Better: A Surgeon's Notes on Performance

The New York Times bestselling author of Complications examines, in riveting accounts of medical failure and triumph, how success is achieved in a complex and risk-filled profession.

The struggle to perform well is universal: each one 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 are on the line with every decision. In his new book, Atul Gawande explores how doctors strive to close the gap between best intentions and best performance in the face of obstacles that sometimes seem insurmountable.

Gawande's gripping stories take us to battlefield surgical tents in Iraq, to delivery rooms in Boston, to a polio outbreak in India, and to malpractice courtrooms around the country. He examines the ethical dilemmas of doctors' participation in lethal injections, the influence of money on modern medicine, and the astoundingly contentious history of hand-washing. Offering a searingly honest first-hand account of work in a field where mistakes are both unavoidable and unthinkable, Better provides rare insight into the elements of success that illuminates every area of human endeavor.

"How self-conscious should a surgeon be? In some ways, we all (and I think I speak for other doctors here, as well as for patients) cling fast to the idea of surgical confidence: the godlike operating-room decisiveness, the courage to cut, the steady hand. But the willingness to turn that paradigm inside out helps Atul Gawande keep things interesting, as he directs his attention to how doctors and... Washington Post Book Review (read the entire Washington Post review) medicine can strive to be, well, 'Better.' In his first book, 'Complications,' which was, like this one, built on essays previously published in the New Yorker and the New England Journal of Medicine, Gawande looked at a range of subjects — a range of topics and a range of patients — but many of the questions that drove him arose directly from his own long and arduous surgical training. Now fully fledged ('Better' includes a humorous episode in which he is asked to name his salary, as a surgeon, and finds himself at a loss, unsure how to value his work, unable to discuss it frankly with colleagues — and unwilling, ultimately, to tell us what figure he names), he takes a direct and sometimes disconcerting look at the job he has chosen.

Again and again he comes back to how easy it is to practice medicine poorly — to the question of how highly trained, hardworking and perfectly well-intentioned people can subvert their own efforts and fail the patients who depend on them when the stakes are life and death.

He isn't talking heroic science here, or even heroic surgery. He's talking about what he calls 'diligence,' the institutionalization of absolute attention to detail. For example, he's talking about the battle — now more than 100 years old — to get doctors to wash their hands, about figuring out why they often don't or won't, and about making changes that can prevent hospital infections and save patients' lives.

The same themes emerge in his section on 'ingenuity,' when he looks at the success rates of specialized centers that take care of children with cystic fibrosis. With cystic fibrosis, as with many other illnesses, when you rank institutions according to their patient outcomes, you get a bell curve: 'a handful of teams showing disturbingly poor outcomes for their patients, a handful obtaining remarkably good results, and a great undistinguished middle.' What distinguishes the very best centers, Gawande argues, is a willingness to confront problems and errors, to look for new and ingenious approaches and to apply those approaches with unusual diligence and aggressiveness.

'Better' resonates with certain recent themes in medical self-awareness — with the 1999 Institute of Medicine report on medical error, for instance, which made headlines with its high numbers of people killed and injured in hospitals. But Gawande adds to the discussion by taking us to interesting places — professionally, geographically, historically — as he examines the details of trying to do the job properly, and by writing about it all so lucidly. He is particularly expert at following the expanding ripples of meaning out from a central medical story. He starts with the children struck down by what everyone hopes will be among the last cases of polio in India. Watching government doctors in the 'mopping up' stage of wiping out polio, he sees a lesson in the logistics of 'diligence,' of attempting to eliminate a disease case by case, house by house, village by village. 'If the eradication of polio is our monument, it is a monument to the perfection of performance — to showing what can be achieved by diligent attention to detail coupled with great ambition.'

One striking essay discusses the treatment of battlefield wounds and addresses the question of how military doctors have been able to drive their mortality statistics way down. From the Korean War through the Persian Gulf War, the death rate of soldiers wounded in battle stayed at about 24 percent, Gawande says, but in Iraq it has dropped to 10 percent. When he questioned military doctors, 'what they described revealed an intriguing effort to do something we in civilian medicine do spottily at best: to make a science of performance.' The story is particularly moving because the voice of a surgeon comes through, admiring the skills shown by his military colleagues, and yet profoundly sad. If the eradication of polio could be a monument, a gift to future generations, the heroic salvage of young people brutally injured in war is something else, something that hints at a much harsher truth of life and death and human nature.

'Better' makes a compelling case for medical self-awareness in the operating room, on the hospital ward and even on the battlefield. Gawande succeeds in looking at medical achievement — and lapses — from a new perspective. His stories evoke the profound desire that doctors feel to cure, along with our besetting anxieties about poor performance and its consequences. He makes his case that failure is 'so easy, so effortless,' but also that 'positive deviance' — deliberate and determined individual improvement — is possible. His own self-consciousness, his ability to ask questions about the nuts and bolts of medical practice, and his storytelling skills make this a book about the complex grandeur of the human endeavor that is medicine.

Perri Klass, a professor of journalism and pediatrics at New York University, is the author of the forthcoming 'Treatment Kind and Fair: Letters to a Young Doctor.'

" Reviewed by Amanda SchafferDaniel StashowerMichael TomaskyPerri Klass, Washington Post Book World (Copyright 2006 Washington Post Book World Service/Washington Post Writers Group)
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"A must-read for medical professionals — and a discerning, humanizing portrait of doctors at work for the rest of us." Kirkus Reviews

"Rather than preaching about improving performance, Gawande bears witness to the remarkable levels of care that can be achieved by describing some incredibly innovative, adaptive, and even mundane...practices in hospitals..." Booklist

"The essays are united, as they highlight opportunities for improvement within the medical community, which serves as a successful framework for Gawande's study of a profession predicated on betterment. These revealing, humanistic essays are highly recommended..." Library Journal

"[T]his brilliant, persuasive and even inspiring book, with its crisp writing and its abundance of well-told tales, might well be taken to heart by any reader." Houston Chronicle

The New York Times bestselling author examines the complex and risk-filled medical profession and how those involved progress from merely good to great. Gawande provides rare insight and offers an honest firsthand account of his own life as a surgeon.

The New York Times bestselling author of Complications examines, in riveting accounts of medical failure and triumph, how success is achieved in a complex and risk-filled profession The struggle to perform well is universal: each one 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 are on the line with every decision. In his new book, Atul Gawande explores how doctors strive to close the gap between best intentions and best performance in the face of obstacles that sometimes seem insurmountable.

Gawande's gripping stories of diligence, ingenuity, and what it means to do right by people take us to battlefield surgical tents in Iraq, to labor and delivery rooms in Boston, to a polio outbreak in India, and to malpractice courtrooms around the country. He discusses the ethical dilemmas of doctors' participation in lethal injections, examines the influence of money on modern medicine, and recounts the astoundingly contentious history of hand washing. And as in all his writing, Gawande gives us an inside look at his own life as a practicing surgeon, offering a searingly honest firsthand account of work in a field where mistakes are both unavoidable and unthinkable.

At once unflinching and compassionate, Better is an exhilarating journey narrated by arguably the best nonfiction doctor-writer around (Salon). Gawande's investigation into medical professionals and how they progress from merely good to great provides rare insight into the elements of success, illuminating every area of human endeavor. Atul Gawande, a MacArthur fellow, is a general surgeon at the Brigham and Women's Hospital in Boston, a staff writer for The New Yorker, an assistant professor at Harvard Medical School and the Harvard School of Public Health. His first book Complications, was a New York Times bestseller and a finalist for the National Book Award. Gawande lives with his wife and three children in Newton, Massachusetts. The struggle to perform well is universal: each one 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 are on the line with every decision. In his new book, Atul Gawande explores how doctors strive to close the gap between best intentions and best performance in the face of obstacles that sometimes seem insurmountable.

Gawande's gripping stories of diligence, ingenuity, and what it means to do right by people take us to battlefield surgical tents in Iraq, labor and delivery rooms in Boston, a polio outbreak in India, and malpractice courtrooms around the country. He discusses the ethical dilemmas of doctors' participation in lethal injections, examines the influence of money on modern medicine, and recounts the astoundingly contentious history of hand washing. And as in all his writing, Gawande gives us an inside look at his own life as a practicing surgeon, offering a searingly honest firsthand account of work in a field where mistakes are both unavoidable and unthinkable.

At once unflinching and compassionate, Better is an exhilarating journey narrated by a writer with a scalpel pen and an X-ray eye (Time). Gawande's investigation into medical professionals and how they progress from merely good to great provides rare insight into the elements of success, illuminating every area of human endeavor. 'What does it take to be good at something, when failure is so easy?' asks writer/physician Gawande . . . Diligence, ingenuity and 'doing right' . . . Gawande illustrates each of these qualities with stories from his own experience, and] his observations of and conversations with other physicians . . . For young doctors . . . Gawande suggests five strategies: Ask unscripted questions, don't complain, 'count something' (be a scientist as well as a doctor), write something (to make yourself part of a larger world) and change in response to new ideas. A must-read for medical professionals-and a discerning, humanizing portrait of doctors at work for the rest of us.--Kirkus Reviews Gawande provides a cleareyed view of the medical profession that both resonates and gives pause. Once again, he spares no one, himself included. Gawande, a surgeon, manages to capture medicine in all of its complex and chaotic glory, and to put it, still squirming with life, down on the page . . . Gawande's meditation on performance is not only an absorbing collection of essays but also an exhilarating call for the rest of us to do the same . . . Gawande has the ability to deconstruct and explain the most difficult issues while preserving, even celebrating, their complexity. He applies a sly sense of humor to even the most unsettling topics. And his voice is so direct that at times it borders on painful (at least from the perspective of a fellow doctor) . . . With this book, Gawande inspires all of us, doctor or not, to be better.--Pauline W. Chen, The New York Times Book Review Better is a masterpiece, a series of stories set inside the four walls of a hospital that end up telling us something unforgettable about the world outside.--Malcolm Gladwell, author of Blink Better is a mesmerizing book with fascinations on every page, told with mastery, insight, compassion, and humility by a surgeon who doesn't flinch from taboo subjects or self-examination. His topics range from the invisible to the unspeakable, and some chapters are exciting medical mysteries. On every page, one meets a candid and thoughtful man, who pays close attention, and who somehow manages to find the right balance between intimacy and respectfulness, in a world that can be inhospitable to both.--Diane Ackerman, author of An Alchemy of Mind It's hard to think of a writer working today who makes such good use of man's quest to avoid pain and death. Atul Gawande is not only ad

Atul Gawande, a 2006 MacArthur fellow, is a general surgeon at the Brigham and Women's Hospital in Boston, a staff writer for the New Yorker, an assistant professor at Harvard Medical School, and a frequent contributor to The New England Journal of Medicine. Gawande lives with his wife and three children in Newton, Massachusetts.