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Better: A Surgeon's Notes on Performance

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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.

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.

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.

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.

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

What impresses me most about Atul Gawande is his ability to maintain an open mind on most issues. For instance, in this work, he examines the medical malpractice issue and rather than accepting one view or another on this controversial issue, he examines the topic from a unique angle--physicians who have themselves had to sue other physicians for malpractice. He takes the same view to a broad range of topics, from the varying success rates for cystic fibrosis treatment to physician's role in state mandated execution to treatment of wounded in Iraq. He takes each issue and approaches from a thought provoking angle.

This work also should be read as a management book because he suggests that in medicine as in any other walk of life, some acheive success using what is believed to be the same methods as others, but in reality the success is due to "positive deviation," small improvements which result in greater results.

I loved his first work, Complications, and this is certainly its equal.

Gawande opens by asking an important question: "What does it take to be good at something in which failure (the practice of medicine) is so easy, effortless?" The answer is grouped into three headings - diligence, doing right, and inquisitiveness. Gawande then uses examples to illustrate each topic.

Diligence: Hospital infection control efforts have long identified increased hand-washing as essential - yet, studies continually report alarmingly low rates of compliance. Examples demonstrate that making this easier, searching out best practices, and sustainment efforts are key to significant improvement. Polio eradication is the subject of Gawande's second example - the follow-up response to a case in India, involving vaccinating 4 of the target 4.2 million with 37,000 vaccinators in four days, and requiring effective ice, vaccine and personnel distribution, as well as follow-up. Then it's on to the U.S. Army's efforts to reduce Iraqi war death rates - data-analysis and follow-up (eg. WEAR those Kevlar vests, changes in treatment), placement of forward operating teams (operations limited to about 3 hours) backed up by four mobile hospitals (up to 3 days care) and level IV hospitals (up to 30 days care in Germany and Spain, backed up by Walter Reed - the average time from injury to the U.S. has dropped to less than four days (from 45 in Vietnam), and the death rate has dropped to 10% (24% in Vietnam).

Doing Right: Here Gawande summarizes the difficulty of health-care professionals "knowing when to quit" (do no more for a patient), the moral dilemma of assisting executions, and problems determining how much to pay physicians (paid about 7X that of the average U.S. worker, vs. 3X in the rest of the world).

Inquisitiveness: Gawande saves the best for last, beginning by citing problems in childbirth and the difficulty training new doctors in the art of forceps use (correct pressure, pulling strength, choice of forceps, placement). Then its on to cystic fibrosis. Here we learn of Dr. Berwick's efforts to improve quality (offers funds - IF recipient centers share their data and methods with others, AND discuss improvement plans with patients. Discussion with a resident afflicted with CF elicits the conclusion that better use of existing knowledge is more important at this time than more research (eg. genetics). Similarly, we learn how rural Indian doctors improvise - thus, basic tools and cleanliness are likelihood to offer greater improvement there than the latest U.S. technology.

Gawande's Recommendations for Physicians: 1)Don't complain, ask questions (include getting input from technicians, LPNs, etc.), quantify outcomes, write so others can learn, and look for opportunity to change to improved methods.

If, from the title, you're expecting a surgeon's personal reflections on pivotal moments in his own career, you are in for a treat. This riveting collection is a whole lot more than that.

Gawande, a surgeon, staff writer for "The New Yorker" and author of "Complications," travels the world in search of excellence and then explores how it's done. He delves into the medical and ethical dilemmas (which often walk hand-in-hand with excellence) and reflects on choices and decisions. His writing is engaging, clear and graceful, inviting the reader to participate.

He divides the book into three sections, "Diligence," "Doing Right," and "Ingenuity." Naturally the themes overlap and stimulate one another.

The subject of the opening essay, "On Washing Hands," will be familiar - and frightening - to many. Two million people acquire nasty infections while hospitalized and 90,000 die from them, according to the CDC (reading this, you will suspect it is a lot more). Gawande explores why medical professionals won't stop spreading disease, the programs designed to make them, and the one (!) ingenious, diligent program that worked. Up to publication time, anyway.

"Diligence" is also the key to the amazing survival rate of Iraq military casualties. Although news reports have outlined this phenomenon (10 percent mortality rate as opposed to 25 percent during WWII and Vietnam) most people would assume the reason is better technology. Not so. It's the innovation and diligence involved in getting people to, first, actually wear their Kevlar, and then stabilizing injuries in the field and transporting them quickly out.

Diligence - and money - is the key to the campaign to wipe out polio. But some ask whether the money wouldn't be better spent on nutrition programs, or malaria, or parasitic disease....

For "Doing Right" Gawande, explores this problem of money, the malpractice system, the unease inherent in the physical doctor/patient relationship, keeping patients alive and deciding when to let go, insurance and its effect on all of the above. He also visits doctors who have participated in prisoner executions.

"Ingenuity" visits a hospital with phenomenal success rates in cystic fibrosis patient health and finds an extremely diligent doctor, examines the Apgar score and its effect on infant mortality rates, and witnesses the incredible versatility of overwhelmed doctors in India. Each of these prompts hopeful thinking for wider improvements.

Gawande's focus is on the human component in medicine; how "positive deviance" from the norm - a willingness to change, to ask unscripted questions - can have a broader effect. Interestingly, while all the essays were equally absorbing, the grimmest were those dealing with the entrenched system - insurance, malpractice, time constraints.

In each of the others it seemed possible for individuals to stimulate improvement, as long as they engaged with colleagues and patients. Psychology plays a role in all innovation. Although a doctor in 1847 recognized physician culpability in childbirth death rates, his abrasive hectoring cost him his job. Yet 20 years later, Lister succeeded in transforming the field through persuasion and respectful explanation.

Thoughtful, enthusiastic and persuasive, Gawande deserves a wide readership among medical professionals as well as the rest of us.

This should be required reading for anyone wanting better service, whether from their doctor or from the internal revenue service. His stories are compelling and to the point. Over and over, he points out that often small, subtle factors make a huge difference in medical outcomes. Surprise -- the ability to listen turns out to be a key diagnostic skill. It helps that he writes so well. PS The next time you go into the hospital ask the nurse or doctor to wash their hands. Gawande tells you why!

What can medicine do to improve the quality of patient care around the world? That is, at its heart, the question that author Atul Gawande throws at readers and practitioners alike. "We can do better," he tells us, and thus begat the title: BETTER.

Having thoroughly enjoyed Complications, I decided to check out Dr. Gawande's other writings and was pleasantly surprised to find this collection of stories. Although both Complications and Better are short story compilations, Complications lacked cohesiveness whereas Better had no such problems.

Leading us down simple and often shocking paths, Gawande gives us complicated facts but in laymen's terms. The simplest would be his chapter on hand washing, and how effective it can be for preventing the spread of infection, especially such newly dangerous things as MRSA, an antibiotic resistant bacterial strain that is killing hospital patients far too often. The ease with which its spread is preventable is as simple as a hand cleanser, yet getting doctors (and other medical staff) to do this is nearly impossible. "We can do better."

The beleaguered medical malpractice insurance requirements that plague every doctors pocketbook is hit hard upon, including a look at why it is necessary and why the system is headed for deep trouble. "We can do better."

Probably the most telling chapters were directed at Dr. Gawande's return to India (his national homeland). Polio is on the run and is nearly extinct as a disease. Yet in small Indian provinces, occasional "hot spots" flare up and a band of less than 10 medical men and women must vaccinate over 4 million children in less than two weeks. And they do it. Gawande tells us if this is possible, can't the U.S. do better at fighting infection? The other striking aspect is how India's doctors often work with substandard supplies (or minimal) on dangerous cases. Or perform a surgery they've never done before or are ill equipped to handle. But handle it they do. One such case involved a boy with hydrocephalus ("water on the brain" caused by a build up of cerebral spinal fluid). No physicians at the hospital Gawande visited had ever done a shunt, the procedure necessary to relieve the pressure. But they eventually do a makeshift surgery that saves the boys life "using about as few supplies as I'd use for a suture repair." Quite an eye-opener. "We can do better."

The chapters on CF (cystic fibrosis) are exceptionally well rendered as we learn that doing better at one thing can have huge benefits. When physicians focus all of their talents on cystic fibrosis, the result was astounding. Life expectancy for CF patients jumped from 17 years of age to over 40. And now it looks like they may very well be able to live into the 70s. It isn't some new super-drug that's extending these peoples lives, but looking at the disease process in terms of better treatment strategies; living proof that doing "Better" can help medicine achieve miraculous results.

Atul Gawande is to be commended for writing a book that flays open the medical system and exposes the diseases beneath; diseases that we can do better at.