Better: A Surgeon's Notes on Performance

by Atul Gawande

In this work against sickness, we begin not with genetic or cellular interactions, but with human ones. They are what make medicine so complex and fascinating. How each interaction is negotiated can determine whether a doctor is trusted, whether a patient is heard, whether the right diagnosis is made, the right treatment given. But in this realm there are no perfect formulas.

THE PARADOX AT the heart of medical care is that it works so well, and yet never well enough. It routinely gives people years of health that they otherwise wouldn’t have had. Death rates from heart disease have plummeted by almost two-thirds since the 1950s. Risk of death from stroke has fallen more than 80 percent. The cancer survival rate is now 70 percent. But these advances have required drugs and machines and operations and, most of all, decisions that can as easily damage people as save them. It’s precisely because of our enormous success that people are bound to wonder what went wrong when we fail.

One American in seven has no coverage, and one in three younger than sixty-five will lose coverage at some point in the next two years. These are people who aren’t poor or old enough to qualify for government programs but whose jobs aren’t good enough to provide benefits, either. They face difficulty finding doctors who will treat them, unconscionable rates of bankruptcy from health care bills, and a proven increased likelihood that problems such as high blood pressure, heart disease, appendicitis, and cancer will go undetected or inadequately treated. Our byzantine insurance system leaves gaps at every turn. Some day soon that must change.

Execution has become a medical procedure in the United States.

There are vital but sometimes murky differences between acting skillfully, acting lawfully, and acting ethically.

Medicine is being made an instrument of punishment. The hand of comfort that more gently places the IV, more carefully times the bolus of potassium, is also the hand of death. We cannot escape this truth.

It is far from clear that a society that punishes its most evil murderers with life imprisonment is worse off than one that punishes them with death. But a society in which the government actively subverts core ethical principles of medical practice is patently worse off for it.

In medicine, we face conflicts about what the right and best actions are in all kinds of areas: relief of suffering for the terminally ill, provision of narcotics for patients with chronic pain, withdrawal of life-sustaining treatment for the critically ill, abortion, and executions, to name just a few. All have been the subject of professional rules and government regulation, and at times those rules and regulations have been and will be wrong. We may then be called on to make a choice. We must do our best to choose intelligently and wisely.

the hardest part of being a doctor, I have found, is to know what you have power over and what you don’t.

We have at our disposal today the remarkable abilities of modern medicine. Learning to use them is difficult enough. But understanding their limits is the most difficult task of all.

Analysts often note how ridiculous it is that we spend more than a quarter of public health care dollars on the last six months of life. Perhaps we could spare this fruitless spending—if only we knew when people’s last six months would be.

What the best may have, above all, is a capacity to learn and change—and to do so faster than everyone else.

ONCE WE ACKNOWLEDGE that, no matter how much we improve our average, the bell curve isn’t going away, we’re left with all sorts of questions. Will being in the bottom half be used against doctors? Will we be expected to tell our patients how we score? Will patients leave us? Will those at the bottom be paid less than those at the top? The answer to all these questions is likely yes.

We in medicine are not the only ones being graded nowadays. Firefighters, CEOs, and salesmen are. Even teachers are being graded, and, in some places, being paid accordingly. Yet we all feel uneasy about being judged by such grades. They never seem to measure the right things. They don’t take into account circumstances beyond our control. They are misused; they are unfair. Still, the simple facts remain: there is a bell curve in all human activities, and the differences you measure usually matter.

The hardest question for anyone who takes responsibility for what he or she does is, What if I turn out to be average?

If the bell curve is a fact, then so is the reality that most doctors are going to be average. There is no shame in being one of them, right? Except, of course, there is. What is troubling is not just being average but settling for it.

Indeed, the scientific effort to improve performance in medicine—an effort that at present gets only a miniscule portion of scientific budgets—can arguably save more lives in the next decade than bench science, more lives than research on the genome, stem cell therapy, cancer vaccines, and all the other laboratory work we hear about in the news. The stakes could not be higher.

True success in medicine is not easy. It requires will, attention to detail, and creativity. But the lesson I took from India was that it is possible anywhere and by anyone. I can imagine few places with more difficult conditions. Yet astonishing successes could be found. And each one began, I noticed, remarkably simply: with a readiness to recognize problems and a determination to remedy them. 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.

The choices a doctor makes are necessarily imperfect but they alter people’s lives. Because of that reality, it often seems safest to do what everyone else is doing—to be just another white-coated cog in the machine. But a doctor must not let that happen—nor should anyone who takes on risk and responsibility in society. So find something new to try, something to change. Count how often you succeed and how often you fail. Write about it. Ask people what they think. See if you can keep the conversation going.