A Surgeon's Notes on Performance
By Atul Gawande
Metropolitan. 273 pp. $24
How self-conscious should a surgeon be? In some ways, we all (and I think I speak for other doctors here, as well as for patients) cling fast to the idea of surgical confidence: the godlike operating-room decisiveness, the courage to cut, the steady hand. But the willingness to turn that paradigm inside out helps Atul Gawande keep things interesting, as he directs his attention to how doctors and medicine can strive to be, well, Better. In his first book, Complications, which was, like this one, built on essays previously published in the New Yorker and the New England Journal of Medicine, Gawande looked at a range of subjects -- a range of topics and a range of patients -- but many of the questions that drove him arose directly from his own long and arduous surgical training. Now fully fledged ( Better includes a humorous episode in which he is asked to name his salary, as a surgeon, and finds himself at a loss, unsure how to value his work, unable to discuss it frankly with colleagues -- and unwilling, ultimately, to tell us what figure he names), he takes a direct and sometimes disconcerting look at the job he has chosen.
Again and again he comes back to how easy it is to practice medicine poorly -- to the question of how highly trained, hard-working and perfectly well-intentioned people can subvert their own efforts and fail the patients who depend on them when the stakes are life and death.
He isn't talking heroic science here, or even heroic surgery. He's talking about what he calls "diligence," the institutionalization of absolute attention to detail. For example, he's talking about the battle -- now more than 100 years old -- to get doctors to wash their hands, about figuring out why they often don't or won't, and about making changes that can prevent hospital infections and save patients' lives.
The same themes emerge in his section on "ingenuity," when he looks at the success rates of specialized centers that take care of children with cystic fibrosis. With cystic fibrosis, as with many other illnesses, when you rank institutions according to their patient outcomes, you get a bell curve: "a handful of teams showing disturbingly poor outcomes for their patients, a handful obtaining remarkably good results, and a great undistinguished middle." What distinguishes the very best centers, Gawande argues, is a willingness to confront problems and errors, to look for new and ingenious approaches and to apply those approaches with unusual diligence and aggressiveness.
Better resonates with certain recent themes in medical self-awareness -- with the 1999 Institute of Medicine report on medical error, for instance, which made headlines with its high numbers of people killed and injured in hospitals. But Gawande adds to the discussion by taking us to interesting places -- professionally, geographically, historically -- as he examines the details of trying to do the job properly, and by writing about it all so lucidly. He is particularly expert at following the expanding ripples of meaning out from a central medical story. He starts with the children struck down by what everyone hopes will be among the last cases of polio in India. Watching government doctors in the "mopping up" stage of wiping out polio, he sees a lesson in the lo0gistics of "diligence," of attempting to eliminate a disease case by case, house by house, village by village. "If the eradication of polio is our monument, it is a monument to the perfection of performance -- to showing what can be achieved by diligent attention to detail coupled with great ambition."
One striking essay discusses the treatment of battlefield wounds and addresses the question of how military doctors have been able to drive their mortality statistics way down. From the Korean War through the Persian Gulf War, the death rate of soldiers wounded in battle stayed at about 24 percent, Gawande says, but in Iraq it has dropped to 10 percent. When he questioned military doctors, "what they described revealed an intriguing effort to do something we in civilian medicine do spottily at best: to make a science of performance." The story is particularly moving because the voice of a surgeon comes through, admiring the skills shown by his military colleagues, and yet profoundly sad. If the eradication of polio could be a monument, a gift to future generations, the heroic salvage of young people brutally injured in war is something else, something that hints at a much harsher truth of life and death and human nature.
Better makes a compelling case for medical self-awareness in the operating room, on the hospital ward and even on the battlefield. Gawande succeeds in looking at medical achievement -- and lapses -- from a new perspective. His stories evoke the profound desire that doctors feel to cure, along with our besetting anxieties about poor performance and its consequences. He makes his case that failure is "so easy, so effortless," but also that "positive deviance" -- deliberate and determined individual improvement -- is possible. His own self-consciousness, his ability to ask questions about the nuts and bolts of medical practice, and his storytelling skills make this a book about the complex grandeur of the human endeavor that is medicine. ·
Perri Klass, a professor of journalism and pediatrics at New York University, is the author of the forthcoming "Treatment Kind and Fair: Letters to a Young Doctor."