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Better: A Surgeon's Notes on Performance by…

Better: A Surgeon's Notes on Performance (2007)

by Atul Gawande

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Showing 1-5 of 55 (next | show all)
Each chapter was compelling and could stand alone (which makes sense, since some started out as long articles in magazines like The New Yorker). Nearly all of the anecdotes were interesting and backed up his points well, and his way of framing things in a novel light was fun to read and think about. It reminded me a bit of Malcolm Gladwell, if you're into that.

Sometimes his own personal biases got in the way, though, particularly in the chapter about medical participation in lethal injections (so the conclusion he drew at the end seemed more informed by his gut than the stories he had just told us about). There was also a graphic description of a C-section in the chapter about obstetrics that bothered me, but otherwise the book was a really good read and an informative glimpse into a field I know little about. ( )
  jrogoff | Sep 22, 2018 |
Atul Gawande is a surgeon in Boston who is now known for the best-selling book Being Mortal. Better was his second book, in which he collects essays (in slightly different form, probably expanded) that were previous published in The New England Journal of Medicine and The New Yorker. In each, he explores ways in which doctors have attempted to improve performance, through the three large themes of diligence, doing right, and allowing ingenuity.

Though the book is was published in 2007, I imagine much of what he tackles in this book is still relevant in the medical field today. These themes are broad and allow him to reflect on topics as diverse as hand-washing (you'd be shocked by how much disease still travels because medical professionals don't wash hands between patients), ethical questions regarding doctors' presence or involvement in administration of the death penalty, and the difficulty in knowing when to stop fighting a disease and let someone live out their last days without medical intervention. It's a fascinating account that I would recommend to anyone. ( )
  bell7 | May 24, 2018 |
[Better] is a collection of articles written and published in The New Yorker and in The New England Journal of Medicine. All were published before 2007, since that was when the book first appeared. None seemed dated.

ON WASHING HANDS explores the history, the science, and the psychology of getting medical workers to wash their damn hands!

CASUALTIES OF WAR reports on astonishing improvement in the survival rate of wounded soldiers achieved during Bush-Cheney Iraq War, not because of miraculous new drugs or equipment, but because of the focus and speed of treatment. Doctors just behind the combat lines control bleeding, do essential surgical procedures, and move the patient—fast!—to a field hospital. A patient gets further treatment there, but one with grievous wounds is quickly transported to a permanent facility, say in Landstuhl, Germany or Walter Reed Hospital in Washington, D.C. There's more to it, of course, and Gawande explains.

NAKED addresses the issue—currently very topical—of the "etiquette of examination." Should a chaperone be called in to observe, say, a gynecologist performing an internal exam? Or a breast exam? There seems to be no universal protocol, so Gawande writes of his own experience, that of colleagues, and interviews he's had with doctors outside the U.S.

WHAT DOCTORS OWE deals with malpractice, as viewed by patients, malpractice attorneys, and doctors.

PIECEWORK explores how doctors are paid.

To get a sense of the numbers involved, I asked our physician group's billing office for a copy of its "master fee schedule," which lists what various insurers pay our doctors for the care they provide. It has twenty-four columns across the top, one for each of the major insurance plans, and, run­ning down the side, a row for every service a doctor can bill for. Our current version goes on for more than six hundred pages. Everything's in there, with a dollar amount attached. For those who have Medicare, the government insurance pro­gram for the elderly—its payments are near the middle of the range—an office visit for a new patient with a "low complex­ity" problem (service No. 99203) pays $77.29. A visit for a "high complexity" problem (service No. 99205) pays $151.92. Setting a dislocated shoulder (service No. 23650) pays $275.70. Remov­ing a bunion: $492.35. Removing an appendix: $621.31. Remov­ing a lung: $1,662.34.

THE SCORE is about building a base of evidence upon which to frame medical decisions and to evaluate results. Gawande uses obstetrics and what is known as the Apgar score to explain the benefits. The narrative thread tells about the birth of a new doctor's first child, a delivery that features an extremely long (almost 40 hours) labor (for a lot of reasons, each of which is explained), concluding in a C-section that itself is not without a complication or two.


Finding a meaningful way to measure performance, as Virginia Apgar showed was possible in child delivery, is a form of ingenuity in itself. What you actually do with that measure involves another type of ingenuity, however, and improvement ultimately requires both kinds. One person who has understood this is a Minneapolis doctor who has spent four decades perfecting care for a single, rare, and fatal disease.
[cystic fibrosis] His experience holds a lesson for all of us.

FOR PERFORMANCE argues that improved performance by medical practitioners can yield greater improvements in outcomes than great laboratory breakthroughs. This was impressed on Gawande during a two-month tour of medical facilities in India.

[D]espite the conditions, the surgeons have persisted in de­veloping abilities that were a marvel to witness. I had gone there thinking that, as an American-trained surgeon, I might have a thing or two I could teach them. But the abilities of an average Indian surgeon outstripped those of any Western sur­geon I know...
  On rounds...with a staff surgeon..., I saw patients he'd successfully treated for prostate ob­struction, diverticulitis of the colon, a tubercular abscess of the chest, a groin hernia, a thyroid goiter, gallbladder disease, a liver cyst, appendicitis, a staghorn stone in the kidney, and a cancer of the right hand—as well as an infant boy born with­out an anus in whom he'd done a perfect reconstruction. Us­ing just textbooks and advice from one another, the surgeons at this ordinary district hospital in India had developed an as­tonishing range of expertise...
  Among the many distressing things...was the incredible numbers of patients with perforated ulcers. In my eight years of surgical training, I had seen only one pa­tient with an ulcer so severe that the stomach's acid had eroded a hole in the intestine. But...people eat intensely hot chili peppers, and pa­tients arrived almost nightly...The only treatment at that point is...a big and trau­matic operation, and often these patients were in no condi­tion to survive it. So Motewar
[an Indian surgeon] did a remarkable thing. He invented a new operation: a laparoscopic repair of the ulcer­ous perforation, using quarter-inch incisions and taking an average of forty-five minutes. When I later told colleagues at home about the operation, they were incredulous…
  True success in medicine is not easy. It requires will, at­tention to detail, and creativity.

This is a long report on a relatively short book. But it's a good book to read and think about. Two thumbs up.
  weird_O | Mar 23, 2018 |
This is the third of Dr. Gawande’s books I’ve read and reviewed for Cannonball Read, and it’s probably my least favorite. However, it’s still a decent book that I’m glad I read.

The book is ostensible about ‘how success is achieved in this complex and risk-filled profession,’ talking about medicine. And there are certainly many really compelling stories about medicine. But I wasn’t really able to follow any sort of coherent theme to the stories. I almost felt like I was reading a collection of interesting essays as opposed to a book that was seeking to make a strong point about how to improve the field of medicine (and, in turn, other field).

Dr. Gawande splits the stories into three sections: diligence, doing right, and ingenuity. There are three-five stories in each section that purport to demonstrate the benefits of diligence, doing right or ingenuity. I think the strongest, most interesting section for me is the Doing Right section, especially in areas such as the ethics of physicians participating in the death penalty. And as I said, all of the stories are interesting to read, but I don’t think Dr. Gawande does a great job connecting them or really telling the ready what point he’s looking to make.

The book ends with a few pages that seem to come out of nowhere but that I think could have been woven into the book to create that theme that I felt was missing. Dr. Gawande proposes five things to do to improve in your field: ask an unscripted question, don’t complain, count something, write something, and change. I can see applying these to my current work, and would have enjoyed reading more about them in relation to the stories he has told throughout the book. ( )
  ASKelmore | Jul 9, 2017 |
I enjoyed Better almost as much as I did [Being Mortal]. In this book, Gawande discusses what it is that make some doctors and some hospital programs better than others. Why hand washing--so important in halting the spread of MRSA--is so difficult to convince staff to do--even doctors! He discusses the upward trend of C-sections and the disuse of forceps in childbearing. Plus, as they say, so much more!

I especially like his five steps to making the practice of medicine--of anything, really--more rewarding. I'll add a zeroeth one right now (for Asimov fans):
0. Read the book
1. Ask an "unscripted" question. Talking to the grocery clerk? Ask a non-grocery related question. See them as a person, not just a clerk.
2. Don't complain. We can all gripe about something, but it tends to feed on itself. And all it accomplishes is to drag you down. Change the subject.
3. Count something. Find something you are interested in and become an expert in it.
4. Write something everyday. A paper to be published. A poem. A blog. A letter to your older sister.
5. Change. Become an early adopter. Exchange that old flip phone for a smart one. Upgrade your operating system. Luckily, we no longer have to learn to program the clocks on our VCRs (if you still have one, consider donating it for parts), but think about what has you stumped and waiting for your third grade granddaughter to come visit. ( )
  kaulsu | Oct 17, 2016 |
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For my parents and sister
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Several years ago, in my final year of medical school, I took care of a patient who has stuck in my mind.
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Amazon.com Product Description (ISBN 0312427654, Paperback)

National Bestseller

The struggle to perform well is universal: each 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 may be on the line with any decision.


Atul Gawande, the New York Times bestselling author of Complications, examines, in riveting accounts of medical failure and triumph, how success is achieved in this complex and risk-filled profession. At once unflinching and compassionate, Better is an exhilarating journey, narrated by "arguably the best nonfiction doctor-writer around" (Salon.com).

(retrieved from Amazon Thu, 12 Mar 2015 18:11:01 -0400)

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The struggle to perform well is universal: each 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. Author 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 stories 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 dilemma of lethal injections, examines the influence of money on modern medicine, and recounts the contentious history of hand washing. And he gives us an inside look at his own life as a practicing surgeon, offering a firsthand account of a field where mistakes are both unavoidable and unthinkable.--From publisher description.… (more)

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