Better: A Surgeon's Notes on Performance [Paperback]

Atul Gawande (Author)

Book Description

Release date: January 22, 2008 | ISBN-10: 9780312427658 | ISBN-13: 978-0312427658 | Edition: 1st

National Bestseller

 

The struggle to perform well is universal: each of us faces fatigue, limited resources, and imperfect abilities in whatever we do. But nowhere is this drive to do better more important than in medicine, where lives may be on the line with any decision.

 

Atul Gawande, the New York Times bestselling author of Complications, examines, in riveting accounts of medical failure and triumph, how success is achieved in this complex and risk-filled profession. At once unflinching and compassionate, Better is an exhilarating journey, narrated by "arguably the best nonfiction doctor-writer around" (Salon.com).

Editorial Reviews

From Publishers Weekly

Starred Review. Surgeon and MacArthur fellow Gawande applies his gift for dulcet prose to medical and ethical dilemmas in this collection of 12 original and previously published essays adapted from the New England Journal of Medicine and the New Yorker. If his 2002 collection, Complications, addressed the unfathomable intractability of the body, this is largely about how we erect barriers to seamless and thorough care. Doctors know they should wash their hands more often to avoid bacterial transfer in the ward, but once a minute does seem extreme. Using chaperones for breast exams seems a fine idea, but it does make situations awkward. "The social dimension turns out to be as essential as the scientific," Gawande writes—a conclusion that could serve as a thumbnail summary of his entire output. The heart of the book are the chapters "What Doctors Owe," about the U.S.'s blinkered malpractice system, and "Piecework," about what doctors earn. Cheerier, paradoxically, are the chapters involving polio and cystic fibrosis, featuring Dr. Pankaj Bhatnagar and Dr. Warren Warwick, two remarkable men who have been able to catapult their humanity into their work rather than constantly stumble over it. Indeed, one suspects that once we cure the ills of the health care system, we'll look back and see that Gawande's writings were part of the story. (Apr.)
Copyright © Reed Business Information, a division of Reed Elsevier Inc. All rights reserved. --This text refers to the Hardcover edition.

From Bookmarks Magazine

A surgeon at the Brigham and Women's Hospital in Boston and an assistant professor at the Harvard School of Public Health, Dr. Atul Gawande succeeds in putting a human face on controversial topics like malpractice and global disparities in medical care, while taking an unflinching look at his own failings as a doctor. Critics appreciated his candor, his sly sense of humor, and his skill in examining difficult issues from many perspectives. He conveys his message—that doctors are only human and therefore must always be diligent and resourceful in fulfilling their duties—in clear, confident prose. Most critics' only complaint was that half of the essays are reprints of earlier articles. Gawande's arguments, by turns inspiring and unsettling, may cause you to see your own doctor in a whole new light.

Copyright © 2004 Phillips & Nelson Media, Inc. --This text refers to the Hardcover edition.

See all Editorial Reviews

Product Details

• Paperback: 288 pages
• Publisher: Picador; 1st edition (January 22, 2008)
• Language: English
• ISBN-10: 9780312427658
• ISBN-13: 978-0312427658
• ASIN: 0312427654
• Product Dimensions: 8.3 x 5.4 x 0.8 inches
• Shipping Weight: 9.6 ounces (View shipping rates and policies)
• Average Customer Review: 4.6 out of 5 stars  See all reviews (164 customer reviews)
• Amazon Best Sellers Rank: #4,432 in Books (See Top 100 in Books)
  • #24 in Books > Medical Books > Medicine > Internal Medicine > Pathology > Diseases
  • #27 in Books > Medical Books > Medicine > Reference

More About the Author

Atul Gawande is the author of The Checklist Manifesto, Better and Complications. He is also a MacArthur Fellow, a general surgeon at the Brigham and Women's Hospital in Boston, a staff writer for The New Yorker, and an assistant professor at Harvard Medical School and the Harvard School of Public Health. He lives with his wife and three children in Newton, Massachusetts.

Most Helpful Customer Reviews

201 of 210 people found the following review helpful

5.0 out of 5 stars Difficult problems are ... difficult April 7, 2007

By Stephen R. Laniel

Format:Hardcover

First, as a quick proxy of how good it is, and as a way of enticing busy readers, I should note that I finished Atal Gawande's book Better: A Surgeon's Notes On Performance in less than four hours. I can't remember the last time that happened. True, it's a relatively short book, and I had some uninterrupted time on a bus. But mostly it's that Gawande is a straightforward, energetic, thoughtful writer whose essays relentlessly pull you forward. Each discusses one or two ideas in enough depth to make you realize that they're not easy problems -- which is all most people need, and which does a world of good on its own. Every country has its unquestioned assumptions; it's the rare writer who helps us question them and gently remind us that if there were easy solutions, we'd have found them by now. Gawande is good at that.

The most moving and thought-provoking of these essays, to me, was "The Doctors of the Death Chamber," in which Gawande interviews four doctors (whom he labels "A," "B," "C" and -- wait for it -- "D," in order to secure their anonymity) who help states carry out the death penalty humanely. The use of "humanely" here is questionable; it's humane in the sense that, if we are to use the death penalty, we must not be needlessly cruel at the time of the criminal's death. But it's inhumane in the larger sense that we are furthering a corrupt system -- we are "tinker[ing] with the machinery of death," to use Justice Blackmun's words. Since a doctor's role is to protect human lives, are anaesthesiologists who help execute people painlessly violating their roles? To put it more succinctly: should a doctor make the best of the machinery of death, or should he take no part in the machine? The American Medical Association has its answer and its role.... Democratically elected governments have their own. It's Gawande's job to teach us that easy answers don't exist for complicated problems like this.

One reason it's so easy to come up with easy answers for questions like this is that we rarely come face to face with the system we critique. Gawande does the legwork for us. He's at his best, in this regard, when he interviews a medical-malpractice attorney, a doctor, and the family of a dead patient involved in one malpractice case. We're all inclined to boo at the malpractice attorney . . . right up to the moment we feel we've been wronged, when that attorney is the man we want on our side. Gawande knows that this is how we work, so he takes some time to look at a case when doctors failed other doctors: Gawande's friend Bill Franklin found that doctors had failed to treat a tumor on Franklin's son that they should have noticed years before -- that someone had actually singled out on an X-ray for further study. This is the test case where ethics hits the road: when it's your own son, and you're a doctor, and you're well aware of the expenses of medical malpractice, what do you do? After trying other routes, Franklin did what so many others do: he sued and won. (Along the way Franklin helped establish a precedent in the Massachusetts Supreme Court, in the case of Franklin v. Massachusetts General Hospital et al., affecting the statute of limitations on malpractice cases. Seems worth reading.)

Better contains lots of great little insights into the medical profession -- for instance, how difficult it is to get doctors and nurses to wash their hands as often as is safe for patients, or the awkwardness of a male doctor palpating a naked female patient. Throughout it all, Gawande's organizing principle is to lay out for us the system in which doctors work, the limitations they operate under, and how they make the best within those limitations.

I'm less inclined than I used to be to believe that Gawande has an agenda, but I do think that a slightly different arrangement of the chapters within Better would have sent a different message. Had the chapter on malpractice come at the end of the book, after we've read about Gawande's own mistakes and about sloppy handwashing, we'd be less sympathetic toward doctors. In "The Score," which I've mentioned before, Gawande tells us that C-sections are vital in a world where doctors can't be expected to be very talented; in "The Bell Curve," he reveals that not all cystic-fibrosis clinics are the same, and that the medical industry was reluctant for years to release data on how well individual clinics performed. With these insights in mind, malpractice would seem to the reader to be completely justified. As it is, the malpractice article is tucked into the middle of the book; Better ends with a story about heroically performing surgery in poor rural India, and with a few pieces of advice to newly-minted doctors. It's a hopeful ending. I can't decide whether this arrangement was deliberately obfuscating. Nor does Gawande spend much time explaining whether malpractice makes doctors better.

He's fair throughout, however, and his point is that doctors' work is hard. Understanding precisely why it's hard, and what they do to get their jobs done under trying conditions, is Better's job, and it succeeds admirably. It's a great, thought-provoking, fun read. Read more ›

69 of 72 people found the following review helpful

5.0 out of 5 stars An Intriguing Work by a Top-Notch Medical Writer April 15, 2007

By Dr. Jonathan Dolhenty VINE™ VOICE

Format:Hardcover

Atul Gawande is a general surgeon at the Brigham and Women's Hospital in Boston and -- from everything I've heard and read about him recently -- one of the best of the new breed of medical writers who devote their prose to informing the general public about important concerns in the world of medicine. If this new book, "Better: A Surgeon's Notes on Performance," is a representative example of his usual writing talent, I will completely agree with the above assessment. This collection of original and previously published essays is highly readable and very interesting. Normally, I am not all that interested in reading about medical topics unless it impacts me personally. I'm not a great fan of hospitals nor am I enthusiastic about going to a physician. Fortunately, for most of my life I have enjoyed relatively excellent health. My attitude, however, changed five years ago and Gawande's book takes on some genuine relevance for me. How so and why?

In a section of his book, entitled "The Mop-Up," Gawande discusses polio and the campaign to wipe it out in Asia wherein he was a momentary observer in the field in 2003. Way back in ancient history, when I was a mere child in the 1940s and America was hit with a polio epidemic, I was diagnosed with polio and almost died. Hence the relevance here for me. But more than that, I am convinced to this day that I was "saved" because of the efforts of a nurse -- I'm sure she was one of Gawande's "positive deviants" which he describes in his book -- who insisted on treating me and others with a controversial treatment (opposed by most of the medical "establishment" at the time) called "The Sister Kenny Method." She never lost a patient, by the way; we all recovered without any significant aftereffects that I know of....

Fortunately, from that time in the 1940s I never needed to be hospitalized again. That is, until 2002. Then I had a heart attack and was forced into a hospital for an angioplasty and had to take note of medical matters, including the state of medical care in this country." So, whereas before that latter year I could ignore books of the type that Gawande writes, I now have a profound interest in all things medical. Even more so since my second heart attack and angioplasty in 2006. (I even subscribe to daily updates via e-mail about medical topics!) I am now very concerned about "better" when it comes to medical care and policy.

Gawande divides his book into three significant sections: Diligence, Doing Right, and Ingenuity. He says that "Diligence" is "the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles." The section "Doing Right" considers topics such as "how much doctors should be paid, and what we owe patients when we make mistakes." Important as these sections are, the final section, "Ingenuity," is of even greater importance in my opinion. Ingenuity, he says, "demands more than anything a willingness to recognize failure" and "arises from deliberate, even obsessive, reflection on failure and a constant searching for new solutions." Amen to that!

Furthermore, Gawande quite realistically concludes: "Betterment is a perpetual labor. The world is chaotic, disorganized, and vexing, and medicine is nowhere spared that reality. To complicate matters, we in medicine are also only human ourselves. ...Yet...to live as a doctor is to live so that one's life is bound up in others' and in science and in the messy, complicated connection between the two. It is to live a life of responsibility. The question...is not whether one accepts the responsibility. Just by doing this work one has. The question is, having accepted the responsibility, how one does such work well." Well said, that. Couldn't agree more.

One of the more politically relevant issues (at least for me) that Gawande discusses is the matter of medical practitioners' involvement in executions. In his essay, "The Doctors of the Death Chamber," he says that "We [doctors and nurses] must do our best to choose intelligently and wisely," and then notes that "Sometimes, however, we will be wrong -- as I think the doctors and nurses are who have used their privileged skills to make possible 876 deaths by lethal injection thus far." I cannot understand how a physician -- "First, do no harm" -- could even contemplate participating in the killing of another human being, even if officially sanctioned. Gawande addresses this issue in what I think is a sensible manner. But the debate on this issue is current, lively and will continue for some time.

I do, however, wish that Gawande had spent more time discussing the future of health care in America as regards the delivery of medical services to all its citizens. He briefly touches on this matter, but not in detail. From my perspective, HMOs are definitely not the solution (they are part of the current problem!) and government-managed health care (socialized medicine) is even less desirable. I mean, the government, in my opinion, cannot even provide a decent public education for our children; how can we expect it to provide decent health care? I have considered a number of proposals, all of them wanting in some way or other. I'd like to see Gawande tackle this problem in a detailed way from a physician's perspective. Maybe another book?

Moreover, regarding the above, it is disturbing to read what one American medical reviewer recently stated: "We spend 50 percent more per capita on health care than any other country, for a total of $2 trillion a year, yet our health system, according to the World Health Organization, ranks 37th worldwide. ...By any measure -- longevity, infant mortality, burden of disease -- we sit in the basement of the industrialized world." For a country that can spend trillions of dollars to wage war and promote "regime changes" throughout the world, that statement is embarrassing and hard to fathom.

All in all, "Better" is a good read and extremely informative. It is full of interesting anecdotes, as well as confronting, if only briefly, some of the major issues in the practice of medicine today such as the influence of money in the healthcare system, the problem of malpractice lawsuits, and medical practice under the tensions of the military battlefield, as well as more mundane issues which are often ignored such as the simple act of hand washing or how nakedness impacts the examination room. Since I have had my own experiences lately with the medical establishment, I can now relate to at least some of the topics that Gawande discusses. Therefore -- and since there is no medical experience like a really personal one -- I highly recommend this book to all readers. I guarantee you'll learn a lot, you'll enjoy the fine writing, and you'll have some thinking to do about the state of medical care in America. Read more ›

41 of 41 people found the following review helpful

5.0 out of 5 stars An insider's perspective which can help you be a more informed patient May 20, 2007

By K. Corn TOP 100 REVIEWERVINE™ VOICE

Format:Hardcover|Amazon Verified Purchase

I'm always on the side of self-education when it comes to medical topics, especially in light of the current health care system and its looming problems. Gawande's skill is in writing movingly ab out all sorts of medical issues, including both failures and successes, in a way that illuminates the complexities of practicing medicine in today's world of HMOs, soaring premiums and more.

Some of his essays may appeal more to you than others but I urge you to read the entire book, as well as to get his other one, Complications. I've read medical memoirs that put me to sleep and have been baffled by how someone could take life and death situations and turn them into dry writing. This isn't the case here and you'll come away from the book with a stronger understanding of all the factors (and possible solutions) that make up the world of medicine, medical ethics and patient care today.

15 of 15 people found the following review helpful

5.0 out of 5 stars An excellent book about how to get better at anything August 18, 2007

By Walter H. Bock VINE™ VOICE

Format:Hardcover

This book will be a great read for you if you're interested in the practice of medicine and how it could be done better. You'll love it if you simply enjoy lucid writing about the practice of medicine.

But this book also offers you great lessons if you want to understand how science and performance management come together as they should in business or any other field of endeavor. That's because the author sets out to answer a question that is as important for people in business as it is for people in medicine.

What does it take to be good at something when it is so easy not to be?

Gawande ways that most people, especially physicians, think that success in medicine comes from canny diagnosis, technical prowess and the ability to empathize. They think that progress in medicine comes from scientific breakthroughs and sophisticated equipment and procedures.

The reality, though, is quote different. Improved performance, according to Gawande, comes from

Diligence
Doing Right
Ingenuity

Again and again Gawande demonstrates how concentrating on patients and on performance leads to improvement for both individuals and for medical practice in general. He does this with a mix of historical examples, patient stories, statistics and stories from his own life and practice.

He divides the book into three sections corresponding to his three necessities for improvement.

In the section on Diligence the chapters are on washing hands, dealing with polio in India, and dealing with casualties from the Iraq war. The chapter on military medicine and the concentration on process improvement is worth the price of the book if you're in business.... One of the most powerful lessons of this book is that process improvements can lead to dramatic improvements in performance.

The section on Doing Right deals with ethical issues that physicians face. The chapters are on medical malpractice, whether and how physicians should be involved in executions, when a physician should fight to keep a patient alive, and the problems and dilemmas of how the business side of medicine affects how medicine is practiced.

The central messages of this section are that "Choices must be made. No choice will always be right. There are ways to make our choices better." How to learn about making better choices is the subject of the third and final section of the book.

In Ingenuity or "thinking anew," Gawande covers measuring the comparative effectiveness of physicians and medical centers, relative and absolute measures of performance, the practice of obstetrics as a model of change, and how physicians in less developed countries get by without the technology and facilities that are characteristic of US medicine.

This section is about how to do better. You can sum it up this way: there is a bell curve in almost all human activities with huge variations in performance between the best and those in the middle of the pack. Measuring results is the way to get results that matter.

This book is about the practice of medicine but it's also about getting better at whatever it is that you do. Gawande's message is that "better is possible." It requires diligence and moral clarity, the willingness to try and measure outcomes, and the discipline to change what you do based on the results you get. Read more ›