted question. 2. Don't complain. 3. Count something. 4. Write something. 5. Change.
When are our efforts enough? Why do we always have to be better? Because we have not eradicated disease. We have not eliminated mistakes. We have not erased social inequities. Read about the people who are dedicating their lives to making things better. It will make you want to be better as well.
Highly recommended to health care professionals and patients alike.

In any human endeavor, variations of performance create a bell curve and most participants are average or below average. Dr. Atul Gawande explores the challenge of practicing medicine and striving to be a "positive deviant" on that curve. Better: A Surgeon's Notes on Performance explores the pursuit of perfection in several areas of medical practice. Athletes, he writes, teach us a lot about "the value of perseverance, of hard work and practice, of precision. But success in medicine has dimensions that cannot be found on a playing field. For one, lives are on the line." (p. 4)

Several chapters of this book appeared first as articles in periodicals. Though the book follows a fascinating theme, do not expect it to be as well-integrated as Complications: A Surgeon's Notes on an Imperfect Science. The overall message is the dialectic between strict adherence to practices known to work (hand-washing) and an inspired ingenuity. How to achieve both?

There is much interesting material here: the WHO campaign to eliminate polio, the history of Cesarian sections in obstetrics, the ethics of assisting in the death chamber, the story behind longer life span for cystic fibrosis patients. These and other chapters are tied together by the quest for improvement of outcomes.

The afterword encapsulates Dr. Gawande's advice to medical students on making a difference in people's lives, and it alone is worth the price of the book. "It often seems safest to do what everyone else is doing ..." he writes in closing. "But a doctor must not let that happen--nor should anyone who takes on risk and responsibility in society."

Altogether this is an informative and thought-provoking book with lessons that go beyond the specifics of medical practice.

Linda Bulger, 2008

Sorry, unable to comment. This book was purchased for distribution to my Hospital Board of Directors. Thank you

I'd read the cystic fibrosis and c-section articles, and while the first was interesting, the second was an appalling disappointment for me, as I, like just about everyone else, really enjoyed _Complications_. While Gawande still has interesting things to say, his conclusions have become simplistic and seem at odds with the stories he tells in the course of each discussion. This was particularly apparent, as another reviewer has already noted, in the essay on the death penalty.

In general, I got the sense he is papering over some very, very serious concerns with medicine as he is accustomed to practicing it. He gives slight recognition to the possibility of _not_ deploying every piece of technology available and describes glowingly, for example, the treatment of very low birth weight babies and inaccurately characterizes the value of the current system of treatment (never mentioning the greater success of kangaroo care elsewhere) both in terms of immediate preservation of life and in terms of long term quality of life.

If cheerleading makes you feel good, this might work for you. But look elsewhere for a thoughtful, balanced assessment of our medical system and how it might be improved.