Performance review

Rashaad Bhyat

doi:10.1503/cmaj.080922

Better: A Surgeon's Notes on Performance Atul Gawande MD Metropolitan Books/Henry Holt Company; 2007 273 pp $14 paper ISBN 13 978-0312427658

As doctors, we spend a lot of time thinking: about patients, about their presenting complaints, about diagnoses. In the course of a whirlwind workday, however, finding the time to ponder one's performance objectively is often a luxury.

In his second book, Better, surgeon Atul Gawande demonstrates that he has made this activity a priority.

Photo by: Metropolitan Books/Henry Holt Company

Gawande is an accomplished writer with an impressive pedigree, having received both his doctor of medicine and master in public health from Harvard University, as well as a master of arts from Oxford University, he is now a staff writer at The New Yorker. In Better, Gawande methodically outlines his thoughts on how continuous innovation and improvement produces enhanced medical care. Drawing upon both research and anecdotes from the far reaches of the medical profession, he illustrates how small changes and determination can produce impressive, better, results.

He proposes 3 core attributes contributing to success in almost any risky field: diligence, ingenuity and doing right. Without “diligent attention to detail coupled with great ambition,” public health officials could not surmount the daunting logistics of polio eradication in rural India. Without the innovation of a simple scoring system (the Apgar score), thousands of newborns might have otherwise perished. Without the impetus to “do right,” medicine might be indistinguishable from other businesses.

Gawande assiduously points out how small, simple changes in routine behaviours lead to drastic changes in performance: the correct and convenient placing of hand-gel dispensers in hospital wards, for example, decreases the spread of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci.

Modifying entrenched human behaviour is an onerous task, even more difficult in medicine, a notoriously conservative profession in which change often comes slowly.

In a field entrusted with promoting health and saving lives, this reticence is disturbing, and perhaps the reason that the author highlights so many examples of where change has been successfully implemented with a positive benefit to performance.

The current Iraq war provides one of the most dramatic illustrations. By 2005, American military physicians and surgeons managed to reduce the battle injury mortality rate to roughly 10% from 24%, a level previously unchanged from the Korean War up to the Gulf War in 1990. Their success resulted from meticulous record keeping, careful examination of policies and procedures surrounding medical care in the field, and the introduction of clear measures to alter the de rigueur practice.

Perhaps the most important concept Gawande identifies in this book is the role of the “positive deviant,” the individual or group that performs above average in a particular endeavour, be it infection control or the management of cystic fibrosis. He encourages us all to be positive deviants, or at least to find out how positive deviants operate in our respective fields and learn from them.

Recently published in paperback, Better is a fascinating read. Gawande writes in a clear conversational style with enough medical jargon to engage physician readers, but not enough to bamboozle the layman. With this book, Gawande reaffirms that he is indeed the thinking doctor's doctor.