Better: A Surgeon's Notes on Performance

by Atul Gawande

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.

Betterment is a perpetual labor. The world is chaotic, disorganized, and vexing, and medicine is nowhere spared that reality.

When you make an effort, you find sometimes you are not the only one willing to do so.

Each year, according to the U.S. Centers for Disease Control, two million Americans acquire an infection while they are in the hospital. Ninety thousand die of that infection.

Stopping the epidemics spreading in our hospitals is not a problem of ignorance—of not having the know-how about what to do. It is a problem of compliance—a failure of an individual to apply that know-how correctly. But achieving compliance is hard.

He made each hospital room work more like an operating room, in otherwords. He also arranged for a nasal culture to be taken from every patient upon admission, whether the patient seemed infected or not. That way the staff knew which patients carried resistant bacteria and could preemptively use more stringent precautions for them—“search-and-destroy” the strategy is sometimes called. Infection rates for MRSA—the hospital contagion responsible for more deaths than any other—fell almost 90 percent, from four to six infections per month to about that many in an entire year.

Understood, however, as the prerequisite of great accomplishment, diligence stands as one of the most difficult challenges facing any group of people who take on tasks of risk and consequence. It sets a high, seemingly impossible, expectation for performance and human behavior.

The striking thing is that WHO doesn’t really have the authority to do any of this. It can’t tell governments what to do. It hires no vaccinators, distributes no vaccine. It is a small Geneva bureaucracy run by several hundred international delegates whose annual votes tell the organization what to do but not how to do it. In India, a nation of a billion people, WHO employs 250 physicians around the country to work on polio monitoring. The only substantial resource that WHO has cultivated is information and expertise. I didn’t understand how this could suffice. Then I went to Karnataka.

Just to stay caught up, a mammoth campaign to immunize every child under the age of five has to be planned each year. The truth is, no cost-benefit calculus can assure us just now that the money is well spent. Yet for all these reservations, the campaign has averted an estimated five million cases of paralytic polio thus far—a momentous achievement in itself.

By the end of the mop-up, UNICEF officials had distributed more than five million doses of fresh vaccine through the thirteen districts. Television, radio, and local newspapers had been blanketed with public service announcements. Rotary of India had printed and delivered 25,000 banners, 6,000 posters, and more than 650,000 handbills. And 4 million of the targeted 4.2 million children had been successfully vaccinated. In 2005, India had just sixty-six new cases of polio.

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

Babies who were born malformed or too small or just blue and not breathing well were listed as stillborn, placed out of sight, and left to die. They were believed to be too sick to live. Apgar believed otherwise, but she had no authority to challenge the conventions. She was not an obstetrician, and she was a female in a male world. So she took a less direct but ultimately more powerful approach: she devised a score. The Apgar score, as it became universally known, allowed nurses to rate the condition of babies at birth on a scale from zero to ten. An infant got two points if it was pink all over, two for crying, two for taking good, vigorous breaths, two for moving all four limbs, and two if its heart rate was over a hundred. Ten points meant a child born in perfect condition. Four points or less meant a blue, limp baby.

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

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.