Better: A Surgeon's Notes On Performance (2007) - Plot & Excerpts
I have had a lot of doctors in my life. The best one I ever had was the surgeon who failed. Before I went under, he told me it would take about 2 hours and had an 85% success rate. When I woke up, nearly five hours had passed, I was in far more pain than I had been led to expect, and he was waiting to tell me that I was in the 15%, that he hadn’t saved my eye, and that he would be ready to talk to me as soon as I was back on my feet.When he retired several years later, I wrote him a thank you note. Because he did his best, and it wasn’t enough, and he knew it, and he told me so honestly and in great detail as many times as I needed to hear it, and he held his office trash can for me to throw up in, and he waived thousands of dollars in bills so he could keep seeing me when I was in law school with the horrible useless insurance, and he cared whether I was having a good life. A surgeon – can you imagine?This book isn’t really about that sort of failure, the kind where current technology and understanding isn’t enough. It’s about designing behavioral triggers to save lives by increasing compliance with hand-washing drills, and it’s about the massive manpower efforts necessary to eliminate infectious diseases from the world, and it’s about what a patient is owed after a failure of any kind. It struck a huge cord with me, because one of the things that medicine and the practice of law at my level have in common is an expectation of a 0% error rate. Seriously – I am explicitly and implicitly told on a daily basis that anything less than perfection is failure. There are no stupid slip-ups, and there are no impossible situations that no one could solve. Which has nothing to do with reality, of course. Learning to live under these conditions is, uh, let’s call it emotionally taxing and leave it at that. Anyone who has ever been through a medical residency is probably nodding right now.So I thought this book – I got there! – was great. Not just for the case studies of Polio outbreaks and third-world surgery, though they’re pretty interesting. But because this book is thinking specifically about that. About the difference between an expectation of infallible perfection, and the seldom-acknowledged reality that our brains are imperfect and even the very best of us sometimes aren’t good enough. “When someone has come to you for your expertise, and your expertise has failed, what do you have left? You have only your character to fall back upon, and sometimes it’s only your pride that comes through.” Succinctly put, and so very true. Ask me about something I fucked up this past summer sometime, and how the surgeon who failed was on my mind in the aftermath, when all I had left to do was take it the best I could. Anyway, rambling. I was intellectually engaged here on multiple levels, the way you are when you’re always thinking and reacting, even when it isn’t always good. Insert a whole rebuttal essay here on Gawande’s ablism in the section on improved rates of survival for devastating combat injuries and all his musing on whether life with this and that disability is actually “worth living,” whatever the fuck that is supposed to mean. Scrub that, I know exactly what that’s supposed to mean, and I think it’s crap. Also, the business of the disabled person in question, not an able-bodied columnist for The New Yorker. /snide.And insert a whole other essay on the execution section, and how Gawande and I have differing opinions on the death penalty – he is for it and I am not – but how fascinating it was that when presented with the ethical dilemma of doctor participation in executions, he concluded that if executions cannot be conducted safely without doctors they shouldn’t happen, and I concluded doctors should be permitted to compromise their oaths. Engaged, like I said.
One of my favorite nonfiction writers. Atul Gawande is always worth a read. In "Better", he considers the question of what might make medicine as a whole industry ... better. In terms of cost, effectiveness, reach, and advancement of knowledge. For doctors and patients, and to a lesser extent, society as a whole. This is an enormous question, of course, and Gawande does manage to address it in a meaningful way by detailing three major case studies and several smaller ones. I found the case study of polio eradication in India the most fascinating. That so few local overseers belonging to UN agencies coordinate such a massive effort for eradication is astounding, especially knowing the challenges of Indian systems intimately like I do. The other case studies, such as hand washing among doctors and the medical side of childbirth are also memorable. Hand washing especially, I went in with something like a "duh why can't they do it properly" attitude, and Gawande's case study left me with a deep understanding of exactly why not. There were two slightly frustrating things about this book. One was that Gawande is so scrupulously apolitical that it gets a bit annoying. When he discusses health insurance, for example, it is hard to see how he can possible do it well while steadfastly remaining apolitical, and yeah, his reticence does hurt the chapter. He leaves many options for alternative systems for healthcare provisions unexamined because of it. The other slightly annoying thing is how Gawande seems to see doctors as demigods, if not actually divine. Often this is an endearing attitude. But sometimes it grates, this high-and-mighty way he has of suggesting throughout that doctors are ever so Special and must be held to godly standards of performance and morality, etc. I am not one to suggest doctors are the same as any other profession like car sales, but Atul Gawande is on a completely new level of reverence for the profession. Like I said, this IS usually endearing. If I had to choose a doctor I'd most certainly choose one who felt the special weight of doctorly responsibility than one who is in it just for the money. But in some chapters, like the one on childbirth, Gawande's reverence leaves him utterly unable to admit the depth of the medical profession's failure in treating women like people, and accepting the fact that sheer greed is what is behind the over medicalization of childbirth throughout the previous venture that continues to this day. Any failures of the medical profession are blamed on lack of knowledge and good intentions. This is annoying. But regardless, a really good book, great fun to read.
What do You think about Better: A Surgeon's Notes On Performance (2007)?
One of my favorite granddaughters (I have 7, all favorites) gave me this book on Kindle for Christmas. I would never have chosen it for myself for several reasons, but thoroughly enjoyed reading it and couldn't wait to start the other one. Yes, Zoe gave me two, both by Atul Gawande (the name was one thing that might have discouraged me from selecting this book - not a good thing to admit). Dr. Gawande is to be the speaker at her graduation from UNC Nursing School in May. We will definitely be there.One reason I liked reading this book is that I agree with most of what he has to say about the practice of medicine, good and bad. His illustrative cases reminded me of many of my own experiences. I guess I was a bit of a maverick. That would explain why the radiology technologists at Children's Mercy Hospital called me Hawkeye and why my partners in Charleston, WV, were not always happy with me.
—Bill
Oh, I wanted this to be great! Alas, only part of it is. To wit: Gawande’s umbrella themes dominate the book, but they are a distraction from his best conclusions, which are tucked quietly in the afterword.In his introduction, Gawande asks, “What does it take to be good at something in which failure can be so easy, so effortless?”—and even though he says, “This is a book about performance in medicine,” the question applies not just to medical practitioners. All of us can ask the same question about our jobs and our lives. What does it take to be good? What does it take to be better? This is why I bought and read Better.Gawande’s answers are anti-climactic at first. He breaks his results down into three categories: diligence, doing right, and ingenuity. Fine. He tells us stories that demonstrate each one, and we see clearly in these stories how being diligent, doing right, and taking fresh approaches improved outcomes. This is a familiar formula: big themes, some examples, conclusion. Great. Sure, the stories are sometimes fascinating, but the problem is that diligence, doing right, and ingenuity are the kinds of words thrown up in primary colors on black-bordered posters with images of skyscapes, mountain-tops, or waterfalls. They are noble ideals, but they are vague as pieces of advice for doing what we do better. I would imagine it’s hard even for doctors to internalize these lessons. But then comes the afterword, where the gold is buried: “Suggestions for Becoming a Positive Deviant”—which, for non-statistics-types, means “suggestions for becoming better.” Huzzah! There are five: 1) Ask an unscripted question, 2) Don’t complain, 3) Count something, 4) Write something, and 5) Change. This is the good stuff. Gawande’s final suggestions here are simple and applicable to anything. They subtly encourage creativity. They are suggestions that teach. If I have an office next year, I will post them on my wall.Do I recommend it? Yes, if only for the afterword. The stories are well told, too, I guess.Would I teach it? No. For non-fiction writing, I might use some of Gawande’s New Yorker articles, though.Lasting impressions: Perfectly fine stories sorted by theme and a summary that makes them all worthwhile.
—Peter
Oh cool, I'll have to check this book out. I would have thought something like this would be dry and dull, but your review made me think differently. :D
—Petra X
