Better Summary

Atul Gawande


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Better Summary

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Atul Gawande’s Better: A Surgeon’s Notes on Performance is a 2007 nonfiction book about the practice of medicine and how doctors can do right by their patients. He discusses personal stories from his career as a surgeon, the history of how medicine has evolved, medical ethics, and more. Gawande is a surgeon at Brigham and Women’s Hospital in Boston, a professor at Harvard Medical School and the Harvard School of Public Health, and an award-winning writer of several books, including Complications: A Surgeon’s Notes on an Imperfect Science.

Gawande’s book is intended as a discussion of human performance in medicine, taking the reader around the world to battlefields, courtrooms, execution chambers, and more. Throughout the book, he focuses his scenes and anecdotes around the patient in question. He does not lose sight of their importance.

The book’s central argument revolves around the three core requirements for a successful practice of medicine: diligence, doing right, and ingenuity. Gawande defines each requirement and discusses examples of what that requirement looks like.

First, Gawande looks at medical diligence. One example of this diligence is the importance of hand-washing. Once a controversial practice, the thorough washing of hands can save lives. He writes that the number of bacteria living on unwashed hands can range from 5,000 to 5 million per square centimeter. Given this statistic, it might sound surprising that many practices find it difficult to get all medical staff to comply with official policies, but following proper procedures to wash hands after every patient encounter is time-consuming. Many staff members cut corners to save on time. Bacteria-killing gels are useful, but not effective enough in increasing compliance. Following proper procedure is essential for preventing the spread of infections like MRSA and VCE within hospitals. Diligence and compliance seem like they should be straightforward and a matter of common sense, but in practice, the pressure of time and efficiency mean staff are less diligent than they need to be.

In Gawande’s next essay, he discusses a different aspect of diligence: the great lengths the WHO went to in order to contain an outbreak of polio in rural third-world countries. Through a great and grueling effort on the ground, medical professionals were able to vaccinate 25 million children in India, China, Bhutan, Thailand, Pakistan, Vietnam, and Burma in a single week. Gawande writes that if we are someday able to eradicate polio through vaccinations, it will be “a monument to the perfection of performance.”

Gawande’s third example of diligence is of military medics working to save the lives of US soldiers injured in Iraq. At one point during the war, casualties were on the rise. Eventually, the military realized that trauma care was the root cause of the increase. An observation of the data led to improvements in trauma care that saved lives and reduced the number of casualties.

In the next section of the book, Gawande considers what it means for doctors to “do right” by their patients. He brings up the issue of medical malpractice and lawsuits through two stories: one of a colleague whose son suffered injury as the result of a medical error, and the other of a former physician who now works as a medical malpractice lawyer. Gawande uses their stories to explore both sides of the issue, concluding that malpractice lawsuits result in poor outcomes for both parties. He writes that a more satisfying way to resolve questions of error is needed. As it is, patients rarely receive satisfactory compensation if they sue for malpractice, while for doctors, a single error could cost them their license.

Gawande also discusses the role physicians play in executions, supervising the sentences of criminals on death row. He profiles “Doctor D,” a man who oversees these deaths despite his anti-death penalty activism. As Gawande explains, Doctor D sees himself as ministering to patients who are akin to terminally ill patients, but from a legal standpoint rather than a medical one. They are going to die regardless, so he considers it his duty to ensure their final moments are free from pain. Gawande considers the complex ethical dilemma posited by doctors participating in sanctioned executions.

The final section of the book explores medical ingenuity. Gawande explains that the term is not so much about intelligence as character: ingenuity, to him, requires an obsessive mind willing to continually evolve to stay at the top of the field.

Gawande uses Virginia Apgar as an example. Back in the 1930s, childbirth mortality rates were high for women. Apgar invented a scoring system to measure the health of a newborn immediately after its birth. The variables in the score could be measured and tracked in a way that led to significant improvements in the childbirth process. Another example is of LeRoy Matthews and Warren Werwick, pediatricians who developed expertise in fighting cystic fibrosis. Their targeted efforts in fighting the disease led to surprising improvements in treating it.

The book concludes with Gawande’s advice for medical students: ask unscripted questions to learn more from patients, don’t complain, count something, write something, and change (or be willing to change).

Better, like Complications before it, was a nonfiction bestseller. selected Better as one of the 10 best books of 2007. Gawande has since written additional books about the human side of medicine, including The Checklist Manifesto and Being Mortal: Medicine and What Matters in the End.