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Better: A Surgeon's Notes on Performance
By Atul Gawande
Metropolitan Books
HC, 288 pgs. US$24.00
ISBN: 0-8050-8211-5

The struggle for better

By Steven Martinovich
web posted April 30, 2007

BetterThere are very few professions which expect perfection not just on a daily basis, but a minute by minute basis. There are fewer professions still where missing perfection may cost you your life. Of course, it is unrealistic to expect perfection from any profession, baseball players are superstars when they hit the ball just a third of the time after all, yet when it comes to medicine that is what we demand.

Atul Gawande, a surgeon at Boston's Brigham and Women's Hospital and medical writer with a well-deserved reputation, realizes better than most of us that perfection is unattainable but he believes that "better" isn't. To that end he offers Better: A Surgeon's Notes on Performance, a collection of related essays exploring how doctors in the United States and the world have made getting better at their craft integral to their practicing of medicine.

Better's essays are divided into three broad categories: "Diligence", "Doing Right" and "Ingenuity", the three factors Gawande believes lead to better medicine. "Diligence," he argues, is the art of paying attention to detail and how determination can make the most hopeless task possible. Something as simple as washing hands, something Gawande shows many doctors and nurses fail to do at an alarming rate, can save thousands of lives every year. Diligence also makes possible a campaign in India to inoculate millions of children in just a few days time.

"Doing Right" explores what happens when mistakes are made, how doctors interact with patients. Though Gawande investigates how doctors are financially compensated and the struggle to define proper doctor-patient contact, it is his essay on malpractice that most readers will likely be drawn to. Doctors candidly admit that they sometimes make mistakes but only rarely are patients compensated. Gawande proposes a worthy alternative to the current malpractice system but given that it would line fewer people's pockets, it is at best a pipe dream.

By far the most interesting section is Gawande's examination of "Ingenuity." Readers will be surprised to learn, for example, that Caesarean sections are a standard surgical procedure because many doctors aren't talented enough to use older methods of birthing babies. There is a disconcerting essay which shows that most doctors and clinics, regardless of reputation, are merely average in their delivery of health care. The final essay sees Gawande in India where he sees doctors perform all manner of procedures that in the west would call for specialists.

If Better shows us anything it's that the biggest improvements in health care won't be the result of stunning new technologies and drugs, but by simply better utilizing the resources we have already. As Gawande points out, deaths due to breast cancer can be cut by one-third simply by more women making use of screening mammography. Even something as simple as increased hand washing by doctors and nurses could prevent outbreaks in hospitals which claim thousands every year.

At the end of the day, Gawande argues, being better is simply a matter of finding someone who does it better and following their lead or innovating new approaches on your own. It is an approach which has earned a following in the business world but one that is still resisted by many physicians for personal, ideological or institutional reasons. Being better, it seems, isn't merely an industry level struggle, but a personal one as well.

Better doesn't pretend to have all the answers because, as Gawande's essays aptly show, the issues are too large and complex. Medicine is a science but it is practiced by human beings on other human beings. We know instinctively because of that the work is difficult and Better makes the case why. Gawande is rightly lauded as a fine surgeon but his writing performs a service just as valuable. Thanks to him we know how hard it really is to be better when human lives are in your hands. ESR

Steven Martinovich is a freelance writer in Sudbury, Ontario.

Buy Better: A Surgeon's Notes on Performance at Amazon.com for only $16.32 (32% off)

Other related essays:

  • Notes from a healer by Steven Martinovich (April 1, 2002)
    Steve Martinovich reviews Complications: A Surgeon's Notes on an Imperfect Science, a surgeon's elegant look at his own world and what you should know about it


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