Book Review: Better

Title

Better: A Surgeon's Notes on Performance

Author

Atul Gawande

Publication Date

2007

Reason For Reading

I've heard good things about the author from a number of sources. Most recently, the professor of my Health Management and Policy class mentioned in class that he was reading the book (or possibly one of the other two books by this author) for the second time, and strongly recommended it. One other thing he mentioned was that an article Gawande wrote for the New Yorker on health care costs was one that made a strong impression on President Obama and recommended members of Congress to read it (cited below). As such, it was also a reading we did for the class.

Synopsis

Using health care (or related) backgrounds and stories, Gawande illustrates what he considers to be the three main things people need to focus on to improve performance in their work - diligence, doing right, and ingenuity. The first section on diligence is broken up into chapters on washing hands in hospitals, eradicating polio in southern India, and treating casualties of war in Afghanistan. The second section on doing right involves chapters on dealing with patients when they have to be naked for exams, malpractice, doctors' earnings, physicians involved with the death penalty, and when to fight for patients. The last section on ingenuity discusses coming up with performance measures for births, the bell curve (specifically how to strive to be above average), and performance with often limited means.

Review

Since he's a surgeon and almost all the settings are in the health care setting, it's easy to think it's specifically written for doctors, but I think it goes beyond that and can apply to any job or any personal aspect of life, really. The stories and anecdotes he selects are often very good examples of what he's trying to illustrate and so the points are clear and make for easy, but interesting, reading. One of his five "suggestions for becoming a positive deviant" in the afterword is to write and use the opportunity to reflect and think problems out, so I think it's especially apt I do a review of this book on the blog, and hopefully we'll spur on further use of the blog, since it's been lagging a bit lately.

Quotes

From the introduction:

"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 humans ourselves. We are distractable, weak, and given to our own concerns. Yet still, 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, then, 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." (9)

From the section on diligence:

"But if mortality is low, the human cost remains high. The airman lost one leg above the knee, the other at the hip, his right hand, and part of his face. How he and others like him will be able to live and function remains an open question. His abdominal injuries prevented him from being able to lift himself out of bed or into a wheelchair. With only one hand, he could not manage his colostomy. We have never faced having to rehabilitate people with such extensive wounds. We are only beginning to learn what to do to make a life worth living possible for them." (61)

From the section on doing right:

"Malpractice attorneys are hardly the most impartial assessors of care, but medicine has offered no genuine alternative--because we physicians are generally unwilling to be held financially responsible for the consequences of our mistakes. Indeed, the one argument that has persuaded many doctors to be more forthright about mistakes is that doing so might make patients less likely to sue." (102)

"The easy thing for any doctor or nurse is simply to follow the written rules. But each of us has a duty not to follow rules and laws blindly. In medicine, we face conflicts about what the right and best actions are in all kinds of areas: relief of suffering for the terminally ill, provision of narcotics for patients with chronic pain, withdrawal of life-sustaining treatment for the critically ill, abortion, and executions, to name just a few. All have been the subject of professional rules and governmental regulation, and at times those rules and regulations have been and will be wrong. We may then be called on to make a choice. We must do our best to choose intelligently and wisely." (153)

"Many talk about the border between what we can do and what we can't as if it were a bright line drawn across the hospital bed. Analysts often note how ridiculous it is that we spend more than a quarter of public health care dollars on the last six months of life. Perhaps we could spare this fruitless spending--if only we knew when people's last six months would be." (159)

From the section on ingenuity:

"In this short speech, I realized, was the core of Warwick's worldview. He believed that excellence came from seeing, on a daily basis, the difference between beeing 99.5 percent successful and being 99.95 percent successful. Many things human beings do are like that, of course: catching fly balls, manufacturing microchips, delivering overnight packages. Medicine's distinction is that lives are lost in those slim margins." (222)

-An additional note on this quote - Warwick is Dr. Warren Warwick of the University of Minnesota, who has been a leading figure dealing with cystic fibrosis for decades.

"What is troubling is not just being average but settling for it. Everyone knows that averageness is, for most of us, our fate. And in certain matters--looks, money, tennis--we would do well to accept this. But in your surgeon, your child's pediatrician, your police department, your local high school? When the stakes are our lives and the lives of our children, we want no one to settle for average." (230)

Further Reading

The Cost Conundrum

The New Yorker

June 1, 2009

Complications: A Surgeon's Notes on an Imperfect Science

Atul Gawande

2002

The Checklist Manifesto: How to Get Things Right

Atul Gawande

2009