Better: A Surgeon's Notes on Performance

by Atul Gawande

three core requirements for success in medicine—or in any endeavor that involves risk and responsibility. The first is diligence, the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles.

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The second challenge is to do right. Medicine is a fundamentally human profession. It is therefore forever troubled by human failings, failings like avarice, arrogance, insecurity, misunderstanding.

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The third requirement for success is ingenuity—thinking anew. Ingenuity is often misunderstood. It is not a matter of superior intelligence but of character. It demands more than anything a willingness to recognize failure, to not paper over the cracks, and to change. It arises from deliberate, even obsessive, reflection on failure and a constant searching for new solutions.

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Malpractice attorneys are hardly the most impartial assessors of care, but medicine has offered no genuine alternative—because we physicians are generally unwilling to be held financially responsible for the consequences of our mistakes. Indeed, the one argument that has persuaded many doctors to be more forthright about mistakes is that doing so might make patients less likely to sue.

At a conference in December 1999, Berwick gave a forty-minute speech distilling his ideas about the failings of American health care. Years afterward, people are still talking about the speech.

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a 1949 Montana forest fire that engulfed a parachute brigade of firefighters. Panicking, they ran, trying to make it up a 76 percent grade and over a crest to safety. But their commander, a man named Wag Dodge, saw that their plan wasn’t going to work. So he stopped, took out some matches, and set the tall dry grass ahead of him on fire. The new blaze caught and rapidly spread up the slope. He stepped into the middle of the burned-out area it left behind, lay down, and called out to his crew to join him. He had invented, on the spot, what came to be called an “escape fire,” and it later became a standard part of Forest Service fire training. His men, however, either thought he was crazy or never heard his calls, and they ran past him. All but two were caught by the inferno and perished. Inside his escape fire, Dodge survived virtually unharmed. As Berwick explained, the firefighters’ organization had unraveled. The men had lost their ability to think coherently, to act together, to recognize that a lifesaving idea might be possible. This is what happens to all flawed organizations in a disaster,

writing lets you step back and think through a problem. Even the angriest rant forces the writer to achieve a degree of thoughtfulness. Most of all, by offering your reflections to an audience, even a small one, you make yourself part of a larger world. Put a few thoughts on a topic in just a newsletter, and you find yourself wondering nervously: Will people notice it? What will they think? Did I say something dumb? An audience is a community. The published word is a declaration of membership in that community and also of a willingness to contribute something meaningful to it. So choose your audience. Write something.