Book Review: Better: A Surgeon's Notes on Performance

April 2008

Atul Gawande’s most recent book uses several situations in medicine to highlight the keys to being successful and effective. In this way, while the book is ostensibly about medicine, its lessons can be applied to many more facets of life outside the operating room.

One of the first situations that Gawande describes is a good example of this - the attempts to control a polio outbreak in India. While it is a medical condition, it’s easy to see how the problem has much more to do with logistics, coordination, designing processes, and quality assurance than it has to do with the actual medicine that is being practiced (i.e. delivering a vaccine).

Gawande next describes surgeons charged with taking care of the war wounded in Iraq and Afghanistan - a distinctly medical situation. But again, his focus is not on the medicine practiced there but instead on the ways that those doctors improved the process used to treat wounded soldiers. Doctors studied patient records to determine what resources were most needed and when in order to save more soldiers. In some instances, changes to equipment were made to help ensure compliance in wearing it, even though soldiers knew it was a matter of life or death. Interestingly, the doctors’ success rate has helped to deflate the number of US casualties in the war - approximately 10% of the wounded now die, a dramatic decrease from previous combats. This means that the death toll (which recently exceeded 4,000) is a deflated estimate of the human cost of the war (not to mention the civilian casualties). This also means that we will continue to pay the cost of the war for years to come, as soldiers with severe injuries continue to require advanced care.

The doctors caring for the war wounded followed one of the pieces of advice that Gawande leaves his readers with: measure something. It doesn’t matter what you measure, just measure something. This advice appeals to the inner scientist and tinkerer in me - we have some results, now what happens to them when you change things?

Overall, a very good read. I found the parts on doctors’ roles in executions to be less interesting than the rest of the book. My favorite part by far was the descriptions of childbirth and particularly the procedure of the C-section. It brings up very interesting points about medicine as a craft (delivering a baby naturally in the face of complications) versus an industry (the C-section) and what that implies for medical training.