Sunday, 24 January 2016

Review: Better: A Surgeon's Notes on Performance by Atul Gawande

Blue shiny book cover of Better A Surgeons Notes on Performance by Atul Gawande
Last year I read and reviewed Complications: A Surgeon's Notes on an Imperfect Science, and immediatley ran out and purchased everything else that Atul Gawande had ever written. See, we say things like that a lot in our little book blogging world, but in this case that is genuinely and literally exactly what I did. These books are perfect in a lot of different ways and I really recommend them to everybody, whether they have a medical background or not.

Summary: In this unflinching look at medicine today, gifted surgeon and bestselling author Atul Gawande visits battlefield surgical tents in Iraq, a polio outbreak in India and malpractice courtrooms. He charts the race to extend cystic fibrosis patients' lives and discusses the ethical implications of doctors' participation in lethal injections in the United States. Examining everything from the influence of money on modern medicines to the contentious history of hand washing, this book provides a rare insight into what it takes to go from good to better.

The key thing to know about this book is that it's not about how doctors can make their patients better, it's about the ways they can improve to make their own practice and treatment regime better. That said, it's far from a manual aimed at lecturing hospital staff, it's an accessible and engaging collection of thoughts that I would say is aimed at the general public.

Mr Gawande has divided his book into three sections - Diligence, Doing Right and Ingenuity - which he says are the three core requirements for success in medicine, or any endeavour that involves risk and responsibility.

Diligence was perhaps my favourite of the three sections as it focuses more on doctors as people, and the tiny little everyday responsibilities that I find fascinating. It looks at how, despite the movement started in the 1840s to encourage doctors to wash their hands, a surprisingly large amount of them still forget when running from patient to patient. We also examine the huge-scale campaigns to eradicate polio and the effort required to vaccinate every single child in India, and the brave doctors who accompany the military to Iraq, Afghanistan and every other campaign across the globe.

Doing Right looks at the obligations that doctors and other medical professionals are under, and whether they are always strictly fair. For example, there's a chapter on whether it should be obligatory for a doctor to attend during a state execution or whether this directly contravenes their purpose, which is to heal people. I also really enjoyed the chapter about how doctors examine the more intimate areas of a person's body and whether a chaperone should be required.

Lastly, we look at Ingenuity, which covers the introduction of the Apgar score (which assesses the health of a newborn baby) as well as looking at how medical centers and hospitals and can improve by comparing the statistics of other, similar centers.

“It is unsettling to find how little it takes to defeat success in medicine. You come as a professional equipped with expertise and technology. You do not imagine that a mere matter of etiquette could foil you. But the social dimension turns out to be as essential as the scientific--matters of how casual you should be, how formal, how reticent, how forthright. Also: how apologetic, how self-confident, how money-minded. In this work against sickness, we begin not with genetic or cellular interactions, but with human ones. They are what make medicine so complex and fascinating. How each interaction is negotiated can determine whether a doctor is trusted, whether a patient is heard, whether the right diagnosis is made, the right treatment given. But in this realm there are no perfect formulas.
However, the topics almost fall into irrelevance when compared to Mr Gawande's prose. He writes with such humanity and grace that you'd be forgiven for thinking he was an author by trade, not a surgeon. I was also impressed by his seeming complete lack of bias. There's a chapter on medical malpractice lawsuits which was angering me more and more as I read on (as a disclaimer, I defend doctors from lawsuits for a living!) but he maintains a perfect tone throughout that accepts that doctors are people too. Mistakes are made, some are unavoidable whilst some are not, but perhaps patients do deserve some compensation when an avoidable mistake is made.

I'm unsure which of the two books, Complications or Better, I prefer. The topics are slightly different but naturally there is some overlap. Complications focuses more on surgical procedures but therefore involves more case studies, which doesn't really interest me because I do nothing but nosy at other people's illnesses at work. I can see how that might interest people not quite as pompous as myself, however.

Better doesn't feature any case studies and the sections on execution chambers and eradicating polio (amongst others) were fascinating. However, there are a few chapters on the cost of treatments, statistics and medical hierarchy that just weren't applicable to countries other than America. I ended up skipping the section on funding because it made so little sense to me. It's written just as well as the remainder of the book, but it just didn't appeal to me as a UK resident.   

To solve the comparison problem, I'd honestly just read both of them. And also Being Mortal: Illness, Medicine and What Matters in the End. I haven't read it yet, but I don't see it being anything less than amazing if his previous books are anything to go by. My one complaint about these series is that the silver leaf around the edges of the book does tend to rub off, which looks quite scruffy 280 pages later.

Read my review of Complications here. And then go read both these books!


  1. This sounds like one I'd like to read. I just haven't gotten round to his last couple of books. But it's funny--I was just talking about Gawande last night. I was at a little birthday party and several of the people there work at the hospital. One guy was talking about the confidentiality laws and how you really cannot say anything about a patient to anyone. You can't go home and say 'this one patient did thus-and-such..." -- just leaving names off is not enough. You can't say anything. So then I said "Well, what about those books, like Atul Gawande, where he talks about cases he's seen?" Reply: "He makes it up." Well, huh. Obviously he doesn't make up the history bits and I suppose he can talk about doctors failing to hand-wash, but he'd have to make up the patient stories. HIPAA, the confidentialty law, is very strict.

    1. Funnily enough I was thinking about this myself, and I don't think he DOES make it up. Firstly, all he'd need to get round confidentiality is a patient's consent, with overrides the legal duty. Secondly, I googled one of the patients in his Complications book and she DOES exist.

      Lastly, I figured that he'd be opening himself up to a larger lawsuit if he made it up. I mean, there's no disclaimer in his book about 'any resemblance to real patients is coincidental etc' and therefore any patient with that set of symptoms etc (who must exist) could easily launch a lawsuit. It makes more sense for it to be a real person who had signed a consent form, I think.

      Haha, clearly this crosses the mind of lots of his readers!

  2. I think I'll start with Complications, just because the American only bits would probably put me off this a little too. But another one for the wishlist! You're my go-to for interesting non-fiction, it's hard to find others who read (and then blog about) it.

    1. Haha, thanks! I love interesting non-fiction but you're right in that it doesn't seem all that popular.

      I'd definitely start with Complications. This one is mostly good, but Complications is good throughout the whole thing :)

  3. I've been meaning to read his Being Mortal.


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