Better: A surgeon's note on performance

By Atul Gawande. 273 pp. New York, Metropolitan Books, 2007. $24 (cloth); $14 (paper). ISBN 978-0-8050-8211-1 (cloth); 978-0-312-42765-8 (paper).

We are used to thinking that a doctor's ability depends mainly on science and skill . . . these may be the easiest parts of care. Even doctors with great knowledge and technical skill can have mediocre results; more nebulous factors like aggressiveness and diligence and ingenuity can matter enormously.
— Atul Gawande, from Better

I first encountered Atul Gawande's writing while browsing through The Best American Essays 2003 (New York: Houghton Mifflin) in an airport bookstore. I was absorbed by his account, in his essay "The Learning Curve," of how a few treatment centers for cystic fibrosis consistently outperformed others in the United States — at the best ones, the life expectancy for patients was almost 14 years longer than it was for patients who were treated in the average clinic. The details of this surprising story have clear implications for the treatment of many chronic illnesses. I was thus pleasantly surprised when, 2 years later, a colleague passed around copies of this essay (first published in The New Yorker) at a weekly meeting of outpatient psychiatrists at our community mental health center. He used the essay to jump-start a discussion on how to improve the care of the chronically mentally ill at our center. This proved to be a wise choice.
Gawande, a general surgeon at Brigham and Women's Hospital in Boston, writes in the style of the physician as investigative reporter-cum-novelist. In "The Learning Curve," he demonstrates as much interest in the characters who play out their roles in the narrative as he does in the clinical realities and broader social contexts in which they operate. This is an approach that pervades Better, a collection of essays (many of which have been adapted or reproduced from other sources, including the Journal) in which Gawande takes on a variety of issues such as malpractice claims, physician compensation, and the limits of medical interventionism. The physician reading these essays is rewarded by revisiting these much-discussed topics with a searching, self-critical interlocutor. The narratives are rich in detail and avoid simplistic conclusions. There are also interesting anecdotes that are unlikely to find their way into traditional medical curricula. For instance, Gawande tells the story of how the U.S. government determined the 1992 Medicare fee schedule, which necessitated an absurd ranking of the relative amounts of effort — and therefore compensation — that is required for various tasks in different specialties. In this reckoning, a hysterectomy came out to be 4.99 times as taxing as a session of psychotherapy.
The most provocative essays in the collection, however, describe situations in which outcomes were made better against improbable odds: the attempt by the World Health Organization in June 2003 to vaccinate 4.2 million children during 3 days in southern India against a polio outbreak; the unprecedented success of U.S. combat support hospitals in limiting battlefield casualties in Iraq; and the grinding but important work of improving hand-washing practices in hospitals. Gawande's choice of a first-person account precludes quantitative analysis or a simple prescription for quality improvement. This makes it difficult to arrive at any definitive sense of the "active" ingredient in any of the complex interventions he describes — is it a charismatic leader, or a common understanding of mission, or is it missing from the account? If this is a weakness from one perspective, it is also the case that stories — especially when they are told this well — are more powerful than statistics in engaging the reader with the issues, provoking inquiry, and highlighting the irreducible human element in health care delivery. The sections in this book are tellingly titled: "Diligence," "Doing Right," and "Ingenuity."
During the past year, discussions at our weekly group — sparked by "The Learning Curve" — have led in many directions. Taking our cue from Don Berwick, one of Gawande's protagonists, to "measure ourselves and be more open about what we are doing," we have debated many questions: Which scale for serious mental illness could rival the efficiency of the Apgar score (discussed in Gawande's essay "The Score")? Can frontline clinicians collect reasonably unbiased responses from their patients? Can we enlist clinicians in identifying treatment failures without fear of blame? Do we have the resources to measure symptomatic status and function? What is a meaningful patient-oriented outcome in a disorder that affects the neurobiology of motivation? In the face of these conceptual and pragmatic barriers, one could read the stories in Better as a kind of talisman against nihilism.
This is an important book that deserves to be widely read, especially by physicians who have recognized the limitations of their individual clinical expertise and have begun to think about their larger role in a system of health care delivery.


Book review by Vinod H. Srihari, M.D. Yale University School of Medicine New Haven, CT 06519 vinod.srihari@yale.edu

NEJM Volume 358:755-756 February 14. 2008, Number 7