Better: A Surgeon's Notes on Performance

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Better: A Surgeon's Notes on Performance

4.11 of 5 stars 4.11 · rating details · 7,590 ratings · 1,046 reviews

The New York Times bestselling author of Complications examines, in riveting accounts of medical failure and triumph, how success is achieved in a complex and risk-filled profession

The struggle to perform well is universal: each one of us faces fatigue, limited resources, and imperfect abilities in whatever we do. But nowhere is this drive to do better more important than...more

Hardcover, 288 pages

Published April 3rd 2007 by Metropolitan Books (first published 2007)

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May 20, 2007 David Singerman rated it 2 of 5 stars

Shelves: medicine, journalism

Not nearly as good as his first, in a number of ways.

What made Complications so exhilarating was that we were learning about being a doctor just as Gawande was learning about being a doctor. Literally: he wrote most of those essays while still a resident. The humility this brought to Gawande's essays makes all the difference. We were forced to consider the ethical implications of a healthcare system that has to deploy inexperienced doctors so that they can be trained and become better doctors....more Not nearly as good as his first, in a number of ways.

What made Complications so exhilarating was that we were learning about being a doctor just as Gawande was learning about being a doctor. Literally: he wrote most of those essays while still a resident. The humility this brought to Gawande's essays makes all the difference. We were forced to consider the ethical implications of a healthcare system that has to deploy inexperienced doctors so that they can be trained and become better doctors. Crucially, we did so, or were introduced to this problem, because the author brought us into his very first OR and lets us see his own anxiety at being one of these inexperienced doctors.

Not anymore. Now we have Atul Gawande, investigative reporter extraordinaire. He cruises around the world, looking for interesting stories about medicine, which are told fine, but they are not personal. And, in that increasingly infuriating New Yorker way, the piece becomes as much about the author as the story: "Blah blah blah," he told me in an email; or, "I went to see him in his office. He was wearing a purple shirt, green pants, and a top hat." Which, again, was fine when we really seemed to be looking out from Gawande's wide eyes.

A consequence of this is that the book promotes a very odd and simplistic message. As you can tell from the title, it's about Doing Better, but the three divisions--the three ways we are told we can do better--are Diligence, Doing Right, and Ingenuity. True enough--but do I need an MD to tell me this? More unfortunately, potentially revelatory stories about, say, containing a polio outbreak in Africa become bookended and framed as stories about Diligence. Maybe, but that the docs are Diligent is the least interesting thing you can say about that story.

This sort of oversimplification worried me from the introduction. It sounded like Malcolm Gladwell's doing, I thought, and I don't like Gladwell, whose M.O. is to oversimplify things and categorize them into Big Themes, often to the point of getting them wrong (see his piece on Enron). And lo! in the acknowledgments, Gawande says he has become best friends with Gladwell. Another great topic ruined by the frizzy-haired Canadian.(less)

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Nov 07, 2008 Robert rated it 5 of 5 stars · review of another edition

"Better" collects surgeon Atul Gawande's recent essays on medicine in three categories--Diligence, Doing Right, and Ingenuity. Each essay, on topics as diverse as washing hands to minimize infections in hospitals and doctors participating in executions, is a marvel of case study and comparative assessment, shifting back and forth between the particular and the general.

The simplicity and directness of Gawande's prose mirrors his mode of thought: always looking for the basic truth, the underlying...more

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Aug 07, 2008 Rebecca rated it 5 of 5 stars Recommends it for: anyone interested in the medical profession, people who like the New Yorker

Shelves: essays, non-fiction

This is a great book. From it's title, I thought it was about how doctors figure out how to make their patients better. But instead, it is about how the medical profession makes itself and its performance better. Gawande classifies the methods he sees in several ways. First, there is diligence, doing right, and ingenuity. He explores these ideals while discussing the campaign to get doctors and nurses to wash their hands in hospitals, improving the field of obstetrics, saving the lives of more a...more This is a great book. From it's title, I thought it was about how doctors figure out how to make their patients better. But instead, it is about how the medical profession makes itself and its performance better. Gawande classifies the methods he sees in several ways. First, there is diligence, doing right, and ingenuity. He explores these ideals while discussing the campaign to get doctors and nurses to wash their hands in hospitals, improving the field of obstetrics, saving the lives of more and more wounded soldiers, and improving life expectancy for people with cystic fibrosis. He emphasizes that improvement is possible, even with the tools and techniques we already have. We have to use them diligently, every day. It's not easy. At the end of the book, he has 5 suggestions for improving performance and generally making a difference in one's career. His audience is typically medical students, but these suggestions work for everyone:

1. Ask an unscripted question. In other words, get to know the people you are working with. They will mean more to you, and you will work with them better. It's just good for society, too.

2. Don't complain. Complaining drags us all down. I love to complain, so this is a hard one for me. But I also know that negative energy is infectious, and kill energy and creativity. But positive energy is also infectious. Neither he nor I am encouraging people to be chipper and annoying - just don't drag everybody down. Change the subject if necessary.

3. Count something. That I can do! Gawande's point is, find a question that interests you in your profession, and observe it. In order to improve performance, you need information on current performance, and also information on why current performance is what it is. So count something. Then give me the data and I will analyze it for you.

4. Write something. Gawande says you should show your writing to other people, write for an audience. I think that you can learn a lot about yourself and your profession through writing, even if no one else sees it. It helps to clarify thoughts.

5. Change. Don't be afraid to make changes when they are necessary.

Here is a quote that I like from the book, the essence of the book in one paragraph:

"Arriving at meaningful solutions is an inevitably slow and difficult process. Nonetheless, what I saw was: better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try."

Gawande is a good writer, and his essays are interesting individually. Despite what I might have indicated here, he does not preach. He provides examples and offers up the lessons he learned from them. And he writes about really interesting topics. In addition to the ones mentioned above, he writes about doctors who participate in executions, trying to innoculate 4.2 million children in 3 days in India with a polio vaccine, the difficult question of patients' dress (or lack thereof) during medical examinations, doctors' income, and the extreme and pedestrian steps that some surgeons must take every day to treat patients in public medical clinics in India. Interesting stuff, well-written, reads quickly. (less)

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Jun 26, 2007 Sanjay rated it 5 of 5 stars

With 'Complications', Boston-based surgeon and New Yorker writer Atul Gawande joined the ranks of Doctors Who Can Write. (Speaking of which, whatever happened to Abraham Verghese?)

In his next work, 'Better', Gawande continues his Montaigne-like ruminations on his profession. The essays here are centred on the theme of improving medical performance, and the book is structured around the three ways to do this: diligence, doing right and ingenuity.

In prose that’s limpid and affecting, Gawande walks...more

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Nov 16, 2012 Ensiform rated it 4 of 5 stars

Shelves: jobs, non-fiction

The author, a general surgeon, discusses some challenges and discoveries of the medical field, and what qualities it takes to improve performance. Drawing on the history of medicine and his own experiences, he investigates not only what makes improvement, but how it is implemented. For example, the simple act of hand-washing nearly removed the risk of “childbed fever,” an infection which killed newborns; but the successful implementation of hand-washing in an institution comes not by diktat but...more The author, a general surgeon, discusses some challenges and discoveries of the medical field, and what qualities it takes to improve performance. Drawing on the history of medicine and his own experiences, he investigates not only what makes improvement, but how it is implemented. For example, the simple act of hand-washing nearly removed the risk of “childbed fever,” an infection which killed newborns; but the successful implementation of hand-washing in an institution comes not by diktat but through spreading positive deviance – seeing where it has become acceptable and trumpeting those practices – hoping to turn the deviance into the norm by giving a voice to those already successful at it. He also writes of watching doctors in India campaign to eradicate polio, a gargantuan endeavor which works not through some miracle pill but through diligence, the simple but exhausting legwork of knocking on doors and spreading the word. He looks at innovation, such as Virginia Apgar’s eponymous test, which is so simple and so obvious, yet drastically improved infant survival rates simply by quantifying results and giving surgeons a number to beat. Or Watson Bowes, a doctor of obstetrics who also improved infant survival rates simply by treating premature babies as though he expected them to thrive. Gawande also discusses some other facets of medical culture, such as malpractice, wages, and lethal injection, but these – while interesting – are vaguer musings compared to the book’s overall arguments about the application of improvement.

It’s a compelling book, written in clear, assured, intelligent prose. Gawande posits that success comes not through science but mainly through performance (as with Indian doctors whom he witnessed perform surgeries in impoverished hospitals with very few instruments, make do with what they had and improvise where they could, but in no event just give up). This conclusion is both heartening and demoralizing, the former because it is so simple – merely expanding current know-how and following basic guidelines can improve survival rates dramatically – but it is also demoralizing because it raises the question of why these simple steps are not already being taken, and it makes us realize that our doctors are fallible, sometimes arrogant and stubborn, humans like the rest of us.(less)

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Dec 27, 2008 Ann rated it 5 of 5 stars Recommends it for: doctors, people who want to improve healthcare, improve processes, or be better in general

Shelves: medicine

A lot of improvements in healthcare can be attributed to tweaking processes, procedures, and organizations. Gawande addresses simple things like how to get hospital employees to wash their hands properly, and more global issues like the eradication of certain infectious diseases. Why are some cystic fibrosis centers so much more successful than others? How do we all become "better" at what we do? Ingenuity, education, and teamwork are all factors. Really interesting stuff.

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Jul 30, 2012 Michael rated it 4 of 5 stars

Shelves: non-fiction, memoir, medicine, essays

Takes the reader comfortably into the world of medicine's challenges under the theme of how efforts to improve performance can save a lot of lives. Like the good chef he proved to be in his earlier set of essays on his experience as a surgical resident, , "Complications", he again makes tasty and nutritious dishes out of a wide variety of ingredients. How has public health gotten so close to eradicating smallpox? How has the casualty death rate for American military medicine gone from about 20%...more

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Dec 14, 2008 Gail rated it 3 of 5 stars

Shelves: science

If I had to pick just one of Gawande's books to read, it would be Complications. But this is still a great collection of stories on fascinating fields of and issues related to medicine.

What I admire so much about Gawande is his ability to wrap his analytical mind so effortlessly around storytelling. His writing is conversational, straightforward and thoughtful. Medicine isn't a topic that would necessarily appeal to me, but with Gawande at the helm, it's fascinating.

In this book, his stories inc...more

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Nov 12, 2008 Patricia rated it 5 of 5 stars

Shelves: non-fiction

Atul Gwande's Better: A Surgeon's Notes on Performance is a collection of essays that probe skillfully and poignantly into the depths of medical ethics and the performance of doctors. He is a fine researcher and an astute observer who carefully delineates many facets of each issue that he explores, be it washing hands, malpractice concerns, or the Apgar score.

As a non-fiction writer, I was acutely aware of how adept Gawande is at using narrative to illustrate and discuss complex moral and ethica...more

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May 25, 2011 Emily rated it 4 of 5 stars

Shelves: non-fiction, meridian

Dr. Gawande is not afraid to take a hard look at his profession, its strengths, its weaknesses, and how to improve. In Better he addresses three general topics that he calls the “core requirements for success in medicine—or in any endeavor that involves risk and responsibility,” including diligence, “doing right” and ingenuity. Along the way, he explores medicine in some exotic locales from the battlefields of Iraq and Afghanistan to polio eradication efforts India, as well as potent ethical imp...more

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Jun 06, 2008 Raghu rated it 4 of 5 stars

This book by Dr.Atul Gawande is about ' performance' - about what it takes to grow from 'good' to better or great. Being a surgeon, the incidents relate to the practice of medicine. It is a fascinating and compassionate book and takes a very balanced view as he discusses diverse issues such as the ethics of doctors in administering lethal injections on people in death row, on the question of doctors being sued for making mistakes in doing a proper diagnosis on a patient which lead to life long n...more This book by Dr.Atul Gawande is about ' performance' - about what it takes to grow from 'good' to better or great. Being a surgeon, the incidents relate to the practice of medicine. It is a fascinating and compassionate book and takes a very balanced view as he discusses diverse issues such as the ethics of doctors in administering lethal injections on people in death row, on the question of doctors being sued for making mistakes in doing a proper diagnosis on a patient which lead to life long negative consequences for the patient, on the work of doctors at the war front as well as the challenges in the eradication of polio in poor nations such as India.
Dr.Gawande organizes his stories under three classifications namely, 'Diligence', 'Doing Right' and 'Ingenuity'. The discussion on doctors aiding the state in giving lethal injections to people on death row is very incisive and the author ultimately concludes that doctors must stand with their ethics code and not participate in executions. Something as ordinary as doctors and nurses 'washing their hands' in the hospitals during their work is discussed in historical detail and comes as a revelation as to how difficult it is to achieve 100% conformance in this simple act and as a result how patients could suffer grieviously. Another fine essay titled 'Naked' , discusses the delicate and fuzzy boundaries of male doctors doing pelvic, rectal or breast examinations on female patients. In another essay, he analyzes the dynamics of doctors being wronged at the hands of other doctors and the issues relating to such medical malpractice cases.
In all the essays, Dr.Gawande shows how seemingly simple issues are not so simple after all.
Finally, the author suggests that everyone can achieve 'better' by adopting a few principles like adopting a quantitative approach in work, by embracing change, by engaging patients through asking unscripted questions etc..
'Better' is an excellent book and its lessons apply to 'performance' in fields not only in medicine. Dr.Gawande writes with great clarity and simplicity and I enjoyed reading the book immensely.(less)

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Jan 14, 2008 Christy rated it 4 of 5 stars

I read a couple intriguing reviews of this book, and then I realized that I have been reading Gawande's pieces in The New Yorker for some time, which made me more intrigued. What finally tipped the scales was that one of our favorite bookstores was having a going-out-of-business sale and they had this book in stock. (I'll miss you, Liberty Books!)

Gawande is very skilled at writing for the layperson and putting an interesting face on medicine. In another person's hands, most of these topics could...more

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Jan 06, 2008 Amy rated it 4 of 5 stars

Complications by Atul Gawande made my top ten list last year, and I've had my eye on this book for awhile now. Since it is still only available in hardback I'd resigned myself to waiting until the paperback version came out, but I found it at the public library right before I left for the break and thought it might make a good airplane read.

I think Complications is still my favorite of the two, but I still thought Better was very interesting. It is a little like a collection of essays, although...more

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Oct 12, 2007 Cassie rated it 3 of 5 stars Recommends it for: doctors, patients, politicians

I really like Gawande's writing style, and for the most part feel like he gives a very rational, nuanced look at medical care in the US. The only exception to this is the essay "The Score." Although his main point in this essay, that a concrete, replicable measurement of baby health led to great improvements in infant mortality in the US, is well-taken, his description of the history of obstetric care and the near inevitability of an increasing c-section rate in the US is shockingly uninformed....more I really like Gawande's writing style, and for the most part feel like he gives a very rational, nuanced look at medical care in the US. The only exception to this is the essay "The Score." Although his main point in this essay, that a concrete, replicable measurement of baby health led to great improvements in infant mortality in the US, is well-taken, his description of the history of obstetric care and the near inevitability of an increasing c-section rate in the US is shockingly uninformed. Many modern industrialized nations have far better maternal and infant outcomes and far lower c-section rates in the US. The difference is not that in those countries doctors make extensive use of forceps instead of c-sections; the difference is that the system of care for laboring mothers depends heavily on the use of midwives. Obstetricians are only used as the exception, not the rule. (The Netherlands is the best example of this.) To say that the package of numerous unproven technological interventions in the physiological process of birth since 1940 have caused the "dramatic" improvements in the outcome statistics is totally unfounded; correlation is not causation. Gawande concludes that there's "no getting around C-sections":

"We have reached the point that, when there's any question of delivery risk, the Cesarean is what clinicians turn to—it's simply the most reliable option. If a mother is carrying a baby more than ten pounds in size, if she's had a C-section before, if the baby is lying sideways or in a breech position, if she has twins, if any number of potentially difficult situations for delivery arise, the standard of care requires that a midwife or an obstetrician at least offer a Cesarean section. Clinicians are increasingly reluctant to take a risk, however small, with natural childbirth....Putting so many mothers through surgery is hardly cause for celebration. But our deep-seated desire to limit risk to babies is the biggest force behind its prevalence; it is the price exacted by the reliability we aspire to."

This is simply not true! There is absolutely no positive correlation between increased c-sections and improved birth outcomes for moms and babies; in fact, there's a negative correlation. If Gawande had looked outside North America for information on this issue, he would not come to this absurd and harmful conclusion. It's really disappointing that someone as thoughtful as Gawande has not looked beyond the party line of doctors in this country on this unbelievably important issue.

If you have any interest in this issue, read Jennifer Block's brilliantly researched new book "Pushed."

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Sep 13, 2007 Cecelia rated it 3 of 5 stars

Shelves: medicine

I loved Atul Gawande's first book, Complications, so I was excited to get my hands on this one. I thought it was good, not great, but still makes some very thought-provoking arguments. It's written for the general public (he thoroughly explains all the medical details) but I think it would be of most interest to those with a vested interest in health care. The malpractice chapter was scary (at least for me) and the capital punishment chapter was a little confusing (not Gawande's writing, just th...more

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Dec 08, 2008 Jan rated it 4 of 5 stars

If Atul Gawande were a cobbler, he'd be writing for the New Yorker about how to make a better shoe. That's because Gawande is a storyteller and a craftsman. His essays appear deceptively simple and ingenuous, but it takes a great deal of art and craft to make them that way. No matter how earnest and idealistic a physician he may seem, he is actually a writer's writer.

That said, as a physician who left the profession, I am buoyed and reassured by Gawande's insights and exhortations. He gives me h...more

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Mar 27, 2009 Brian rated it 5 of 5 stars

An outstanding examination of medical malpractice, doctor compensation, and a defense of C-sections.

Dr. Atul Gawande is a 2nd generation doctor, son of a urologist. I decided to read this book after watching two excellent presentations at NIH, the Art of Failure, and the Science of Failure, where he discusses the errors doctors can make in the rush of healing.

The book doesn't focus solely on those issues, but looks at the whole of the healthcare system and how it might be made better. In each ch...more An outstanding examination of medical malpractice, doctor compensation, and a defense of C-sections.

Dr. Atul Gawande is a 2nd generation doctor, son of a urologist. I decided to read this book after watching two excellent presentations at NIH, the Art of Failure, and the Science of Failure, where he discusses the errors doctors can make in the rush of healing.

The book doesn't focus solely on those issues, but looks at the whole of the healthcare system and how it might be made better. In each chapter, he takes on a topic writes with heart about the problem, both from the perspective of a doctor and a patient. For instance, his chapter on medical malpractice and lawsuits, he switches from side to side to side, exploring the motivations of each, and the costs, justice, and consequences of our adversarial system. He writes: "98% of American families that are hurt by medical errors don't sue...Of those that do sue–~55k per year, most will lose...Fewer than 1/100 deserving families receive any money...And only the worst is brought out in all of us."

His chapter on medical fees "Piecework" describes another adversarial system, that of the insurance companies and the doctors as service providers. He explains that insurers block 30% of payments, and that a well run office might be able to get that down to 15% blocked payments, which explains the recent move of some practices to refuse all insurance.

A third excellent chapter is"The Score", which focuses on childbirth, cesarean section births, and the Apgar score. He gives an interesting history of human birthing, and the challenges that our big heads and narrow hips pose. Basically, "for thousands of years, childbirth was the most common cause of death for young women and infants." So much for "natural childbirth". In the past few hundred years, the main way of saving mothers and infants were hard to learn techniques of fetus-shifting and specialized forceps. He describes the origin of the Apgar score, and how it revolutionized obstetrics. More recently, C-sections have become the preferred solution to birth problems because they are simple to learn and are predictable. The older techniques were numerous, with one technique per problem. He asserts that in the near future, it may be likely that c-sections will be safe enough for uncomplicated pregnancies. He, like all of us, worries about the complete medicalization of birth.

I give this book my highest recommendation.(less)

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Feb 21, 2009 Brigitte rated it 4 of 5 stars

Shelves: memoir

The point of this book, as the title indicates, is to detail how to make the medical profession better, how to save more lives. Dr. Gawande makes a convensing argument that it is not research science that will accomplish this, but more diligent care of the mundane (but necessary) variety. He makes this point best when he talks of his experiences with the Indian health care system. It is easy for them to get expensive, cutting-edge equipment, yet they don't have enough basic supplies like scaples...more

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Mar 26, 2013 Paula rated it 4 of 5 stars

This is a great commentary on the American health system, and healthcare around the world. Its worth reading although there are many more problems brought to the forefront than solutions. In the authors defense, there really is no way..

How do you take the brightest, charge them a fortune to go to med school, require 10+ years training, then require them to run their own business while we sue their pants off the first time they might make a mistake, or might not make a mistake - but there is a de...more

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Mar 24, 2013 Michael rated it 4 of 5 stars · review of another edition

Shelves: nonfiction-reference

As usual for Gawande, full of fascinating observations both anecdotal and generalized. The stories are the draw here—the real-world examples of medicine interacting with people's lives, and how those interactions help doctors learn (and often—but not always—saves lives). As in the somewhat stronger Complications, the book is frequently moving thanks to how relentlessly humble Gawande is, and how he foregrounds the humanity of both patients and doctors. Gawande's work is full of statistics but is...more

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Mar 01, 2013 Daniel rated it 5 of 5 stars

Shelves: business-leadership

Atul Gawande shares several examples of how outcomes of medicine have improved and the general principles that allowed those fields of medicine and individual doctors to improve too. It's great writing: clear, concise, and moving, but its also great thinking (how to initiate and sustain improved performance). Because Atul Gawande is such a good writer and thinker, he is able to explain the general principles in such a way that they become applicable to any other field.

My two favorite parts: The...more

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Feb 17, 2013 Marco rated it 5 of 5 stars

Shelves: favorites, medical

I love this book so much! It gives such a great insight into what it is like to be a doctor. And not just any doctor. It recounts the tales of surgeons working in Iraq, struggling to save the lives of soldiers on the battlefield, along with doctors that work hard to contain polio outbreaks in India by vaccinations, a feat that is nigh impossible when an efficient national health service just doesn't exist, as well as surgeons working in wards, both in the past, and in the present.

I didn't really...more

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Nov 24, 2012 Lightreads rated it 4 of 5 stars

Shelves: collected-nonfiction, nonfiction

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 no...more 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.
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Oct 29, 2012 Francis Fish rated it 5 of 5 stars

Shelves: thought-provoking

This book is an easy read but very thought provoking.

One of the most interesting bits was where he examines the difference between the average Cystic Fibrosis centres and the best ones. All human activity has a bell curve attached to it, but CF treatment is very well understood and systematic. So why does one centre have startlingly better results than another?

In essence the better centre didn't compromise, they didn't think that (for example) 80% lung function was good enough, the patients unde...more This book is an easy read but very thought provoking.

One of the most interesting bits was where he examines the difference between the average Cystic Fibrosis centres and the best ones. All human activity has a bell curve attached to it, but CF treatment is very well understood and systematic. So why does one centre have startlingly better results than another?

In essence the better centre didn't compromise, they didn't think that (for example) 80% lung function was good enough, the patients under their care were expected to have 100% or better.

It's the difference between 99.99% and 99.5% - we'd all be happy with 99.5, but excellence is in the remaining fraction of a percent, because when you add this up over several years this tiny difference means a lot. The sums are simple 99.5 over 5 years will give 97%, 99.99 will still be 99.99 or thereabouts. If you take this up over a patient's life of 30 or 50 years the difference would be even more apparent.

I've hit this in other walks of life, for example project management, where you maybe have a 0.9 chance of finishing on time every iteration. This means that the chances of still being on track are as low as 0.6 after 5 iterations - it's just mathematics. When building software having a fire break every so often to deal down the technical debt and reset the projects is perfectly doable, but if you're looking for excellence in medical care or some other industry that could kill people then you have to become fanatical about getting higher scores

There are plenty of other excellent articles in the book, the fight to eradicate polio and the crazy situation faced by doctors in India are really great articles, and I learned a lot about how we could really help the people in poor countries. I admire Gawande's honesty about his own shortcomings, this gives the writing a validity that it would otherwise lack. And the nutty unjust system that is the law based compensation for medical errors, that wrecks the chances of the poor to get help and helps no-one but the lawyers.(less)

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Apr 21, 2012 Dave rated it 3 of 5 stars

Not quite as good as "Complications", as chapters on insurance and the death penalty go nowhere, but still very much worth the read beyond that as Gawande does an excellent job reviewing the absolute necessity of frequent hand-washing, the enormous task of attempting to finally eliminate polio, the evolution of birth and how it is now orders of magnitude safer than just a century ago, and most powerfully a chapter on cystic fibrosis. A genetic disease that strikes ~1000 American children per yea...more

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Dec 22, 2011 Josh Paul rated it 4 of 5 stars

Shelves: non-fiction

I went into reading Better with a healthy antipathy towards the medical profession, and while I retain that attitude I was impressed Gawande personally.

Much of the book is essentially a defense of what might be called "boring virtues." These are things like diligence, and persistence and Gawande argues that they are among the most important factors in succeeding as a doctor (or just about anything else). This is the hospital as McDonald's view - the difference is that instead of grinding out (in...more

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Nov 26, 2011 Shauna rated it 4 of 5 stars

Shelves: non-fiction

A good presentation of humans in the art of medicine. There are things that medicine must change and only through sharing these stories will society as a whole help us answer them. Favorite quotes:

“To do right: I puzzle over how we know when we should keep fighting for a sick patient and when we should stop.”

"But if mortality is low, the human cost remains high. The airman lost one leg above the knee, the other at the hip, his right hand, and part of his face. How he and others like him will be...more

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Sep 02, 2011 Amy rated it 3 of 5 stars

Better is the second book written by Atul Gawande, a general surgeon in Boston. His goal for this book was, by giving different scenarios, to explain how the medical system could be better. Gawande explains how the simple act of a doctor washing his hands can prevent the spread of disease within a hospital, how countries like India combat outbreaks of polio, and how doctors and nurses today are faced with the ethical question of participating in lethal injections for those on death row.

His stori...more

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Jul 08, 2011 A. rated it 4 of 5 stars

This is a pretty good book if you like to read about medicine. He discusses many different situations he has been in as a surgeon. I am amazed at how much he has seen and done. The dilemnas he discusses are primarily how far to go to save a life. He talks about quality of a person's life. For example if you are in a war situation and lose limbs what will your quality of life actually be once your life is saved? Or if you are battling cancer is it worth a year of discomfort even if you die at the...more

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May 19, 2011 Barbara rated it 5 of 5 stars

Shelves: non-fiction, medicine

This is essentially, a book on performance - what impacts it, what its consequences are, and options for improving it. Since the author is a surgeon, the examples given are drawn from medicine, but the messages are loud and clear for everyone. The first section is devoted to diligence and the difference that attention to detail can make in halting the spread of infection, containing the threatened resurgence of a nearly eradicated disease, or improving the survival chances for military personnel...more

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About Atul Gawande

Atul Gawande is a general and endocrine surgeon at Brigham and Women's Hospital in Boston, Massachusetts, and associate director of their Center for Surgery and Public Health. He is also an assistant professor at the Harvard School of Public Health and an assistant professor of surgery at Harvard Medical School.

http://us.macmillan.com/author/atulga...

More about Atul Gawande...

Books by Atul Gawande

Complications: A Surgeon's Notes on an Imperfect Science

The Checklist Manifesto: How to Get Things Right

A Mão que nos Opera: Confissões de um Cirurgião Sobre Uma Ciência Imperfeita

Scoot Over, Skinny: The Fat Nonfiction Anthology

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“better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.” — 43 people liked it

“We always hope for the easy fix: the one simple change that will erase a problem in a stroke. But few things in life work this way. Instead, success requires making a hundred small steps go right - one after the other, no slipups, no goofs, everyone pitching in.” — 26 people liked it

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