Better: A Surgeon’s Notes on Performance

betterIn this collection of essays, many previously published in The New Yorker, general surgeon Atul Gawande looks at how doctors can improve their performance, saving more lives and offering better health outcomes for anyone in their care. He looks at seemingly simple solutions, such as hand-washing in hospitals, and considers why such obviously beneficial practices aren’t adhered to and what hospitals can do to increase compliance. The essays address such topics as battlefield medicine, malpractice, insurance, childbirth, and medical practice in poor areas of India, where doctors can get grants for MRI machines, but do not have basic supplies. As in his earlier book, Complications, Gawande proves himself to be a thoughtful physician, ready to look at difficult questions from multiple angles and to accept that the answers aren’t easy. Unlike a lot of popular nonfiction, this is not a book that presents easy answers and quick formulas to follow. Every easy answer, as it turns out, has a potential downside.

Gawande structures his essays in such a way that you can’t help but want to finish them. He usually starts with a specific incident, such as a malpractice suit in which a doctor and patient remembered a conversation differently, and uses that incident as a launching point to discuss the issues involved. He draws in other examples and anecdotes and references numerous articles and studies. At at the end, he circles back around to the original incident, telling readers how it was resolved. Gawande did the same sort of thing in Complications, and I found it more effective there. Some of that was the nature of the stories, many of which were drawn from Gawande’s own practice. In these essays, he was more often an outside observer, writing about other doctors and their patients. Plus, because I read the whole book in a day, his approach to structuring his pieces started to feel like a formula by the time I was halfway through. I suppose it was effective enough, however, because I did want to know how every story was resolved.

One of the most interesting chapters, to me, was on the involvement of medical personnel in administering the death penalty. I had no idea that assisting with lethal injections is against the American Medical Association’s code of ethics. I’m against the death penalty, so I sympathize with that view. Yet there are doctors who choose to participate in the process, sometimes just by pronouncing death but sometimes advising on how to place the IVs or otherwise assisting with the procedure. Gawande interviews two doctors and two nurses who do this work to find out why they choose to go against the AMA’s position and perhaps risk their licenses. For some, it comes down to wanting to be sure that if this terrible thing is going to be done that it’s done in a way that causes as little pain as possible. Gawande is sympathetic to their view but ultimately unconvinced, concluding  that by participating these medical professionals could be enabling the death penalty to continue. Plus, as professionals who are supposed to be dedicated to preserving life, how can they use their expertise to take life?

The chapter on childbirth included some new to me thoughts about the use of forceps in delivery. I had assumed that forceps were no longer used because they were too dangerous. In my mind, they were an artifact of Victorian medicine that we’ve sensibly abandoned. Yet Gawande says that in some situations, when used correctly, they are the safest and easiest way to deliver a baby during a difficult labor. The problem is that learning the proper technique is extremely difficult, especially when compared to Caesarian sections, when a doctor can stand across the table and point to where the medical student needs to cut. Now, even doctors who mastered forceps technique in an earlier era have largely given it up in order to discourage those who have not mastered it from trying.

Most of the book focuses on choices doctors make, regarding how to charge for services,  what techniques to use, or how to create an environment of trust when patients feel vulnerable. But Gawande raises some questions that patients need to consider as well. For example, would you ever settle for a doctor or medical practice that’s merely average, if indeed you could make such comparisons? And is the current malpractice system in the U.S. the best way to handle medical mistakes? Whatever the question, he seems reasonable and sensible and rarely pushes for one specific solution. This is not a book of clear answers, but a book of questions and possible answers to consider. I appreciate being given the arguments and left to think about them myself.

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14 Responses to Better: A Surgeon’s Notes on Performance

  1. Lisa says:

    I always enjoy his essays in the New Yorker, and learn something from them, but I haven’t come across his books.

    • Teresa says:

      I think a lot of the pieces in his first two books were published in The New Yorker, so if you liked those, you’d like the books, as long as they don’t duplicate too much of what you’ve read.

  2. Christy says:

    I hadn’t thought about the doctors who assist with death sentences. I wonder how one goes about finding a willing doctor / nurse for that. I really need to read a book by Gawande at some point – I think all the reviews I’ve read of his books have been positive.

    • Teresa says:

      In the case of the doctors and nurses Gawande talked to, some of them had patients who worked in the prison system, and those patients broached the subject. I hadn’t thought about their role, either, and I had no idea about the AMA’s position.

  3. The things you praised in this book are all of the things I loved in Complications. Gawande is such a good medical writer because he is able to approach problems from different perspectives. I never miss reading his essays when I come across them. I think I have this one on my shelves, but haven’t read it yet.

    • Teresa says:

      I didn’t think this was quite as good as Complications, but I did still like it a lot. He does such a great job of picking apart the issues.

  4. vicki (skiourophile / bibliolathas) says:

    I’m keen to read his work now. I work in a hospital, and I find it completely astonishing how the importance of hand hygiene still needs to be constantly reinforced 150+ years after Semmelweis made the link between puerperal fever and hand-washing. (Frankly, it is terrifying!)

    • Teresa says:

      If you work in a hospital, I imagine you would enjoy this. My nurse step-mother loved his first book because she could relate to so much of it. I wonder how different some of the things he talks about are in Australia.

      Hand-washing does seem so basic, but when Gawande calculates how much time hosptial staff actually have to spend washing their hands, I could see how easy it would be to slip up. One hospital he wrote about found that the key was getting staff involved in deciding where hand-washing stations should go so that it was as convenient as possible.

  5. Jeanne says:

    The hand-washing also must make their hands raw, if they do it as much as they should.

    • Teresa says:

      That was another thing the hospital Gawande wrote about had to address, finding soaps and gels that didn’t irritate the skin when used frequently.

  6. Jenny says:

    I have liked the individual essays by Atul Gawande that I’ve read (only one or two), and I keep hoping the library will get his ebooks. The physical books are always checked out! I am thinking of just buying a Nook copy of an Atul Gawande essay collection — it seems like the kind of thing I’d like to have on hand anyway.

  7. I too preferred Complications, but Gawande is such an amazing writer and the issues he discussed in this book are so important that it was still really compelling. I really pay attention to my doctors washing their hands now!

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