Better: A Surgeon's Notes on Performance

by Atul Gawande

Peoples was known in training for three things: his unflappability, his intellect (he had published seventeen papers on work toward a breast cancer vaccine before he finished his training), and the five children he and his wife had during his residency.

I admire this man’s work ethic

But then I remember those surgeons in Baghdad in the dark hours at their PCs. Knowing their results was so important to them that they skipped sleep to gather the data. They understood that such vigilance over the details of their own performance—the same kind of vigilance practiced by WHO physicians working to eradicate polio from the world and the Pittsburgh VA hospital units seeking to eliminate hospital infections—offered the only chance to do better.

she didn’t think anything of it. He was, as she put it, “forever going to school.” One year, he took English literature classes at a local college. Another year, he took classes in Judaism. He took pilot lessons and before long was entering airplane aerobatics competitions. Law school, too, began as another pastime—“It was just for kicks,” he said. After he finished, though, he took

It’s like driving a car, he explained—I could have a perfect driving record, but if one day I run a red light and hit a child, then I am negligent, he said.

Lets remove humans from driving

Doctors quickly learn that how much they make has little to do with how good they are. It largely depends on how they handle the business side of their practice.

They must hire office personnel to deal with the insurance companies. A well-run office can get the insurer’s rejection rate down from 30 percent to, say, 15 percent. That’s how a doctor earns money, she told me. It’s a war with insurance, every step of the way.

And they discovered that the vast majority of these premature babies, babies only two or three pounds in size, could survive to be normal and healthy—just by the doctors’ fighting for them.

The seemingly easiest and most sensible rule for a doctor to follow is: Always Fight. Always look for what more you could do. I am sympathetic to this rule. It gives us our best chance of avoiding the worst error of all—giving up on someone we could have helped.

Rourke called her obstetrician’s office at 8:30, when the phones were turned on, but she knew what the people there were going to say: Don’t come to the hospital until the contractions are five minutes apart and last at least a minute.

She had considered hiring a doula—a birthing coach—to stay with her through delivery. There are studies showing that having a doula can lower the likelihood a mother will end up with a Cesarean section or an epidural.

The process is a solution to an evolutionary problem: how a mammal can walk upright, which requires a small, fixed, bony pelvis, and also possess a large brain, which entails a baby whose head is too big to fit through that small pelvis. Part of the solution is that, in a sense, all human mothers give birth prematurely. Other mammals are born mature enough to walk and seek food within hours; our newborns are small and helpless for months.

(The name “Cesarean” section may have arisen from the tale that Caesar was born of his mother, Aurelia, by an abdominal delivery, but historians regard the story as a myth, since Aurelia lived long after his birth.)

“Do what is right and do it now,” she used to say.

“As a professor, you have to be a role model. You don’t want to be the cowboy who goes in to do something that your residents are not going to be able to do,” he told me.

To fix medicine, Berwick maintained, we need to do two things: measure ourselves and be more open about what we are doing.

“Sum it up over a year, and it is the difference between an 83 percent chance of making it through [the year] without getting sick and only a 16 percent chance.” He turned to Janelle. “How do you stay well all your life? How do you become a geriatric patient?” he asked her. Her foot finally stopped tapping. “I can’t promise you anything. I can only tell you the odds.” In this short speech, I realized, was the core of Warwick’s worldview. He believed that excellence came from seeing, on a daily basis, the difference between being 99.5 percent successful and being 99.95 percent successful.

Even doctors with great knowledge and technical skill can have mediocre results; more nebulous factors like aggressiveness and diligence and ingenuity can matter enormously.

“You look at the rates of improvement in different quartiles, and it’s the centers in the top quartile that are improving fastest,” Marshall says. “They are at risk of breaking away.” What the best may have, above all, is a capacity to learn and change—and to do so faster than everyone else.

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

What is troubling is not just being average but settling for it.

More than one doctor told me that it was easier to get a new MRI machine than to maintain basic supplies and hygiene.

Each day I was there, the surgeons found time between cases to take a brief late-afternoon break at a café across the street from the hospital. For fifteen or thirty minutes, they drank chai and swapped stories about their cases of the day—what they had done and how. Just this interaction seemed to prod them to aim higher than merely getting through the day. They came to feel they could do anything they set their minds to. Indeed, they believed not only that they were part of the larger world but also that they could contribute to it.

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.

MY FOURTH SUGGESTION was: Write something. I do not mean this to be an intimidating suggestion. It makes no difference whether you write five paragraphs for a blog, a paper for a professional journal, or a poem for a reading group. Just write. What you write need not achieve perfection. It need only add some small observation about your world.

You should also not underestimate the power of the act of writing itself. I did not write until I became a doctor. But once I became a doctor, I found I needed to write. For all its complexity, medicine is more physically than intellectually taxing. Because medicine is a retail enterprise, because doctors provide their services to one person after another, it can be a grind. You can lose your larger sense of purpose. But 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.

Viagra, it was recently discovered, may cause partial vision loss.

Nonetheless, make yourself an early adopter. Look for the opportunity to change. I am not saying you should embrace every new trend that comes along. But be willing to recognize the inadequacies in what you do and to seek out solutions. As successful as medicine is, it remains replete with uncertainties and failure. This is what makes it human, at times painful, and also so worthwhile.

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.