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Better: A surgeon’s notes on performance

Article in Journal of Clinical Investigation · June 2007

DOI: 10.1172/JCI32520 · Source: PubMed Central


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Oliver J Warren
Imperial College London


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Book review

A surgeon’s notes on performance
Atul Gawande
Metropolitan Books. New York, New York, USA. 2007.
288 pp. $24.00. ISBN: 978-0-8050-8211-1 (hardcover).
Reviewed by Ara Darzi and Oliver Warren
Department of Biosurgery and Surgical Technology, St. Mary’s Hospital,
Imperial College London, London, United Kingdom.

I n Better: a surgeon’s notes on performance,

Atul Gawande, best-selling author of Com-
the almost obsessive diligence of the clini-
cians responsible and their need to “make a
Finally “ingenuity” is addressed, a matter
“more about character and less about supe-
plications: a surgeon’s notes on an imperfect science out of performance.” rior intelligence.” The near-obsessive nature
science, general and endocrine surgeon at When considering “doing right,” the required not only to attain excellence, but
Brigham and Women’s Hospital, and assis- author tackles a number of compelling to then perpetually evolve to stay ahead is
tant professor at Harvard Medical School issues, including the litigious nature of illustrated by the fascinating tale of LeRoy
and Harvard School of Public Health, American society toward health care pro- Matthews and Warren Warwick, pediatri-
investigates human performance in medi- viders. We are introduced to two interest- cians who led the development of centers of
cine. He takes the reader to courtrooms, ing individuals, a physician colleague of expertise for cystic fibrosis. As fellow clini-
clinics, war zones, and execution chambers Gawande’s whose son was harmed by medi- cians, we find these stories describing phe-
to demonstrate the incredible environ- cal error and an ex-clinician now practicing as nomenal improvements in patients’ results
ments in which doctors care for and treat a medical malpractice lawyer, and thus gain through the targeted efforts of a few doctors
patients. While drawing on a vast array of novel insight into the difficulties associated to be inspirational and to serve as examples
sources, including his own personal expe- with rectifying the occasional harm that may of what can be achieved if a culture of intel-
rience, Gawande interweaves into nearly inevitably result from health care. Gawande’s lectually rigorous self-improvement is adopt-
every chapter fascinating vignettes about approach is novel and intelligent and allows ed within a unit. However, the next logical
the most important person in his view of all parties to consider this troublesome area step is to question why we are not all this way.
medicine: the patient. By ensuring that from enlightened viewpoints. As he declares, Gawande does not shrink from considering
every message is personalized in this man- litigation is a “singularly unsatisfactory solu- this bell curve of clinician performance and
ner, he brings a warm, humane touch to tion,” bringing out the worst in everyone and how it applies to his surgical practice and
this superb book. often failing to help those injured by medical medicine as a whole. We are in an uncom-
Gawande defines “three core require- error. The search continues for more produc- fortable period for clinicians, as more and
ments” for successful performance in medi- tive ways of recompensing victims, but cre- more of our work is subject to public scru-
cine — diligence, doing right, and ingenuity ative potential solutions are offered and are tiny and objective assessment, a situation
— and in turn considers specific problem worthy of consideration. that meets with significant opposition from
areas in each. He cites three distinct exam- Gawande moves on to consider what may many colleagues. How, when, and by whom
ples in which diligence is essential to the be the most controversial topic in the book: should this grading occur? Will being in the
successful execution of medical therapy: the role of physicians in state-sanctioned below-average group be used against us? Will
the WHO’s mop-up of a polio outbreak in executions. “Doctor D” is an anti–capital those at the bottom be remunerated less than
rural India; the efforts of the US military’s punishment activist who has supervised those at the top? Answers are not offered to
medical staff to save the lives of servicemen the executions of six of his “patients” and all these questions, but as fellow surgeons, we
seriously injured in Iraq; and the work of who donates his entire fee for this service to share the author’s only definitive conclusion
infection-control specialists to ensure hand a children’s shelter. He considers those on — that there is no shame in being average, but
washing to prevent the spread of hospital- death row to be “legally” terminally ill and settling for average is unacceptable.
acquired infections. The numbers cited in thus feels a responsibility to ensure their Better opens a door to the oft-closed
each example are impressive and daunt- final minutes are as pain free as possible. world of medical performance for careful
ing: 4.2 million Indian children vaccinat- The paradox is intriguing, and Gawande is scrutiny, explores variations in standards of
ed by 37,000 vaccinators over three days; not judgmental. His moral indignation at clinical practice, and challenges all involved
60 to 70 surgeons supporting the 130,000 the very thought of colleagues participat- in health care to adopt the role of “positive
troops fighting in Iraq (where injuries are ing in this process rescinds to a realization deviant.” By refusing to flinch when faced
horrific); 2 million Americans contracting that the ethical issues are perhaps more with controversy, Gawande has created an
hospital-acquired infections per annum. All complex than first thought, a realization essential text for both patients and their
of these efforts are demonstrably linked by we share as readers. doctors, to the betterment of us all.

1454 The Journal of Clinical Investigation    Volume 117    Number 6    June 2007

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