Better: A Surgeon's Notes on Performance

by Atul Gawande

Except, of course, there is. What is troubling is not just being average but settling for it. Everyone knows that average-ness is, for most of us, our fate. And in certain matters—looks, money, tennis—we would do well to accept this. But in your surgeon, your child’s pediatrician, your police department, your local high school? When the stakes are our lives and the lives of our children, we want no one to settle for average.

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Nonetheless, studies consistently show that more regular use of this one technology alone would reduce deaths from breast cancer by one-third. This is just one example of what improving performance in medicine could achieve.

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went with his kidney stones. The Nanded hospital, however, is the lone public hospital serving a district of 1,400 villages like Uti, a population of 2.3 million people. It has five hundred beds, three main operating rooms, and, I found when I visited, just nine general surgeons. (Imagine Kansas with just nine surgeons.)

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Then he would speak in a slow and quiet way that made one listen carefully to hear him. He could be brusque at times. But he did what he could to give everyone at least a few moments of individual attention. With no time for

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The health care system, however, was not built to manage such illnesses—it was designed primarily for infectious disease. The Indian government’s annual health care budget of just four dollars per person is woefully little for infectious disease—and impossibly inadequate for something like a heart attack. Improving nutrition, immunization, and sanitation remains a deserved priority. Yet the tide of people needing surgery and other kinds of specialized care does not stop. At least 50 of the 250-some patients seen by the surgeons in Nanded that morning turned out to need an operation. The hospital had operating rooms and staff, however, for only fifteen such operations per day. Everyone else had to wait.

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fluid with a needle, but the fluid was infected and too thick for the needle. We needed to put in a chest tube. But chest tubes—cheap and basic implements—were out of stock. So the resident handed the man’s brother a prescription for one, and he ran out into the sweltering night to find a medical store that could supply it. Unbelievably, ten minutes later he came back with one in hand, a 28 French straight chest tube, exactly what we needed. Shortages of supplies are so common that around any hospital in India you will find rows of ramshackle stands with vendors selling everything from medications to pacemakers.

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illnesses. And what’s required is rational, reliable organization as much as resources. For surgeons in India, both are in short supply.

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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.

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