Saturday, 31 May 2008

Better: A Surgeon's Notes on Performance

Better: A Surgeon’s Notes on Performance: not a book that I would ever have considered picking up, let alone reading. The groupie who suggested Better is a doctor, and an American one at that: ah, we thought, this book will be very medical, very deep. But that is the great thing about book groups; members are encouraged to read out of their comfort zone, often with a pleasant result.

Atul Gawende is a surgeon in one of Boston’s leading hospitals – no ordinary surgeon I might add. He also has a degree in PPE from Balliol, is an assistant professor at Harvard School of Public Health, a staff writer on The New Yorker and a writer of two books to date. This,his second, is based on some essays that he originally wrote for the New Yorker.

He’s arranged the essays into a book of three parts: Diligence, Doing Right and Ingenuity. It is a warm, easy to digest, interesting read in which the author is not ashamed to admit to his own mistakes. And the overall message is: how can doctors do better? What does it take to go from being good, to being better. Indeed, how can we all do better at whatever it is we attempt.

Each of Gawende’s chapters focuses on a particular area of medicine and one in which change - sometimes of the most minor - can make the difference between correct and incorrect diagnosis, average and excellent treatment, life and death. In the first part, Diligence, he starts with a chapter entitled ‘On Washing Hands’ and shows that just how well it is followed can impact of the worldwide hospital problem of MRSA.

In the next chapter, ‘The Mop Up’, he looks at vaccination programmes and how this has had world changing results, but that when it is not carried out the effect can be fatal. In these chapters, as in all the following ones, Gawande does not preach, nor does he patronize, but instead he deconstructs the reasoning behind these practices and shows how the issues are often more complex than it might seem on the surface. Everywhere he finds paradox, conundrums, quandaries, heroism and dedication.

In the second part, Doing Right, there is a chapter ‘On Fighting’ and how it is necessary to fight for your patient when everything around the doctor tells him that he has done all he can. I guess it could be called ‘going that extra mile’. His style for each chapter begins with a short story, usually open-ended. He then goes off at a tangent with a human tale or other. Finally, at the end of the chapter, he draws all the threads of his tale together and often leaves the reader with a question, philosophical poser or bon mot.

‘The Score’ is a chapter in part three, entitled Ingenuity, in which Gawende relates the story of a multi-talented female doctor who, in 1933, was thwarted in her attempt to be accepted as a surgeon because of her sex. She went on to devise a test that is still used today to score the condition of a new born baby. Ingenuity, the reader can see, applies to us all no matter what job we do.

The chapter, ‘The Bell Curve’, describes the treatment of cystic fibrosis: he explains the graph – the bell curve - that shows the results of all the centers treating it in the USA. He explains that no matter how the treatments improve there will always be a bell curve which shows the average outcome of treatment. However, at the end of this long and interesting essay he concludes that the average may always be there but that is always room to raise the bar and for every one to try and be above average.

All of us in the book group enjoyed the book, everyone finished it, and it made us question how we do things, if we are happy to be average, if we do go that extra mile and try to be better as often as we should. Our French groupie described is as a ‘very American’ book – which it is – but a very good one. I shall read it again, if for nothing else, to remind me to try harder and to wash my hands that bit longer and that bit better.


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