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Better: A Surgeon's Notes on Performance
The struggle to perform well is universal: each one of us faces fatigue, limited resources, and imperfect abilities in whatever we do. But nowhere is this drive to do better more important than in medicine, where lives are on the line with every decision. In his new book, Atul Gawande explores how doctors strive to close the gap between best intentions and best performance in the face of obstacles that sometimes seem insurmountable. Gawande's gripping stories of diligence, ingenuity, and what it means to do right by people take us to battlefield surgical tents in Iraq, to labor and delivery rooms in Boston, to a polio outbreak in India, and to malpractice courtrooms around the country. He discusses the ethical dilemmas of doctors participation in lethal injections, examines the influence of money on modern medicine, and recounts the astoundingly contentious history of hand washing. And as in all his writing, Gawande gives us an inside look at his own life as a practicing surgeon, offering a searingly honest firsthand account of work in a field where mistakes are both unavoidable and unthinkable. At once unflinching and compassionate, Better is an exhilarating journey narrated by arguably the best nonfiction doctor-writer around (Salon). Gawande's investigation into medical professionals and how they progress from merely good to great provides rare insight into the elements of success, illuminating every area of human endeavor.
288 pages, Hardcover
First published April 3, 2007
1,920 people are currently reading
37.2k people want to read
About the author
Atul Gawande
31books5,781followersAtul Atmaram Gawande is an American surgeon, writer, and public health researcher. He practices general and endocrine surgery at Brigham and Women's Hospital in Boston, Massachusetts. He is a professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health and the Samuel O. Thier Professor of Surgery at Harvard Medical School. In public health, he was the chairman of Ariadne Labs, a joint center for health systems innovation, and chairman of Lifebox, a nonprofit that works on reducing deaths in surgery globally. On June 20, 2018, Gawande was named the CEO of healthcare venture Haven, owned by Amazon, Berkshire Hathaway, and JP Morgan Chase and stepped down as CEO in May 2020, remaining as executive chairman while the organization sought a new CEO.
He is the author of the books Complications: A Surgeon's Notes on an Imperfect Science; Better: A Surgeon's Notes on Performance; The Checklist Manifesto; and Being Mortal: Medicine and What Matters in the End.
On November 9, 2020, he was named a member of President-elect Joe Biden's COVID-19 Advisory Board. On December 17, 2021, he was confirmed as the Assistant Administrator of the United States Agency for International Development, and he was sworn in on January 4, 2022.
He is the author of the books Complications: A Surgeon's Notes on an Imperfect Science; Better: A Surgeon's Notes on Performance; The Checklist Manifesto; and Being Mortal: Medicine and What Matters in the End.
On November 9, 2020, he was named a member of President-elect Joe Biden's COVID-19 Advisory Board. On December 17, 2021, he was confirmed as the Assistant Administrator of the United States Agency for International Development, and he was sworn in on January 4, 2022.
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November 24, 2012
I have had a lot of doctors in my life. The best one I ever had was the surgeon who failed. Before I went under, he told me it would take about 2 hours and had an 85% success rate. When I woke up, nearly five hours had passed, I was in far more pain than I had been led to expect, and he was waiting to tell me that I was in the 15%, that he hadn’t saved my eye, and that he would be ready to talk to me as soon as I was back on my feet.
When he retired several years later, I wrote him a thank you note. Because he did his best, and it wasn’t enough, and he knew it, and he told me so honestly and in great detail as many times as I needed to hear it, and he held his office trash can for me to throw up in, and he waived thousands of dollars in bills so he could keep seeing me when I was in law school with the horrible useless insurance, and he cared whether I was having a good life. A surgeon � can you imagine?
This book isn’t really about that sort of failure, the kind where current technology and understanding isn’t enough. It’s about designing behavioral triggers to save lives by increasing compliance with hand-washing drills, and it’s about the massive manpower efforts necessary to eliminate infectious diseases from the world, and it’s about what a patient is owed after a failure of any kind. It struck a huge cord with me, because one of the things that medicine and the practice of law at my level have in common is an expectation of a 0% error rate. Seriously � I am explicitly and implicitly told on a daily basis that anything less than perfection is failure. There are no stupid slip-ups, and there are no impossible situations that no one could solve.
Which has nothing to do with reality, of course. Learning to live under these conditions is, uh, let’s call it emotionally taxing and leave it at that. Anyone who has ever been through a medical residency is probably nodding right now.
So I thought this book � I got there! � was great. Not just for the case studies of Polio outbreaks and third-world surgery, though they’re pretty interesting. But because this book is thinking specifically about that. About the difference between an expectation of infallible perfection, and the seldom-acknowledged reality that our brains are imperfect and even the very best of us sometimes aren’t good enough. “When someone has come to you for your expertise, and your expertise has failed, what do you have left? You have only your character to fall back upon, and sometimes it’s only your pride that comes through.� Succinctly put, and so very true. Ask me about something I fucked up this past summer sometime, and how the surgeon who failed was on my mind in the aftermath, when all I had left to do was take it the best I could.
Anyway, rambling. I was intellectually engaged here on multiple levels, the way you are when you’re always thinking and reacting, even when it isn’t always good. Insert a whole rebuttal essay here on Gawande’s ablism in the section on improved rates of survival for devastating combat injuries and all his musing on whether life with this and that disability is actually “worth living,� whatever the fuck that is supposed to mean. Scrub that, I know exactly what that’s supposed to mean, and I think it’s crap. Also, the business of the disabled person in question, not an able-bodied columnist for The New Yorker. /snide.
And insert a whole other essay on the execution section, and how Gawande and I have differing opinions on the death penalty � he is for it and I am not � but how fascinating it was that when presented with the ethical dilemma of doctor participation in executions, he concluded that if executions cannot be conducted safely without doctors they shouldn’t happen, and I concluded doctors should be permitted to compromise their oaths.
Engaged, like I said.
When he retired several years later, I wrote him a thank you note. Because he did his best, and it wasn’t enough, and he knew it, and he told me so honestly and in great detail as many times as I needed to hear it, and he held his office trash can for me to throw up in, and he waived thousands of dollars in bills so he could keep seeing me when I was in law school with the horrible useless insurance, and he cared whether I was having a good life. A surgeon � can you imagine?
This book isn’t really about that sort of failure, the kind where current technology and understanding isn’t enough. It’s about designing behavioral triggers to save lives by increasing compliance with hand-washing drills, and it’s about the massive manpower efforts necessary to eliminate infectious diseases from the world, and it’s about what a patient is owed after a failure of any kind. It struck a huge cord with me, because one of the things that medicine and the practice of law at my level have in common is an expectation of a 0% error rate. Seriously � I am explicitly and implicitly told on a daily basis that anything less than perfection is failure. There are no stupid slip-ups, and there are no impossible situations that no one could solve.
Which has nothing to do with reality, of course. Learning to live under these conditions is, uh, let’s call it emotionally taxing and leave it at that. Anyone who has ever been through a medical residency is probably nodding right now.
So I thought this book � I got there! � was great. Not just for the case studies of Polio outbreaks and third-world surgery, though they’re pretty interesting. But because this book is thinking specifically about that. About the difference between an expectation of infallible perfection, and the seldom-acknowledged reality that our brains are imperfect and even the very best of us sometimes aren’t good enough. “When someone has come to you for your expertise, and your expertise has failed, what do you have left? You have only your character to fall back upon, and sometimes it’s only your pride that comes through.� Succinctly put, and so very true. Ask me about something I fucked up this past summer sometime, and how the surgeon who failed was on my mind in the aftermath, when all I had left to do was take it the best I could.
Anyway, rambling. I was intellectually engaged here on multiple levels, the way you are when you’re always thinking and reacting, even when it isn’t always good. Insert a whole rebuttal essay here on Gawande’s ablism in the section on improved rates of survival for devastating combat injuries and all his musing on whether life with this and that disability is actually “worth living,� whatever the fuck that is supposed to mean. Scrub that, I know exactly what that’s supposed to mean, and I think it’s crap. Also, the business of the disabled person in question, not an able-bodied columnist for The New Yorker. /snide.
And insert a whole other essay on the execution section, and how Gawande and I have differing opinions on the death penalty � he is for it and I am not � but how fascinating it was that when presented with the ethical dilemma of doctor participation in executions, he concluded that if executions cannot be conducted safely without doctors they shouldn’t happen, and I concluded doctors should be permitted to compromise their oaths.
Engaged, like I said.
December 4, 2013
Not nearly as good as his first, in a number of ways.
What made so exhilarating was that we were learning about being a doctor just as Gawande was learning about being a doctor. Literally: he wrote most of those essays while still a resident. The humility this brought to Gawande's essays makes all the difference. We were forced to consider the ethical implications of a healthcare system that has to deploy inexperienced doctors so that they can be trained and become better doctors. Crucially, we did so, or were introduced to this problem, because the author brought us into his very first OR and lets us see his own anxiety at being one of these inexperienced doctors.
Not anymore. Now we have Atul Gawande, investigative reporter extraordinaire. He cruises around the world, looking for interesting stories about medicine, which are told fine, but they are not personal. And, in that increasingly infuriating New Yorker way, the piece becomes as much about the author as the story: "Blah blah blah," he told me in an email; or, "I went to see him in his office. He was wearing a purple shirt, green pants, and a top hat." Which, again, was fine when we really seemed to be looking out from Gawande's wide eyes.
A consequence of this is that the book promotes a very odd and simplistic message. As you can tell from the title, it's about Doing Better, but the three divisions--the three ways we are told we can do better--are Diligence, Doing Right, and Ingenuity. True enough--but do I need an MD to tell me this? More unfortunately, potentially revelatory stories about, say, containing a polio outbreak in Africa become bookended and framed as stories about Diligence. Maybe, but that the docs are Diligent is the least interesting thing you can say about that story.
This sort of oversimplification worried me from the introduction. It sounded like Malcolm Gladwell's doing, I thought, and I don't like Gladwell, whose M.O. is to oversimplify things and categorize them into Big Themes, often to the point of getting them wrong (see his piece on Enron). And lo! in the acknowledgments, Gawande says he has become best friends with Gladwell. Another great topic ruined by the frizzy-haired Canadian.
What made so exhilarating was that we were learning about being a doctor just as Gawande was learning about being a doctor. Literally: he wrote most of those essays while still a resident. The humility this brought to Gawande's essays makes all the difference. We were forced to consider the ethical implications of a healthcare system that has to deploy inexperienced doctors so that they can be trained and become better doctors. Crucially, we did so, or were introduced to this problem, because the author brought us into his very first OR and lets us see his own anxiety at being one of these inexperienced doctors.
Not anymore. Now we have Atul Gawande, investigative reporter extraordinaire. He cruises around the world, looking for interesting stories about medicine, which are told fine, but they are not personal. And, in that increasingly infuriating New Yorker way, the piece becomes as much about the author as the story: "Blah blah blah," he told me in an email; or, "I went to see him in his office. He was wearing a purple shirt, green pants, and a top hat." Which, again, was fine when we really seemed to be looking out from Gawande's wide eyes.
A consequence of this is that the book promotes a very odd and simplistic message. As you can tell from the title, it's about Doing Better, but the three divisions--the three ways we are told we can do better--are Diligence, Doing Right, and Ingenuity. True enough--but do I need an MD to tell me this? More unfortunately, potentially revelatory stories about, say, containing a polio outbreak in Africa become bookended and framed as stories about Diligence. Maybe, but that the docs are Diligent is the least interesting thing you can say about that story.
This sort of oversimplification worried me from the introduction. It sounded like Malcolm Gladwell's doing, I thought, and I don't like Gladwell, whose M.O. is to oversimplify things and categorize them into Big Themes, often to the point of getting them wrong (see his piece on Enron). And lo! in the acknowledgments, Gawande says he has become best friends with Gladwell. Another great topic ruined by the frizzy-haired Canadian.
June 15, 2016
This is my 4th book by Gawande. It's good, very similar to most of the rest. His best so far has been , but the rest are well worth listening to. I'm listing the TOC below & will try to note anything of significant interest. It's all interesting, though.
Introduction Doctors are human, but are held to very high standards & often fail to meet them. No surprises.
-- pt. 1.
Diligence - Keep on trying to do everything exactly right.
On washing hands - It's incredibly easy to transfer deadly diseases between patients. A clean stethoscope should hang in each room. If a doctor doesn't glove & touches you with anything he used on a previous patient, especially in a hospital, you're in grave danger of contracting a deadly disease!
The mop-up -
Casualties of war - There is a lot of bad press about VA hospitals now, but Gawande concentrates on the battle field here & it seems like the military is doing very well by its men.
-- pt. 2.
Doing right - isn't as simple as it seems.
Naked - Patients react differently & I was surprised there were so few guidelines.
What doctors owe - $30K - $300K per year for malpractice insurance?!!! Gawande says doctors are sued once every 6 years on average & all have a crazy story. He tells a couple, but also delves into how badly our current system of malpractice lawsuits is. While there is the occasional big settlement, like 99 out of 100, get zip - zero. New Zealand has a different method, one similar to the one we use for vaccines - each vaccine has $0.75 added to its cost which goes into a fund for the 1 in 10,000 that has a problem. He doesn't think that would work for medical procedures, but he knows the current one isn't either.
Piecework - is about how doctors are paid & gets pretty involved. Very interesting & complicated. While a few sell out, he doesn't think most do it for the money & he has the figures to back it up.
The doctors of the death chamber - He's dead set against it, but does a good job of presenting the other side of the argument first. I disagree with his stance because I think he ignores some facts, such as people that can & do continue to order murder & torture from their cells.
On fighting - asks how long & hard a doctor should fight for a patient's life. Having seen a few horrific, lingering deaths at their hands & growing up on a farm where we put suffering animals down, we have differing ideas. He makes a case for fighting, but discusses this more & better in his other book "Being Mortal".
-- pt. 3.
Ingenuity - isn't always being brilliant, but in looking at things a different way. His book covers this better, but this is all new material.
The score - is a discussion of the Apgar score & what a difference it made to obstetrics. He points out how this differs so much from the normal methods medicine uses to improve.
The bell curve - is about the outliers on the good end, the positive deviants, & leads well into the next section using Cystic Fibrosis treatments as the platform.
For performance - concentrates on how so many do so much with so little. Gawande doesn't spare himself as he relates some of his experience in India.
-- Afterword :
Suggestions for becoming a positive deviant - are interesting & apply to most any profession, especially one involving service to others. I found some interesting ideas for IT help desk customer service.
Notes on sources -
Another wonderfully written, informative walk through the medical field. It's great to see it from their side.
Introduction Doctors are human, but are held to very high standards & often fail to meet them. No surprises.
-- pt. 1.
Diligence - Keep on trying to do everything exactly right.
On washing hands - It's incredibly easy to transfer deadly diseases between patients. A clean stethoscope should hang in each room. If a doctor doesn't glove & touches you with anything he used on a previous patient, especially in a hospital, you're in grave danger of contracting a deadly disease!
The mop-up -
Casualties of war - There is a lot of bad press about VA hospitals now, but Gawande concentrates on the battle field here & it seems like the military is doing very well by its men.
-- pt. 2.
Doing right - isn't as simple as it seems.
Naked - Patients react differently & I was surprised there were so few guidelines.
What doctors owe - $30K - $300K per year for malpractice insurance?!!! Gawande says doctors are sued once every 6 years on average & all have a crazy story. He tells a couple, but also delves into how badly our current system of malpractice lawsuits is. While there is the occasional big settlement, like 99 out of 100, get zip - zero. New Zealand has a different method, one similar to the one we use for vaccines - each vaccine has $0.75 added to its cost which goes into a fund for the 1 in 10,000 that has a problem. He doesn't think that would work for medical procedures, but he knows the current one isn't either.
Piecework - is about how doctors are paid & gets pretty involved. Very interesting & complicated. While a few sell out, he doesn't think most do it for the money & he has the figures to back it up.
The doctors of the death chamber - He's dead set against it, but does a good job of presenting the other side of the argument first. I disagree with his stance because I think he ignores some facts, such as people that can & do continue to order murder & torture from their cells.
On fighting - asks how long & hard a doctor should fight for a patient's life. Having seen a few horrific, lingering deaths at their hands & growing up on a farm where we put suffering animals down, we have differing ideas. He makes a case for fighting, but discusses this more & better in his other book "Being Mortal".
-- pt. 3.
Ingenuity - isn't always being brilliant, but in looking at things a different way. His book covers this better, but this is all new material.
The score - is a discussion of the Apgar score & what a difference it made to obstetrics. He points out how this differs so much from the normal methods medicine uses to improve.
The bell curve - is about the outliers on the good end, the positive deviants, & leads well into the next section using Cystic Fibrosis treatments as the platform.
For performance - concentrates on how so many do so much with so little. Gawande doesn't spare himself as he relates some of his experience in India.
-- Afterword :
Suggestions for becoming a positive deviant - are interesting & apply to most any profession, especially one involving service to others. I found some interesting ideas for IT help desk customer service.
Notes on sources -
Another wonderfully written, informative walk through the medical field. It's great to see it from their side.
July 19, 2020
"Betterment is a perpetual labor. The world is chaotic, disorganized, and vexing and medicine is nowhere spared that reality. To complicate matters, we in medicine are also only humans ourselves. We are distractible,weak, and given to our own concerns".
Very accessible and thoroughly interesting book, shedding light upon the inner workings of health professionals. It also explores how one can be a "better" doctor, improve performance, ethics in medicine, what doctors owe. It's easy to read; no excessive medical/clinical jargon. Atul Gawande shares his own personal experiences, as well as experiences and advices from other doctors and health professionals he interviews.
The book is divided into three main parts:
Diligence
Doing Right
Ingenuity.
Medicine is a complex and challenging field; there are innumerable complications and limitations.
We have remarkable abilities of modern medicine, Learning to use them is difficult enough. But understanding their limits is the most difficult task of all. Small details and observations are crucial. From washing hands (for prevention of spread of infection) to big surgical operations; doctors bear a huge responsibility; they have to make crucial decisions, they are even entrusted to open up humans like melons.
He discusses about ethics, etiquette of physical examination, malpractices, and it's legal outcomes in medicine.
If doctoring is all about business, or if it's no different from selling cars, why choose to endure a decade of medical training instead of , say, two years of business school?
The reason has to be that doctors remain at least partly motivated by the hope of doing meaningful and respected work for society.
Should doctors be present whilst administering lethal injections in prison cells? Should doctors be of assistance in these cases, if only to pronounce a criminal dead? Doctors are supposed to cure people.
In the end, there are suggestions for becoming a positive deviant:
First: Ask an unscripted question.
A doctor's job is talking to strangers. learn about them; learn to hold a conversation. Listen and make note of what you learn.
Second: Don't complain.
A doctor has plenty to carp about, but resist it. It doesn't solve anything.
Third: Count something
Count your number of successes and failures. Count number of patients who develop a certain complication,count mistakes, count something that interests you.
Fourth: write something
write about your observations, offer your reflections to an audience, put your thoughts on paper.
Fifth: Change
Adopt, be willing to recognize inadequacies in what you do and seek solutions. Try new things.
The choices a doctor makes are necessarily imperfect but they alter people's lives.
Overall, this is a brilliant book; kept me engaged throughout. Certainly worth reading!
I was not sure what to expect from this book. And I certainly did not expect to learn this information:
In 1817, for example, Princess Charlotte of Wales, Ling George IV's twenty-one-year-old daughter, spent four days in labor. Her nine-pound boy was in sideways position with a head too large for Charlotte's pelvis. Only after the fiftieth hour of active labor did he finally emerge-stillborn. Six hours later, Charlotte died, from hemorrhagic shock. As she was George's only child, the throne passed to his brother instead of her, then to his niece--which is how Victoria became queen.
Atul Gawande- a doctor, surgeon, researcher, a fine writer- also holds a degree in "political science".... Extraordinary!
Very accessible and thoroughly interesting book, shedding light upon the inner workings of health professionals. It also explores how one can be a "better" doctor, improve performance, ethics in medicine, what doctors owe. It's easy to read; no excessive medical/clinical jargon. Atul Gawande shares his own personal experiences, as well as experiences and advices from other doctors and health professionals he interviews.
The book is divided into three main parts:
Diligence
Doing Right
Ingenuity.
Medicine is a complex and challenging field; there are innumerable complications and limitations.
We have remarkable abilities of modern medicine, Learning to use them is difficult enough. But understanding their limits is the most difficult task of all. Small details and observations are crucial. From washing hands (for prevention of spread of infection) to big surgical operations; doctors bear a huge responsibility; they have to make crucial decisions, they are even entrusted to open up humans like melons.
He discusses about ethics, etiquette of physical examination, malpractices, and it's legal outcomes in medicine.
If doctoring is all about business, or if it's no different from selling cars, why choose to endure a decade of medical training instead of , say, two years of business school?
The reason has to be that doctors remain at least partly motivated by the hope of doing meaningful and respected work for society.
Should doctors be present whilst administering lethal injections in prison cells? Should doctors be of assistance in these cases, if only to pronounce a criminal dead? Doctors are supposed to cure people.
In the end, there are suggestions for becoming a positive deviant:
First: Ask an unscripted question.
A doctor's job is talking to strangers. learn about them; learn to hold a conversation. Listen and make note of what you learn.
Second: Don't complain.
A doctor has plenty to carp about, but resist it. It doesn't solve anything.
Third: Count something
Count your number of successes and failures. Count number of patients who develop a certain complication,count mistakes, count something that interests you.
Fourth: write something
write about your observations, offer your reflections to an audience, put your thoughts on paper.
Fifth: Change
Adopt, be willing to recognize inadequacies in what you do and seek solutions. Try new things.
The choices a doctor makes are necessarily imperfect but they alter people's lives.
Overall, this is a brilliant book; kept me engaged throughout. Certainly worth reading!
I was not sure what to expect from this book. And I certainly did not expect to learn this information:
In 1817, for example, Princess Charlotte of Wales, Ling George IV's twenty-one-year-old daughter, spent four days in labor. Her nine-pound boy was in sideways position with a head too large for Charlotte's pelvis. Only after the fiftieth hour of active labor did he finally emerge-stillborn. Six hours later, Charlotte died, from hemorrhagic shock. As she was George's only child, the throne passed to his brother instead of her, then to his niece--which is how Victoria became queen.
Atul Gawande- a doctor, surgeon, researcher, a fine writer- also holds a degree in "political science".... Extraordinary!
June 9, 2020
At a time when coronavirus has shifted medical care and delivery to a forefront of public discourse, and a messy combination of research and misinformation is pouring out at the leading edge of science, I feel myself prone to wrapping myself in a blanket of scientific security. No other science writer can I turn to more readily than Atul Gawande. Having become a fan of his New Yorker articles and books, I respect him more and more as I become further acquainted with his work. Better, though not my favorite of his, reminds me why Gawande is one of my trusty “science� writers.
Facilitated by personable writing and a clear thesis, he carves an entryway into medicine’s inner workings and healthcare delivery for the general public in a smooth and painless way. Better includes a number of New Yorker pieces that he wrote in the late 90s and early 2000s. These short narrative pieces can come across as vignettes, yet he ties each of the parts together to form a cohesive argument for how physicians can improve medical performance. Divided into three sections, he aims to address the ways that doctors can be diligent, do right, and use ingenuity to ultimately benefit the patient. We are taken on his personal journeys, interviews, and analysis of historical records from as varied settings as cystic fibrosis centers, hospitals in India, military zones in Afghanistan and Iraq, and execution chambers.
"The paradox at the heart of medical care is that it works so well, and yet never well enough." Because of this, Gawande articulates a compelling necessity to strive for doing better. One of the chapters I found most memorable was "Bell Curve," in which he discusses how specialized treatment centers fall on a bell curve of patient outcomes even when controlling for differences in patient demographics. Like other sections of the books, he weaves in case studies with statistics to closely scrutinize standard medical practices. In his dedication and openness to understanding successful methods of improving healthcare delivery, he can reveal important lessons that resonate with us all.
I never walk away from Gawande's books feeling like an expert—rightly so, because they are aimed at broader comprehension and finding big picture patterns in medicine. His subject matter does invite controversy, as he writes about lethal injections for the death penalty and medical malpractice suits. Yet in other places, he provides compelling evidence that give credence to his prescriptive calls for improvement, such as feasible ways of encouraging doctors to wash hands with a demonstrative account of the lives it can save when implemented with diligence. The issues he covers are by no means irrelevant for today's healthcare system, give or take a few inevitably outdated statistics since 2007; even more important, many of them remain unresolved today. By no means comprehensive, Better still presents as a direct and solid opinion piece on ways to improve medical care and how "better" physicians are one essential piece in the fabric of attaining the best possible outcomes for patients.
Facilitated by personable writing and a clear thesis, he carves an entryway into medicine’s inner workings and healthcare delivery for the general public in a smooth and painless way. Better includes a number of New Yorker pieces that he wrote in the late 90s and early 2000s. These short narrative pieces can come across as vignettes, yet he ties each of the parts together to form a cohesive argument for how physicians can improve medical performance. Divided into three sections, he aims to address the ways that doctors can be diligent, do right, and use ingenuity to ultimately benefit the patient. We are taken on his personal journeys, interviews, and analysis of historical records from as varied settings as cystic fibrosis centers, hospitals in India, military zones in Afghanistan and Iraq, and execution chambers.
"The paradox at the heart of medical care is that it works so well, and yet never well enough." Because of this, Gawande articulates a compelling necessity to strive for doing better. One of the chapters I found most memorable was "Bell Curve," in which he discusses how specialized treatment centers fall on a bell curve of patient outcomes even when controlling for differences in patient demographics. Like other sections of the books, he weaves in case studies with statistics to closely scrutinize standard medical practices. In his dedication and openness to understanding successful methods of improving healthcare delivery, he can reveal important lessons that resonate with us all.
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. Everyone knows that averageness 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.
I never walk away from Gawande's books feeling like an expert—rightly so, because they are aimed at broader comprehension and finding big picture patterns in medicine. His subject matter does invite controversy, as he writes about lethal injections for the death penalty and medical malpractice suits. Yet in other places, he provides compelling evidence that give credence to his prescriptive calls for improvement, such as feasible ways of encouraging doctors to wash hands with a demonstrative account of the lives it can save when implemented with diligence. The issues he covers are by no means irrelevant for today's healthcare system, give or take a few inevitably outdated statistics since 2007; even more important, many of them remain unresolved today. By no means comprehensive, Better still presents as a direct and solid opinion piece on ways to improve medical care and how "better" physicians are one essential piece in the fabric of attaining the best possible outcomes for patients.
January 18, 2016
The first chapter of this book was on the effect that hand-washing has on infection rates of MRSA and VRE in hospitals. It was fascinating! I never thought I would find twenty pages on hand-washing so engrossing - I have high hopes for this book!
The book got better and better. Proper review will be forthcoming, definitely. But when?
The book got better and better. Proper review will be forthcoming, definitely. But when?
May 16, 2021
Better is a collage of essays by Atul Gawande, MD, MPH and its� intent is to enrich outcomes via mindful application of “Diligence,� “Doing Right� and “Ingenuity� as it applies to his profession. Listening---but not really listening---and filtering are qualities of an astute surgeon knowing exactly what the patient needs. On one such case of a hydrocephalic child requiring immediate resolution.
“Unless surgery is performed to provide a new route out of the brain and skull for the fluid, the resulting brain damage becomes severe... �
---Atul Gawande
“Better� is a rocky complicated emprise with a bubbling stream of truth ever flowing and his mindful goal on becoming “better� is illuminated. He converts the complicated to simple by breaking it down to a basic level of understanding as it hums loudly in our delicate ears---so we fully comprehend.
In this book the achievements of military medicine (thus imparting decreased mortality rates from battle wounds) are discussed and focused attention to detail to reduce error � is no doubt a requisite. Gawande provides a cleareyed view of the medical profession that both resonates and gives pause. In analysis, he spares no one---himself included. Science.
As Better quickly comes to its� last page, Gawande compares his “orderly life� with his patient/cases within. And how a surgeon is equated to an automaton and “it can be hard not to feel that one is a milky-coated cog in a machine.� Via this seemingly insignificant text he inspires all of us---surgeon or not--- to be better. Buy!
“Unless surgery is performed to provide a new route out of the brain and skull for the fluid, the resulting brain damage becomes severe... �
---Atul Gawande
“Better� is a rocky complicated emprise with a bubbling stream of truth ever flowing and his mindful goal on becoming “better� is illuminated. He converts the complicated to simple by breaking it down to a basic level of understanding as it hums loudly in our delicate ears---so we fully comprehend.
In this book the achievements of military medicine (thus imparting decreased mortality rates from battle wounds) are discussed and focused attention to detail to reduce error � is no doubt a requisite. Gawande provides a cleareyed view of the medical profession that both resonates and gives pause. In analysis, he spares no one---himself included. Science.
As Better quickly comes to its� last page, Gawande compares his “orderly life� with his patient/cases within. And how a surgeon is equated to an automaton and “it can be hard not to feel that one is a milky-coated cog in a machine.� Via this seemingly insignificant text he inspires all of us---surgeon or not--- to be better. Buy!
February 24, 2020
Your life would definitely become better after reading this book.
November 7, 2008
"Better" collects surgeon Atul Gawande's recent essays on medicine in three categories--Diligence, Doing Right, and Ingenuity. Each essay, on topics as diverse as washing hands to minimize infections in hospitals and doctors participating in executions, is a marvel of case study and comparative assessment, shifting back and forth between the particular and the general.
The simplicity and directness of Gawande's prose mirrors his mode of thought: always looking for the basic truth, the underlying commonality between disparate conditions, the fundamental practice, or virtue, that can cause medical science (or, the practice of medicine) to generate "better" results.
In many ways, the thesis of "Better" is that great improvements are often the result not through breakthrough discoveries or "new paradigms" but rather of minimizing error through tracking results, comparing them, and altering techniques.
The hand washing essay focuses on the nuisance factor, reduced in some hospitals by the use of easy to use gels. The essay on cystic fibrosis focuses on the improvements possible through diligently pushing patients' minds and bodies to accept ever-more-demanding but relatively simple treatments.
Gawande's insights into medical history (indeed, his mastery of ancient anecdotes) is enlivened by his observations of practices he sees on a day-to-day basis. He's great at finding just the right specialist to interview, or at getting a nurse or doctor to admit that he/she moonlights in prisons, monitoring lethal injections.
A fundamental principle Gawande honors is "openness" in admitting the limitations inherent in the practice of medicine. It's important for doctors, and patients, to understand this principle in order to be realistic, focused, and determined to do better.
Gawande's previous collection of essays, Complications, is less thematic and places more emphasis on fascinating medical detective work and biological conundrums.
He's terrific.
The simplicity and directness of Gawande's prose mirrors his mode of thought: always looking for the basic truth, the underlying commonality between disparate conditions, the fundamental practice, or virtue, that can cause medical science (or, the practice of medicine) to generate "better" results.
In many ways, the thesis of "Better" is that great improvements are often the result not through breakthrough discoveries or "new paradigms" but rather of minimizing error through tracking results, comparing them, and altering techniques.
The hand washing essay focuses on the nuisance factor, reduced in some hospitals by the use of easy to use gels. The essay on cystic fibrosis focuses on the improvements possible through diligently pushing patients' minds and bodies to accept ever-more-demanding but relatively simple treatments.
Gawande's insights into medical history (indeed, his mastery of ancient anecdotes) is enlivened by his observations of practices he sees on a day-to-day basis. He's great at finding just the right specialist to interview, or at getting a nurse or doctor to admit that he/she moonlights in prisons, monitoring lethal injections.
A fundamental principle Gawande honors is "openness" in admitting the limitations inherent in the practice of medicine. It's important for doctors, and patients, to understand this principle in order to be realistic, focused, and determined to do better.
Gawande's previous collection of essays, Complications, is less thematic and places more emphasis on fascinating medical detective work and biological conundrums.
He's terrific.
September 7, 2018
"...To complicate matters, we in medicine are also only human ourselves. We are distractible, weak, and given to our own concerns. Yet still, to live as a doctor is to live so that one's life is bound up in others' and in science and in the messy, complicated connection between the two. It is to live a life of responsibility..."
I’m writing this review from the perspective of a patient who has spent years in the medical system. After reading this book, I have more empathy for the doctors that helped me throughout my treatment. I think as patients, we expect nothing but the best from our doctors. But just like all of us, doctors are human and even the best of them make mistakes. What makes their errors more pronounced, however, is the dire consequences they can have on human lives.
"Better" is an introspective and well-written account on how medical professionals can improve current healthcare practices. What I love most about this book is Dr. Gawande's willingness to discuss uncomfortable and taboo topics like, what do doctors owe their patients when they fail? And how can hospitals improve hand-washing compliance? In doing so, he is starting an important conversation.
And while this book contains valuable information, it was too dry for my taste. In my opinion, the best non-fiction books have the skillful ability to make complicated topics entertaining. Although I learned a lot from this book, it was not the most enjoyable read for me. I am planning on reading "Complications" next, which I think is more up my alley. It is a collection of essays Dr. Gawande wrote while he was in residency, and I have heard it really puts you into the mind of a new doctor. I look forward to reading it soon!
I’m writing this review from the perspective of a patient who has spent years in the medical system. After reading this book, I have more empathy for the doctors that helped me throughout my treatment. I think as patients, we expect nothing but the best from our doctors. But just like all of us, doctors are human and even the best of them make mistakes. What makes their errors more pronounced, however, is the dire consequences they can have on human lives.
"Better" is an introspective and well-written account on how medical professionals can improve current healthcare practices. What I love most about this book is Dr. Gawande's willingness to discuss uncomfortable and taboo topics like, what do doctors owe their patients when they fail? And how can hospitals improve hand-washing compliance? In doing so, he is starting an important conversation.
And while this book contains valuable information, it was too dry for my taste. In my opinion, the best non-fiction books have the skillful ability to make complicated topics entertaining. Although I learned a lot from this book, it was not the most enjoyable read for me. I am planning on reading "Complications" next, which I think is more up my alley. It is a collection of essays Dr. Gawande wrote while he was in residency, and I have heard it really puts you into the mind of a new doctor. I look forward to reading it soon!
January 13, 2017
Excellent. He writes well.
This covers several subjects that are core to current medicine as it is presently practiced. Ones which are RARELY discussed. Like when are 3rd parties as witness in the room during exams deemed mandatory. This varies with extreme difference for culture nuance or governmental law. England has different practice for this as common, for instance. And the paper drape issue!!
There are several subjects of doctor experience now/ then and how change in medical practices occur. Or not.
But beyond, this taught me facts about current practices in India, in war zones and with childbirth "norm" directions for "best" that I was not fully aware had changed as much as they have. And also about $$$ earned by doctors and when /what sueing equates to salary.
But the best was his advice to COUNT something. Anything. It does matter if you keep COUNT records. Results not obvious become revealed.
This covers several subjects that are core to current medicine as it is presently practiced. Ones which are RARELY discussed. Like when are 3rd parties as witness in the room during exams deemed mandatory. This varies with extreme difference for culture nuance or governmental law. England has different practice for this as common, for instance. And the paper drape issue!!
There are several subjects of doctor experience now/ then and how change in medical practices occur. Or not.
But beyond, this taught me facts about current practices in India, in war zones and with childbirth "norm" directions for "best" that I was not fully aware had changed as much as they have. And also about $$$ earned by doctors and when /what sueing equates to salary.
But the best was his advice to COUNT something. Anything. It does matter if you keep COUNT records. Results not obvious become revealed.
November 12, 2016
The science of performance - doing things better and smarter. Gawande applies this directly to medicine and public health as he shares stories of health care around the globe - I particular liked his history of cystic fibrosis treatment, and the continued work on eradicating polio in southeast Asia and the subcontinent.
The afterword on 'postitive deviance' was quite good and can be applied widely.
While not the same gravitas as 'Being Mortal', this book solidifies Gawande's place as an important thinker. Love his work.
The afterword on 'postitive deviance' was quite good and can be applied widely.
While not the same gravitas as 'Being Mortal', this book solidifies Gawande's place as an important thinker. Love his work.
December 14, 2008
If I had to pick just one of Gawande's books to read, it would be Complications. But this is still a great collection of stories on fascinating fields of and issues related to medicine.
What I admire so much about Gawande is his ability to wrap his analytical mind so effortlessly around storytelling. His writing is conversational, straightforward and thoughtful. Medicine isn't a topic that would necessarily appeal to me, but with Gawande at the helm, it's fascinating.
In this book, his stories include a closer look at issues physicians and others in the medical field could tackle better (hence the title). The subject material ranges from hand washing in hospitals to eradicating polio in India to chapters covering what doctors earn to what doctors owe (a look at a U.S. malpractice system riddled with holes).
Again, if you're a first-timer to Gawande, start with Complications but know this one will keep you turning the page from start to finish with equal ease.
What I admire so much about Gawande is his ability to wrap his analytical mind so effortlessly around storytelling. His writing is conversational, straightforward and thoughtful. Medicine isn't a topic that would necessarily appeal to me, but with Gawande at the helm, it's fascinating.
In this book, his stories include a closer look at issues physicians and others in the medical field could tackle better (hence the title). The subject material ranges from hand washing in hospitals to eradicating polio in India to chapters covering what doctors earn to what doctors owe (a look at a U.S. malpractice system riddled with holes).
Again, if you're a first-timer to Gawande, start with Complications but know this one will keep you turning the page from start to finish with equal ease.
March 16, 2024
Gawande is such a smooth writer it almost makes me uneasy. I can possibly foresee a day when I won't want any more of him, as with Malcolm Gladwell, whom I tired of quickly. But for now, four stars.
Serendipitously, as often happens with my reading, two randomly chosen currently-read books (this one and the novel The Catherine Wheel) both contained references to the diseases sprue and yaws, and also contained a female character/person named Honor.
October 12, 2007
I really like Gawande's writing style, and for the most part feel like he gives a very rational, nuanced look at medical care in the US. The only exception to this is the essay "The Score." Although his main point in this essay, that a concrete, replicable measurement of baby health led to great improvements in infant mortality in the US, is well-taken, his description of the history of obstetric care and the near inevitability of an increasing c-section rate in the US is shockingly uninformed. Many modern industrialized nations have far better maternal and infant outcomes and far lower c-section rates in the US. The difference is not that in those countries doctors make extensive use of forceps instead of c-sections; the difference is that the system of care for laboring mothers depends heavily on the use of midwives. Obstetricians are only used as the exception, not the rule. (The Netherlands is the best example of this.) To say that the package of numerous unproven technological interventions in the physiological process of birth since 1940 have caused the "dramatic" improvements in the outcome statistics is totally unfounded; correlation is not causation. Gawande concludes that there's "no getting around C-sections":
"We have reached the point that, when there's any question of delivery risk, the Cesarean is what clinicians turn to—it's simply the most reliable option. If a mother is carrying a baby more than ten pounds in size, if she's had a C-section before, if the baby is lying sideways or in a breech position, if she has twins, if any number of potentially difficult situations for delivery arise, the standard of care requires that a midwife or an obstetrician at least offer a Cesarean section. Clinicians are increasingly reluctant to take a risk, however small, with natural childbirth....Putting so many mothers through surgery is hardly cause for celebration. But our deep-seated desire to limit risk to babies is the biggest force behind its prevalence; it is the price exacted by the reliability we aspire to."
This is simply not true! There is absolutely no positive correlation between increased c-sections and improved birth outcomes for moms and babies; in fact, there's a negative correlation. If Gawande had looked outside North America for information on this issue, he would not come to this absurd and harmful conclusion. It's really disappointing that someone as thoughtful as Gawande has not looked beyond the party line of doctors in this country on this unbelievably important issue.
If you have any interest in this issue, read Jennifer Block's brilliantly researched new book "Pushed."
"We have reached the point that, when there's any question of delivery risk, the Cesarean is what clinicians turn to—it's simply the most reliable option. If a mother is carrying a baby more than ten pounds in size, if she's had a C-section before, if the baby is lying sideways or in a breech position, if she has twins, if any number of potentially difficult situations for delivery arise, the standard of care requires that a midwife or an obstetrician at least offer a Cesarean section. Clinicians are increasingly reluctant to take a risk, however small, with natural childbirth....Putting so many mothers through surgery is hardly cause for celebration. But our deep-seated desire to limit risk to babies is the biggest force behind its prevalence; it is the price exacted by the reliability we aspire to."
This is simply not true! There is absolutely no positive correlation between increased c-sections and improved birth outcomes for moms and babies; in fact, there's a negative correlation. If Gawande had looked outside North America for information on this issue, he would not come to this absurd and harmful conclusion. It's really disappointing that someone as thoughtful as Gawande has not looked beyond the party line of doctors in this country on this unbelievably important issue.
If you have any interest in this issue, read Jennifer Block's brilliantly researched new book "Pushed."
July 30, 2012
Takes the reader comfortably into the world of medicine's challenges under the theme of how efforts to improve performance can save a lot of lives. Like the good chef he proved to be in his earlier set of essays on his experience as a surgical resident, , "Complications", he again makes tasty and nutritious dishes out of a wide variety of ingredients. How has public health gotten so close to eradicating smallpox? How has the casualty death rate for American military medicine gone from about 20% in Vietnam to about 10% in the current conflicts? What were the key strategies allowing the average age of death from the genetic disease cystic fibrosis to move from 3 years old to currently over 30 (and why is it often over 50 with care at some centers)? He has a lot to say about the importance for doctors to keep trying to improve through dliligence, innovation, and performance monitoring, whether they are Western obstetricians compelled to move to cesarians out of safety concerns or general surgeons in a public hospital in India having to improvise under appalling conditions of limited resources. The fascinating set of examples in the book serve to illustrate his final list of simple recommendations to becoming the "postive deviant" at the good side of the bell curve of medical performance: 1) always take time to ask unscripted questions of patients and fellow staff; 2) don't complain; 3) count something of interest in your medical practice; 4) write something about what you think or do; 5) change something that might make your efforts work better. There is a lot of wisdom and optimism in this well written book.�
Read
March 31, 2009Oh, I wanted this to be great! Alas, only part of it is. To wit: Gawande’s umbrella themes dominate the book, but they are a distraction from his best conclusions, which are tucked quietly in the afterword.
In his introduction, Gawande asks, “What does it take to be good at something in which failure can be so easy, so effortless?”—and even though he says, “This is a book about performance in medicine,� the question applies not just to medical practitioners. All of us can ask the same question about our jobs and our lives. What does it take to be good? What does it take to be better? This is why I bought and read Better.
Gawande’s answers are anti-climactic at first. He breaks his results down into three categories: diligence, doing right, and ingenuity. Fine. He tells us stories that demonstrate each one, and we see clearly in these stories how being diligent, doing right, and taking fresh approaches improved outcomes. This is a familiar formula: big themes, some examples, conclusion. Great.
Sure, the stories are sometimes fascinating, but the problem is that diligence, doing right, and ingenuity are the kinds of words thrown up in primary colors on black-bordered posters with images of skyscapes, mountain-tops, or waterfalls. They are noble ideals, but they are vague as pieces of advice for doing what we do better. I would imagine it’s hard even for doctors to internalize these lessons.
But then comes the afterword, where the gold is buried: “Suggestions for Becoming a Positive Deviant”—which, for non-statistics-types, means “suggestions for becoming better.� Huzzah! There are five: 1) Ask an unscripted question, 2) Don’t complain, 3) Count something, 4) Write something, and 5) Change. This is the good stuff. Gawande’s final suggestions here are simple and applicable to anything. They subtly encourage creativity. They are suggestions that teach. If I have an office next year, I will post them on my wall.
Do I recommend it? Yes, if only for the afterword. The stories are well told, too, I guess.
Would I teach it? No. For non-fiction writing, I might use some of Gawande’s New Yorker articles, though.
Lasting impressions: Perfectly fine stories sorted by theme and a summary that makes them all worthwhile.
In his introduction, Gawande asks, “What does it take to be good at something in which failure can be so easy, so effortless?”—and even though he says, “This is a book about performance in medicine,� the question applies not just to medical practitioners. All of us can ask the same question about our jobs and our lives. What does it take to be good? What does it take to be better? This is why I bought and read Better.
Gawande’s answers are anti-climactic at first. He breaks his results down into three categories: diligence, doing right, and ingenuity. Fine. He tells us stories that demonstrate each one, and we see clearly in these stories how being diligent, doing right, and taking fresh approaches improved outcomes. This is a familiar formula: big themes, some examples, conclusion. Great.
Sure, the stories are sometimes fascinating, but the problem is that diligence, doing right, and ingenuity are the kinds of words thrown up in primary colors on black-bordered posters with images of skyscapes, mountain-tops, or waterfalls. They are noble ideals, but they are vague as pieces of advice for doing what we do better. I would imagine it’s hard even for doctors to internalize these lessons.
But then comes the afterword, where the gold is buried: “Suggestions for Becoming a Positive Deviant”—which, for non-statistics-types, means “suggestions for becoming better.� Huzzah! There are five: 1) Ask an unscripted question, 2) Don’t complain, 3) Count something, 4) Write something, and 5) Change. This is the good stuff. Gawande’s final suggestions here are simple and applicable to anything. They subtly encourage creativity. They are suggestions that teach. If I have an office next year, I will post them on my wall.
Do I recommend it? Yes, if only for the afterword. The stories are well told, too, I guess.
Would I teach it? No. For non-fiction writing, I might use some of Gawande’s New Yorker articles, though.
Lasting impressions: Perfectly fine stories sorted by theme and a summary that makes them all worthwhile.
February 6, 2017
Motivational and practical, sans self-help spiel.
Dr Gawande writes with a measured voice, but his curiosity and enthusiasm to basically be the best you can be at what you do is infectious.
Regardless of your vocation or even during your vacations, his tips should be applicable for a more positive and fulfilling experience, and hopefully, results. Not every section interested me equally (I was most drawn in by the Ingenuity section). But then I came to realise that the section which didn't fascinate me as much was in fact my weakest area (Diligence), and that's where I need to push myself more.
Will you actually get better from practising what this book is promoting? Who knows, but Dr Gawande believes it's possible, and Russell Peters (or rather the Chinese merchant his dad haggled with) had said what this book is basically asking you to do:
Equally applicable to women, the Chinese merchant happened to be addressing Russell Peters' dad, so
Dr Gawande writes with a measured voice, but his curiosity and enthusiasm to basically be the best you can be at what you do is infectious.
Regardless of your vocation or even during your vacations, his tips should be applicable for a more positive and fulfilling experience, and hopefully, results. Not every section interested me equally (I was most drawn in by the Ingenuity section). But then I came to realise that the section which didn't fascinate me as much was in fact my weakest area (Diligence), and that's where I need to push myself more.
Will you actually get better from practising what this book is promoting? Who knows, but Dr Gawande believes it's possible, and Russell Peters (or rather the Chinese merchant his dad haggled with) had said what this book is basically asking you to do:
Equally applicable to women, the Chinese merchant happened to be addressing Russell Peters' dad, so
June 16, 2019
I've now read all of Atul Gawande's books and each one is excellent. Surgeon, writer, philosopher (and now CEO?) What a polymath! This book gave me insights not only into improvement opportunities in medicine but into enhancing effectiveness in general. (The story and research on hand-washing alone is incredibly useful.)
I can't wait for whatever Gawande does next.
I can't wait for whatever Gawande does next.
July 18, 2024
This was an interesting one... I enjoyed his book Becoming Mortal years ago but forgot he had written more so when I saw this on the library app, I snatched it up.
Glad my brain 🧠 was able to concentrate on this one :).
Not narrated by the author but narrator did a wonderful job 👏.
Learning what goes on behind the scenes gets me thinking and seeing different things in a new light.
I was surprised but also not surprised to understand what doctors deal with regarding payments for services and insurance companies.
This definitely is food for thought.. would recommend this and his other one as well :)
Glad my brain 🧠 was able to concentrate on this one :).
Not narrated by the author but narrator did a wonderful job 👏.
Learning what goes on behind the scenes gets me thinking and seeing different things in a new light.
I was surprised but also not surprised to understand what doctors deal with regarding payments for services and insurance companies.
This definitely is food for thought.. would recommend this and his other one as well :)
June 24, 2022
This is a great discussion exploring many curiosities of healthcare. Gawande explores a broad range of topics including hand washing, lethal injection, polio, and lawsuits just to name a few. Great discussions sharing interesting perspectives on each of the topics. Gawande finished out the book discussing the importance of performance focus in the field of medicine, as well as providing 5 very practical actions to take to be a “positive deviation� towards improved performance in healthcare.
November 21, 2018
This is the 3rd book by this author that I’ve read and it’s good, albeit similar to the previous ones. In this book, he explores what it takes to be good at something (medicine) in which failure is so easy and effortless. He talks of 3 virtues - diligence, doing right and ingenuity - which when practiced with earnest, will profoundly impact performance.
Some of the most engrossing bits of the book are where he talks about the following:
- Polio eradication drive in India
- Efforts undertaken to reduce the mortality rate for combat injured soldiers in the US - “The
mortality rate for combat injured soldiers is reducing in the US but the technology to save the
wounded seems to have barely kept up with the technology inflicting wounds.�
- Real-life stories of lawsuits against doctors, from the perspective of a doctor
- The debate over the role of doctors during executions (in the US) � Is the involvement of medical
personnel during executions a violation of ethics? How difficult is it for physicians to aid/be
involved in executions? The research that he presents here is especially fascinating and gets you
thinking � what would you do?
- The Obstetrics branch of medicine has grown by leaps and bounds � how the Apgar score changed
everything, resulting in the setting up of neonatal ICUs, increased use of spinal and epidural
anesthesia (this produced babies with better scores), prenatal ultrasounds, fetal heart monitors
and how all this resulted in outstandingly low mortality rate for new born babies.
He concludes the book by considering whether deaths are a poor or accurate metric for doctors� performance. If the performance bell curve does indeed exist for doctors as well, what does it mean for a doctor to be average? And more importantly, what does it mean for the patient seeking treatment?
As in his previous books, I like his style of writing � filled with anecdotes, cases and research interspersed with his own observations and thoughts. Filled with interesting facts and studies about the medical field, this book is a 3.5/5.
Some of the most engrossing bits of the book are where he talks about the following:
- Polio eradication drive in India
- Efforts undertaken to reduce the mortality rate for combat injured soldiers in the US - “The
mortality rate for combat injured soldiers is reducing in the US but the technology to save the
wounded seems to have barely kept up with the technology inflicting wounds.�
- Real-life stories of lawsuits against doctors, from the perspective of a doctor
- The debate over the role of doctors during executions (in the US) � Is the involvement of medical
personnel during executions a violation of ethics? How difficult is it for physicians to aid/be
involved in executions? The research that he presents here is especially fascinating and gets you
thinking � what would you do?
- The Obstetrics branch of medicine has grown by leaps and bounds � how the Apgar score changed
everything, resulting in the setting up of neonatal ICUs, increased use of spinal and epidural
anesthesia (this produced babies with better scores), prenatal ultrasounds, fetal heart monitors
and how all this resulted in outstandingly low mortality rate for new born babies.
He concludes the book by considering whether deaths are a poor or accurate metric for doctors� performance. If the performance bell curve does indeed exist for doctors as well, what does it mean for a doctor to be average? And more importantly, what does it mean for the patient seeking treatment?
As in his previous books, I like his style of writing � filled with anecdotes, cases and research interspersed with his own observations and thoughts. Filled with interesting facts and studies about the medical field, this book is a 3.5/5.
May 19, 2018
Atul Gawande is one of those people who seems infuriatingly good at a wide variety of things. He's not only a surgeon operating (har har) out of Boston, but he's also a staff writer for The New Yorker, a professor, a public policy advocate, and a New York Times best selling author. I think his most famous book is The Checklist Manifesto, where he describes how simple tools like pen-and-paper checklists can drastically improve performance in high stakes jobs like surgery or piloting.
Better is a more loosely held together book than that, or any of his other books from what I see. It's mostly a collection of essays about how doctors can do their jobs better, with the occasional detour into neighboring topics, like the chapters on malpractice lawsuits or how delicate a situation it can be to examine patients' private bits. But mostly you get essays about eradicating polio, improving battlefield surgery, reducing death from childbirth, and increasing the lifespan of people with cystic fibrosis. These aren't stories about how Gawande does all these things. Rather, they're a blending of Gawande's own experiences (like the time he shadowed a polio immunization crew in India) and stories drawn from the history of medicine and the author's own reporting.
Gawande is a great writer and he holds your attention through all of this by telling fascinating and gripping stories about people. Well, most of the time. I did find myself starting to skim in a few places, mostly when he fell into a rut of describing a long list of maladies or patients one by one. But generally he keeps things moving. He also keeps them from getting too technical or mired in medical jargon. There's hardly any of that, in fact; this is a book clearly written for the layperson to understand. It's the kind of "stretch outside your own area of expertise" book that I think I really benefit from in order to keep me from just reading the same kinds of things over and over again.
Better is a more loosely held together book than that, or any of his other books from what I see. It's mostly a collection of essays about how doctors can do their jobs better, with the occasional detour into neighboring topics, like the chapters on malpractice lawsuits or how delicate a situation it can be to examine patients' private bits. But mostly you get essays about eradicating polio, improving battlefield surgery, reducing death from childbirth, and increasing the lifespan of people with cystic fibrosis. These aren't stories about how Gawande does all these things. Rather, they're a blending of Gawande's own experiences (like the time he shadowed a polio immunization crew in India) and stories drawn from the history of medicine and the author's own reporting.
Gawande is a great writer and he holds your attention through all of this by telling fascinating and gripping stories about people. Well, most of the time. I did find myself starting to skim in a few places, mostly when he fell into a rut of describing a long list of maladies or patients one by one. But generally he keeps things moving. He also keeps them from getting too technical or mired in medical jargon. There's hardly any of that, in fact; this is a book clearly written for the layperson to understand. It's the kind of "stretch outside your own area of expertise" book that I think I really benefit from in order to keep me from just reading the same kinds of things over and over again.
March 6, 2020
This is the second book written by Gawande. Though it may not have the depth and appeal of his 2014 book - Being Mortal, it is still a very thought provoking book. Even though he only talks about medical issues, the lessons and insights should resonate with any profession. We all face the problems of limited resources, imperfect information, and complex problems, and we try to do the best we can under the circumstances. However, very few professions deal with such direct and dire consequences as medicine. Therefore, learning how doctors deal with these problems is a great way to realize that if they can do it, so can we.
Gawande is a great story teller.
Gawande is a great story teller.
January 2, 2021
a brilliant collection of anecdotes and research outlining that sometimes our ability to do better (in medicine and life) doesn’t always rely on groundbreaking scientific advancement. diligence, ingenuity, and re imagination of existing systems and processes can sometimes be far better. wash your hands ;)
October 13, 2019
Why don't we do it better? Why don't we wash our hands when we know it makes a difference? Why don't people give their children polio vaccines? Why do some doctors, who are doing everything right, only have middling results � and what helps others do better? As Atul Gawande concludes, in Better: A Surgeon's Notes on Performance, You go into this work thinking it is all a matter of canny diagnosis, technical prowess, and some ability to empathize with people. But it is not, you soon find out. (p. 8)
What makes the difference? Gawande talks about several things, but many of his suggestions are based on what I would call strength-based work: rather than telling patients what they needed to do, the doctors he saw as exemplars of their field focused on strengthening the skills their patients already had. For example, the difference between average physicians working with people with cystic fibrosis and the doctors at a stellar clinic seemed to be how they approached their patients:
Gawande also considered changes we've observed, then spun them differently than I'd expected. He argued that the the significant drop in mortality from gunshots since the mid-1960s (16% in 1964 to 5% in 2007) is not due to a decrease in crime, as aggravated assaults using firearms, have more than tripled during this period, but due to the increased quality of trauma care. (Remember that during the next US presidential debates.) And, the mortality rate during the Revolutionary War was 42%, and in more recent wars was only 10%. He attributed these changes to watching what works, and being creative risk-takers, who are willing to think outside the box.
These improvements don't come without costs and difficult questions, however. Gawande asked:
We have no idea whether it is possible to live a good life with no arms and only one leg. But we don’t want the doctors to give up. Instead, we want them to consider it their task to learn how to rehabilitate survivors despite the unprecedented severity of their injuries. We want doctors to push and find a way. (p. 160)
Part of doing better is asking the right questions.
I have read another Gawande book and loved it. I didn't love this one. Gawande included interesting examples, but I didn't always see his book's structure. He suggested that doing better was attributed to diligence (like his senior resident who kept his eye on Gawande's patient with unclear symptoms: Because he checked on her, she survived [p. 3]), doing right even though we are limited humans, and having ingenuity and thinking outside the box. I knew that he had this structure, but I often couldn't see it. I might have liked Better better if I hadn't known and it was just a set of unconnected essays.
Still, these essays say important things for those of us who will see a doctor, but also those of us who work in other fields. We can all do better.
What makes the difference? Gawande talks about several things, but many of his suggestions are based on what I would call strength-based work: rather than telling patients what they needed to do, the doctors he saw as exemplars of their field focused on strengthening the skills their patients already had. For example, the difference between average physicians working with people with cystic fibrosis and the doctors at a stellar clinic seemed to be how they approached their patients:
“Why aren’t you taking your treatments?� He appeared neither surprised nor angry. He seemed genuinely curious, as if he’d never run across this interesting situation before.This attitude of curiosity and respect held even with a mother who refused a polio vaccination for her child. One doctor yelled at this mother. Pankaj, instead, confronted the doctor:
“I don’t know.�
He kept pushing. “What keeps you from doing your treatments?�
“I don’t know.�
“Up here”—he pointed at his own head—“what’s going on?�
“I. Don’t. Know,� she said.
He paused for a moment. Then he turned to me, taking a new tack. “The thing about patients with CF is that they’re good scientists,� he said. “They always experiment. We have to help them interpret what they experience as they experiment. So they stop doing their treatments. And what happens? They don’t get sick. Therefore, they conclude, Dr. Warwick is nuts.� (pp. 220-221)
"Why are you shouting?... Before, she was listening, at least. But now? She’s not going to listen anymore.�...Sometimes a circuitous route from Point A to B is shorter than the more direct one.
“She doesn’t know what is right for her child!�
“What does that matter?� Pankaj replied. “Your shouting doesn’t help anything. And neither will a story going around that we are forcing drops on people.� (p. 45)
Gawande also considered changes we've observed, then spun them differently than I'd expected. He argued that the the significant drop in mortality from gunshots since the mid-1960s (16% in 1964 to 5% in 2007) is not due to a decrease in crime, as aggravated assaults using firearms, have more than tripled during this period, but due to the increased quality of trauma care. (Remember that during the next US presidential debates.) And, the mortality rate during the Revolutionary War was 42%, and in more recent wars was only 10%. He attributed these changes to watching what works, and being creative risk-takers, who are willing to think outside the box.
These improvements don't come without costs and difficult questions, however. Gawande asked:
We have no idea whether it is possible to live a good life with no arms and only one leg. But we don’t want the doctors to give up. Instead, we want them to consider it their task to learn how to rehabilitate survivors despite the unprecedented severity of their injuries. We want doctors to push and find a way. (p. 160)
Part of doing better is asking the right questions.
I have read another Gawande book and loved it. I didn't love this one. Gawande included interesting examples, but I didn't always see his book's structure. He suggested that doing better was attributed to diligence (like his senior resident who kept his eye on Gawande's patient with unclear symptoms: Because he checked on her, she survived [p. 3]), doing right even though we are limited humans, and having ingenuity and thinking outside the box. I knew that he had this structure, but I often couldn't see it. I might have liked Better better if I hadn't known and it was just a set of unconnected essays.
Still, these essays say important things for those of us who will see a doctor, but also those of us who work in other fields. We can all do better.
October 3, 2020
This is the third book by this author that I've read. He is a solid 4 stars for me. The author is a doctor and a writer because he writes about his experiences in a kind and dignified manner. His books get me thinking, and for some reason, I always feel like I'm better off having read it.
I like his research, his ideas, and tI also like that it doesn't feel like he is trying to hide anything. I have one other book by him that seems to be the favorite of many of his readers. So I hope I can get to it soon. So 4 stars.
I like his research, his ideas, and tI also like that it doesn't feel like he is trying to hide anything. I have one other book by him that seems to be the favorite of many of his readers. So I hope I can get to it soon. So 4 stars.
January 12, 2025
First book finished in 2025 and first buddy read with my husband, and hopefully not the last.
Interesting, relevant, and inspiring.
Interesting, relevant, and inspiring.
June 4, 2019
No matter how bad things get at work, I’m always that person who says, “it’s not like we’re saving lives.� In this book, Atul Gawande discusses just how stressful improving performance in order to save lives actually is. He starts with something as simple as washing hands (which we should all apparently do 500% more often), and moves on to more complicated topics such as providing care amidst a polio outbreak in India, confronting medical needs of soldiers injured in Iraq, and the frustration doctors face when seeking compensation from insurance companies.
Most interesting to me was his section around how doctors have been involved with carrying out the death penalty and how this creates an impediment to their oath to “do no harm.� Is it wrong for a doctor to assist in putting someone to death? Is it worse for them to stand by and do nothing while someone dies horribly because others were not trained to properly carry out the sentence?
My least favorite chapter was on childbirth and the various techniques for assisting with a birth which may have complications. While I suppose most people consider childbirth “a miracle� I think that an equally accurate description might be “grisly,� and Gawande goes into a lot of detail about various techniques which may prove my point. I honestly had to take a break.
Anyway, read this if you’re interested in process improvement, personal growth, or medical anything. It’s fairly short and goes quickly.
See more of my reviews: //
Most interesting to me was his section around how doctors have been involved with carrying out the death penalty and how this creates an impediment to their oath to “do no harm.� Is it wrong for a doctor to assist in putting someone to death? Is it worse for them to stand by and do nothing while someone dies horribly because others were not trained to properly carry out the sentence?
My least favorite chapter was on childbirth and the various techniques for assisting with a birth which may have complications. While I suppose most people consider childbirth “a miracle� I think that an equally accurate description might be “grisly,� and Gawande goes into a lot of detail about various techniques which may prove my point. I honestly had to take a break.
Anyway, read this if you’re interested in process improvement, personal growth, or medical anything. It’s fairly short and goes quickly.
See more of my reviews: //
November 12, 2008
Atul Gwande's Better: A Surgeon's Notes on Performance is a collection of essays that probe skillfully and poignantly into the depths of medical ethics and the performance of doctors. He is a fine researcher and an astute observer who carefully delineates many facets of each issue that he explores, be it washing hands, malpractice concerns, or the Apgar score.
As a non-fiction writer, I was acutely aware of how adept Gawande is at using narrative to illustrate and discuss complex moral and ethical issues. He does not skirt controversial notions such as what happens to the soldiers who have been saved from grave injury on the battlefield and come home limbless and with horribly scared faces? Or why hospitals avoid publicizing the results of their effectiveness in treating certain conditions?
At the end of his book, he makes five suggestions about how doctors might make a worthy difference. All of these suggestions make sense for anyone wanting to make a difference. I'm only going to mention on that hits close to home: He says, "write something. . . it makes no difference if you write five paragraphs for a blog, a paper for a professional journal, or a poem for a reading group. Just write."
Let me add, just read Gwande's Better.
As a non-fiction writer, I was acutely aware of how adept Gawande is at using narrative to illustrate and discuss complex moral and ethical issues. He does not skirt controversial notions such as what happens to the soldiers who have been saved from grave injury on the battlefield and come home limbless and with horribly scared faces? Or why hospitals avoid publicizing the results of their effectiveness in treating certain conditions?
At the end of his book, he makes five suggestions about how doctors might make a worthy difference. All of these suggestions make sense for anyone wanting to make a difference. I'm only going to mention on that hits close to home: He says, "write something. . . it makes no difference if you write five paragraphs for a blog, a paper for a professional journal, or a poem for a reading group. Just write."
Let me add, just read Gwande's Better.
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