Better: A Surgeon's Notes on Performance

by Atul Gawande

The author, a general surgeon, discusses some challenges and discoveries of the medical field, and what qualities it takes to improve performance.  Drawing on the history of medicine and his own experiences, he investigates not only what makes improvement, but how it is implemented.  For example, the simple act of hand-washing nearly removed the risk of “childbed fever,” an infection which killed newborns; but the successful implementation of hand-washing in an institution comes not by diktat but through spreading positive deviance – seeing where it has become acceptable and trumpeting those practices – hoping to turn the deviance into the norm by giving a voice to those already successful at it. He also writes of watching doctors in India campaign to eradicate polio, a gargantuan endeavor which works not through some miracle pill but through diligence, the simple but exhausting legwork of knocking on doors and spreading the word.  He looks at innovation, such as Virginia Apgar’s eponymous test, which is so simple and so obvious, yet drastically improved infant survival rates simply by quantifying results and giving surgeons a number to beat.  Or Watson Bowes, a doctor of obstetrics who also improved infant survival rates simply by treating premature babies as though he expected them to thrive.  Gawande also discusses some other facets of medical culture, such as malpractice, wages, and lethal injection, but these – while interesting – are vaguer musings compared to the book’s overall arguments about the application of improvement.

It’s a compelling book, written in clear, assured, intelligent prose.  Gawande posits that success comes not through science but mainly through performance (as with Indian doctors whom he witnessed perform surgeries in impoverished hospitals with very few instruments, make do with what they had and improvise where they could, but in no event just give up).  This conclusion is both heartening and demoralizing, the former because it is so simple – merely expanding current know-how and following basic guidelines can improve survival rates dramatically – but it is also demoralizing because it raises the question of why these simple steps are not already being taken, and it makes us realize that our doctors are fallible, sometimes arrogant and stubborn, humans like the rest of us.

four stars