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| Better: A Surgeon's Notes on Performance | 
 enlarge | Author: Atul Gawande
Publisher: Picador
Category: Book
List Price: $14.00
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Avg. Customer Rating:  80 reviews
Sales Rank: 1407
Media: Paperback
Edition: 1st
Number Of Items: 1
Pages: 288
Shipping Weight (lbs): 0.5
Dimensions (in): 8.1 x 5.4 x 0.9
ISBN: 0312427654
Dewey Decimal Number: 616
EAN: 9780312427658
ASIN: 0312427654
Publication Date: January 22, 2008
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Condition: Ships immediately! Perfect and New! Has a publisher remainder mark. 1st. 2008 Paperback.
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Product Description
National Bestseller The struggle to perform well is universal: each of us faces fatigue, limited resources, and imperfect abilities in whatever we do. But nowhere is this drive to do better more important than in medicine, where lives may be on the line with any decision. Atul Gawande, the New York Times bestselling author of Complications, examines, in riveting accounts of medical failure and triumph, how success is achieved in this complex and risk-filled profession. At once unflinching and compassionate, Better is an exhilarating journey, narrated by "arguably the best nonfiction doctor-writer around" (Salon.com).
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| Customer Reviews: Read 75 more reviews...
 Difficult problems are ... difficult April 7, 2007
117 out of 123 found this review helpful
First, as a quick proxy of how good it is, and as a way of enticing busy readers, I should note that I finished Atal Gawande's book Better: A Surgeon's Notes On Performance in less than four hours. I can't remember the last time that happened. True, it's a relatively short book, and I had some uninterrupted time on a bus. But mostly it's that Gawande is a straightforward, energetic, thoughtful writer whose essays relentlessly pull you forward. Each discusses one or two ideas in enough depth to make you realize that they're not easy problems -- which is all most people need, and which does a world of good on its own. Every country has its unquestioned assumptions; it's the rare writer who helps us question them and gently remind us that if there were easy solutions, we'd have found them by now. Gawande is good at that.
The most moving and thought-provoking of these essays, to me, was "The Doctors of the Death Chamber," in which Gawande interviews four doctors (whom he labels "A," "B," "C" and -- wait for it -- "D," in order to secure their anonymity) who help states carry out the death penalty humanely. The use of "humanely" here is questionable; it's humane in the sense that, if we are to use the death penalty, we must not be needlessly cruel at the time of the criminal's death. But it's inhumane in the larger sense that we are furthering a corrupt system -- we are "tinker[ing] with the machinery of death," to use Justice Blackmun's words. Since a doctor's role is to protect human lives, are anaesthesiologists who help execute people painlessly violating their roles? To put it more succinctly: should a doctor make the best of the machinery of death, or should he take no part in the machine? The American Medical Association has its answer and its role. Democratically elected governments have their own. It's Gawande's job to teach us that easy answers don't exist for complicated problems like this.
One reason it's so easy to come up with easy answers for questions like this is that we rarely come face to face with the system we critique. Gawande does the legwork for us. He's at his best, in this regard, when he interviews a medical-malpractice attorney, a doctor, and the family of a dead patient involved in one malpractice case. We're all inclined to boo at the malpractice attorney . . . right up to the moment we feel we've been wronged, when that attorney is the man we want on our side. Gawande knows that this is how we work, so he takes some time to look at a case when doctors failed other doctors: Gawande's friend Bill Franklin found that doctors had failed to treat a tumor on Franklin's son that they should have noticed years before -- that someone had actually singled out on an X-ray for further study. This is the test case where ethics hits the road: when it's your own son, and you're a doctor, and you're well aware of the expenses of medical malpractice, what do you do? After trying other routes, Franklin did what so many others do: he sued and won. (Along the way Franklin helped establish a precedent in the Massachusetts Supreme Court, in the case of Franklin v. Massachusetts General Hospital et al., affecting the statute of limitations on malpractice cases. Seems worth reading.)
Better contains lots of great little insights into the medical profession -- for instance, how difficult it is to get doctors and nurses to wash their hands as often as is safe for patients, or the awkwardness of a male doctor palpating a naked female patient. Throughout it all, Gawande's organizing principle is to lay out for us the system in which doctors work, the limitations they operate under, and how they make the best within those limitations.
I'm less inclined than I used to be to believe that Gawande has an agenda, but I do think that a slightly different arrangement of the chapters within Better would have sent a different message. Had the chapter on malpractice come at the end of the book, after we've read about Gawande's own mistakes and about sloppy handwashing, we'd be less sympathetic toward doctors. In "The Score," which I've mentioned before, Gawande tells us that C-sections are vital in a world where doctors can't be expected to be very talented; in "The Bell Curve," he reveals that not all cystic-fibrosis clinics are the same, and that the medical industry was reluctant for years to release data on how well individual clinics performed. With these insights in mind, malpractice would seem to the reader to be completely justified. As it is, the malpractice article is tucked into the middle of the book; Better ends with a story about heroically performing surgery in poor rural India, and with a few pieces of advice to newly-minted doctors. It's a hopeful ending. I can't decide whether this arrangement was deliberately obfuscating. Nor does Gawande spend much time explaining whether malpractice makes doctors better.
He's fair throughout, however, and his point is that doctors' work is hard. Understanding precisely why it's hard, and what they do to get their jobs done under trying conditions, is Better's job, and it succeeds admirably. It's a great, thought-provoking, fun read.
An Intriguing Work by a Top-Notch Medical Writer April 15, 2007
36 out of 38 found this review helpful
Atul Gawande is a general surgeon at the Brigham and Women's Hospital in Boston and -- from everything I've heard and read about him recently -- one of the best of the new breed of medical writers who devote their prose to informing the general public about important concerns in the world of medicine. If this new book, "Better: A Surgeon's Notes on Performance," is a representative example of his usual writing talent, I will completely agree with the above assessment. This collection of original and previously published essays is highly readable and very interesting. Normally, I am not all that interested in reading about medical topics unless it impacts me personally. I'm not a great fan of hospitals nor am I enthusiastic about going to a physician. Fortunately, for most of my life I have enjoyed relatively excellent health. My attitude, however, changed five years ago and Gawande's book takes on some genuine relevance for me. How so and why?
In a section of his book, entitled "The Mop-Up," Gawande discusses polio and the campaign to wipe it out in Asia wherein he was a momentary observer in the field in 2003. Way back in ancient history, when I was a mere child in the 1940s and America was hit with a polio epidemic, I was diagnosed with polio and almost died. Hence the relevance here for me. But more than that, I am convinced to this day that I was "saved" because of the efforts of a nurse -- I'm sure she was one of Gawande's "positive deviants" which he describes in his book -- who insisted on treating me and others with a controversial treatment (opposed by most of the medical "establishment" at the time) called "The Sister Kenny Method." She never lost a patient, by the way; we all recovered without any significant aftereffects that I know of.
Fortunately, from that time in the 1940s I never needed to be hospitalized again. That is, until 2002. Then I had a heart attack and was forced into a hospital for an angioplasty and had to take note of medical matters, including the state of medical care in this country." So, whereas before that latter year I could ignore books of the type that Gawande writes, I now have a profound interest in all things medical. Even more so since my second heart attack and angioplasty in 2006. (I even subscribe to daily updates via e-mail about medical topics!) I am now very concerned about "better" when it comes to medical care and policy.
Gawande divides his book into three significant sections: Diligence, Doing Right, and Ingenuity. He says that "Diligence" is "the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles." The section "Doing Right" considers topics such as "how much doctors should be paid, and what we owe patients when we make mistakes." Important as these sections are, the final section, "Ingenuity," is of even greater importance in my opinion. Ingenuity, he says, "demands more than anything a willingness to recognize failure" and "arises from deliberate, even obsessive, reflection on failure and a constant searching for new solutions." Amen to that!
Furthermore, Gawande quite realistically concludes: "Betterment is a perpetual labor. The world is chaotic, disorganized, and vexing, and medicine is nowhere spared that reality. To complicate matters, we in medicine are also only human ourselves. ...Yet...to live as a doctor is to live so that one's life is bound up in others' and in science and in the messy, complicated connection between the two. It is to live a life of responsibility. The question...is not whether one accepts the responsibility. Just by doing this work one has. The question is, having accepted the responsibility, how one does such work well." Well said, that. Couldn't agree more.
One of the more politically relevant issues (at least for me) that Gawande discusses is the matter of medical practitioners' involvement in executions. In his essay, "The Doctors of the Death Chamber," he says that "We [doctors and nurses] must do our best to choose intelligently and wisely," and then notes that "Sometimes, however, we will be wrong -- as I think the doctors and nurses are who have used their privileged skills to make possible 876 deaths by lethal injection thus far." I cannot understand how a physician -- "First, do no harm" -- could even contemplate participating in the killing of another human being, even if officially sanctioned. Gawande addresses this issue in what I think is a sensible manner. But the debate on this issue is current, lively and will continue for some time.
I do, however, wish that Gawande had spent more time discussing the future of health care in America as regards the delivery of medical services to all its citizens. He briefly touches on this matter, but not in detail. From my perspective, HMOs are definitely not the solution (they are part of the current problem!) and government-managed health care (socialized medicine) is even less desirable. I mean, the government, in my opinion, cannot even provide a decent public education for our children; how can we expect it to provide decent health care? I have considered a number of proposals, all of them wanting in some way or other. I'd like to see Gawande tackle this problem in a detailed way from a physician's perspective. Maybe another book?
Moreover, regarding the above, it is disturbing to read what one American medical reviewer recently stated: "We spend 50 percent more per capita on health care than any other country, for a total of $2 trillion a year, yet our health system, according to the World Health Organization, ranks 37th worldwide. ...By any measure -- longevity, infant mortality, burden of disease -- we sit in the basement of the industrialized world." For a country that can spend trillions of dollars to wage war and promote "regime changes" throughout the world, that statement is embarrassing and hard to fathom.
All in all, "Better" is a good read and extremely informative. It is full of interesting anecdotes, as well as confronting, if only briefly, some of the major issues in the practice of medicine today such as the influence of money in the healthcare system, the problem of malpractice lawsuits, and medical practice under the tensions of the military battlefield, as well as more mundane issues which are often ignored such as the simple act of hand washing or how nakedness impacts the examination room. Since I have had my own experiences lately with the medical establishment, I can now relate to at least some of the topics that Gawande discusses. Therefore -- and since there is no medical experience like a really personal one -- I highly recommend this book to all readers. I guarantee you'll learn a lot, you'll enjoy the fine writing, and you'll have some thinking to do about the state of medical care in America.
 "Becoming a positive deviant" April 12, 2008
34 out of 38 found this review helpful
In any human endeavor, variations of performance create a bell curve and most participants are average or below average. Dr. Atul Gawande explores the challenge of practicing medicine and striving to be a "positive deviant" on that curve. Better: A Surgeon's Notes on Performance explores the pursuit of perfection in several areas of medical practice. Athletes, he writes, teach us a lot about "the value of perseverance, of hard work and practice, of precision. But success in medicine has dimensions that cannot be found on a playing field. For one, lives are on the line." (p. 4)
Several chapters of this book appeared first as articles in periodicals. Though the book follows a fascinating theme, do not expect it to be as well-integrated as Complications: A Surgeon's Notes on an Imperfect Science. The overall message is the dialectic between strict adherence to practices known to work (hand-washing) and an inspired ingenuity. How to achieve both?
There is much interesting material here: the WHO campaign to eliminate polio, the history of Cesarian sections in obstetrics, the ethics of assisting in the death chamber, the story behind longer life span for cystic fibrosis patients. These and other chapters are tied together by the quest for improvement of outcomes.
The afterword encapsulates Dr. Gawande's advice to medical students on making a difference in people's lives, and it alone is worth the price of the book. "It often seems safest to do what everyone else is doing ..." he writes in closing. "But a doctor must not let that happen--nor should anyone who takes on risk and responsibility in society."
Altogether this is an informative and thought-provoking book with lessons that go beyond the specifics of medical practice.
Linda Bulger, 2008
An insider's perspective which can help you be a more informed patient May 20, 2007
25 out of 25 found this review helpful
I'm always on the side of self-education when it comes to medical topics, especially in light of the current health care system and its looming problems. Gawande's skill is in writing movingly ab out all sorts of medical issues, including both failures and successes, in a way that illuminates the complexities of practicing medicine in today's world of HMOs, soaring premiums and more.
Some of his essays may appeal more to you than others but I urge you to read the entire book, as well as to get his other one, Complications. I've read medical memoirs that put me to sleep and have been baffled by how someone could take life and death situations and turn them into dry writing. This isn't the case here and you'll come away from the book with a stronger understanding of all the factors (and possible solutions) that make up the world of medicine, medical ethics and patient care today.
Modern business principles in the medical industry? April 9, 2007
17 out of 27 found this review helpful
When I was an MBA student, I became fascinated with the continuous improvement philosophy espoused by Deming. This is the philosophy that drives Toyota and many other companies to achieve ever-higher levels of quality. Coincidentally, at that time in my life a coworker named Atul exemplified this philosophy in everything he did. So here we are with a book authored many years later by a person named Atul, and that book talks about improving performance.
In some areas of endeavor, constant improvements in performance are mandatory for a business to survive. A prime example is the online business world. Sites that don't constantly improve and innovate lose customers and die. We can go back to the Toyota example and see exactly why Toyota dominates the US auto market. While American automakers have been playing infighting games, Toyota has focused on making a better car. They have continually eliminated defects and instituted improvements, no matter how minor.
In other areas, improvement is completely at odds with the culture. A prime example is the typical government agency. "Customers" of government agencies have no choice in vendor. Bureaucrats continue to draw their salaries, while 20 or 100 people do the job of one person about as poorly as is humanly possible. This has led to countless jokes about the DMV. It's also responsible for the adage, "Government takes the path of least competence." Behavior that isn't tolerated in performance-driven companies is actually rewarded in many government organizations. There are exceptions, and I will note one of those in a moment.
In between these two ends of the spectrum, we find the medical care industry. And it's here were Atul Gawande lives and breathes. In this book, he shatters many myths about medical care. For example, it's simply not true that the quality of care is consistent from care center to care center. In fact, enormous variations exist and the consequences can be profound.
Gawande is obviously a clear thinker. This is evident in the fact that he so adroitly addresses so many facets of medical care in less than 300 pages. While this book isn't a page turner in the traditional sense--that is, it doesn't have cliff-hangers that make you keep reading--I was surprised at how well it maintained my interest and how quickly I finished reading it. The writing is clear and engaging, even though the author is discussing a very complex industry.
As Gawande points out, the real challenges before doctors today lay not in breakthrough technology but in the proper application of what they already have. This is not to say doctors are misapplying things. As the title implies, doctors (and all medical professionals) have room for improvement--for being better--at how they apply the tools they have.
This isn't just theory or some windbag expressing an unfounded opinion. As you have probably guessed, "Atul Gawande" isn't an Irish name. His family is originally from India, and Gawande gives us numerous examples of the amazing results Indian doctors obtain despite not having the tools and budgets we are accustomed to in the United States.
We don't have to travel to India to see how medical professionals can ratchet up the quality of care by using the constant improvement philosophy. Gawande brings us to one Cystic Fibrosis clinic in America and then another, so we can see how different approaches produce different results.
Earlier, I mentioned government agencies as examples of incompetence. Interestingly, the Veteran's Administration is way ahead of private industry when it comes to medical care. Gawande, who doesn't work in the VA, probably is not aware of the quality revolution that took place there.
Once the most dismal of medical care providers (following the typical government agency formula of focusing on bloated processes and ignoring results), the VA is now an example of productivity and quality that the private sector can only envy. In fact, the VA actually provides healthcare while the mainstream medical system has mostly limited itself to providing disease care and injury fixes.
"Better" is a book written by a practicing surgeon, and it looks inside the medical system. It can help medical professionals see ways to improve how they do things. But if you're not a medical professional, is this book worth reading? In my opinion, yes. The chapter on medicine's bell curve would justify that all by itself. Anyone who might need a specialist (for example, a neurologist) would benefit from understanding the points Gawande makes when he discusses the differences in quality of care at various centers.
This book reminds me of books that have been written about other industries and on business process improvement in general. Perhaps the most famous of the business process improvement books is Tom Peters' seminal work, "In Search of Excellence." Customers in a business to business relationship look to such books as "Lean Thinking" to better work with their vendors and suppliers. These books address many of the same fundamental issues Gawande covers in "Better."
One way to improve is to drive defects out. Another way is to look at what's working and adapt it to your situation. A third way, and Gawande provides plenty of examples, is to simply look for (and try) ways of doing things better. Just as books about Toyota's "quality miracle" have driven improvements in hundreds of other industries, so can the lessons learned in this book drive improvements in other industries.
So, in that sense it has very broad application in addition to providing insight into curing the ills of our medical care system. It's an excellent resource for any business person. But it's also an excellent resource for any consumer of medical services. You don't have to settle for "good enough." You can seek, and get, better.
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