Review: Better: A surgeon’s notes on performance, by Atul Gawande

When I was taking my qualifying examinations for my Ph.D. in Psychology, one of my examiners asked me to address what he called the “moon question”: “If human beings are so dumb (according to decision psychology), how did we get to the moon?” The answer, of course, is that despite the predilection in cognitive psychology for inducing and examining error (because error usually provides powerful tests of process models of human behavior), most people are pretty good thinkers most of the time, and some people are very good thinkers most of the time.

Atul Gawande’s excellent 2002 collection Complications: A Surgeon’s Notes on an Imperfect Science struck a responsive chord with medical decision scientists with its insightful examination of medical error. Gawande has now collected 11 new essays in Better: A Surgeon’s Notes on Performance (Metropolitan Books, 2007), which shift the focus to how some physicians come to excel in their craft (in his terms, becoming “positive deviants”). He asks “what does it take to become good at something in which failure is so easy, so effortless?”

Gawande focuses on three areas in which he characterize good physicians: diligence, doing right, and ingenuity.

Part I of the book, on diligence, comprises three essays. The first reviews the tremendous impact of physician hand-washing behavior on patient outcomes, and the ongoing efforts of some dedicated health workers to reinforce the need for doctors to wash their hands consistently and thoroughly. The second chronicles WHO’s approach to containing a new polio case in India, a massive vaccination effort organized by volunteer health care workers. The third demonstrates the remarkable progress in the effectiveness of military medicine through a look at the organization of American combat hospitals in Iraq. The lesson of this part is that performance improvement demands painstaking attention to detail and a continuous effort to get it right – despite sometimes insurmountable constraints.

Part II of the book, on doing right, includes five essays. These cover such apparently disparate topics as conducting pelvic and rectal exams, malpractice litigation (which he considers replacing with a system modeled after the National Vaccine Injury Compensation program, or New Zealand’s malpractice system), physician billing and income, the role of physicians and nurses in state-ordered executions, and how aggressively physicians should treat patients with terminal diagnoses. The overall theme of this part of the book is that medicine is intimately pervaded by questions of social ethics, personal morality, and individual preference, and that “doing right” necessarily requires facing up to difficult choices — and making them.

Part II of the book, on ingenuity, contains three final essays. The first illustrates the impact of measurement on results by looking at the impact of the Apgar score on obstetrical outcomes. By providing a clinical score that measures the status of a newborn, can be universally applied, and is a natural basis for comparing practices, Gawande argues, the Apgar has
driven performance improvements in labor and delivery. The second examines the considerable variability in success among cystic fibrosis treatment centers and looks at some of the factors that may contribute to the performance of the most successful centers. The third provides a look at surgeons in rural India who, lacking access to specialists, develop expertise far broader than Western general surgeons.

Gawande concludes with an afterword based on a lecture to medical students offering five tips to becoming a positive deviant in medicine: “ask an unscripted question”, “don’t complain”, “count something”, “write something”, and “change”. It’s clear in this book that Gawande is not merely espousing platitudes, but is charting a course toward betterment for physicians and following that course.

The writing is clear, forceful, and engaging, and once I picked up the book, it was difficult to put down. Although the essays (other than the afterword) tend to raise questions – sometime troubling ones – rather than offer prescriptions, the questions themselves are important and demand attention from contemporary practitioners. Gawande may not be able to tell physicians how to make the choices that will face them, but he does a great service in highlighting both the content of some of those choices and the need for informed judgment itself. For decision scientists, there is a wealth of material here that calls for further descriptive and prescriptive study in the lab and in the field.

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