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highly recommended |
Difficult problems are ... difficult 
First, as a quick proxy of how good it is, and as a way of enticing busy readers, I should note that I finished Atal Gawande's book Better: A Surgeon's Notes On Performance in less than four hours. I can't remember the last time that happened. True, it's a relatively short book, and I had some uninterrupted time on a bus. But mostly it's that Gawande is a straightforward, energetic, thoughtful writer whose essays relentlessly pull you forward. Each discusses one or two ideas in enough depth to make you realize that they're not easy problems -- which is all most people need, and which does a world of good on its own. Every country has its unquestioned assumptions; it's the rare writer who helps us question them and gently remind us that if there were easy solutions, we'd have found them by now. Gawande is good at that.
The most moving and thought-provoking of these essays, to me, was "The Doctors of the Death Chamber," in which Gawande interviews four doctors (whom he labels "A," "B," "C" and -- wait for it -- "D," in order to secure their anonymity) who help states carry out the death penalty humanely. The use of "humanely" here is questionable; it's humane in the sense that, if we are to use the death penalty, we must not be needlessly cruel at the time of the criminal's death. But it's inhumane in the larger sense that we are furthering a corrupt system -- we are "tinker[ing] with the machinery of death," to use Justice Blackmun's words. Since a doctor's role is to protect human lives, are anaesthesiologists who help execute people painlessly violating their roles? To put it more succinctly: should a doctor make the best of the machinery of death, or should he take no part in the machine? The American Medical Association has its answer and its role. Democratically elected governments have their own. It's Gawande's job to teach us that easy answers don't exist for complicated problems like this.
One reason it's so easy to come up with easy answers for questions like this is that we rarely come face to face with the system we critique. Gawande does the legwork for us. He's at his best, in this regard, when he interviews a medical-malpractice attorney, a doctor, and the family of a dead patient involved in one malpractice case. We're all inclined to boo at the malpractice attorney . . . right up to the moment we feel we've been wronged, when that attorney is the man we want on our side. Gawande knows that this is how we work, so he takes some time to look at a case when doctors failed other doctors: Gawande's friend Bill Franklin found that doctors had failed to treat a tumor on Franklin's son that they should have noticed years before -- that someone had actually singled out on an X-ray for further study. This is the test case where ethics hits the road: when it's your own son, and you're a doctor, and you're well aware of the expenses of medical malpractice, what do you do? After trying other routes, Franklin did what so many others do: he sued and won. (Along the way Franklin helped establish a precedent in the Massachusetts Supreme Court, in the case of Franklin v. Massachusetts General Hospital et al., affecting the statute of limitations on malpractice cases. Seems worth reading.)
Better contains lots of great little insights into the medical profession -- for instance, how difficult it is to get doctors and nurses to wash their hands as often as is safe for patients, or the awkwardness of a male doctor palpating a naked female patient. Throughout it all, Gawande's organizing principle is to lay out for us the system in which doctors work, the limitations they operate under, and how they make the best within those limitations.
I'm less inclined than I used to be to believe that Gawande has an agenda, but I do think that a slightly different arrangement of the chapters within Better would have sent a different message. Had the chapter on malpractice come at the end of the book, after we've read about Gawande's own mistakes and about sloppy handwashing, we'd be less sympathetic toward doctors. In "The Score," which I've mentioned before, Gawande tells us that C-sections are vital in a world where doctors can't be expected to be very talented; in "The Bell Curve," he reveals that not all cystic-fibrosis clinics are the same, and that the medical industry was reluctant for years to release data on how well individual clinics performed. With these insights in mind, malpractice would seem to the reader to be completely justified. As it is, the malpractice article is tucked into the middle of the book; Better ends with a story about heroically performing surgery in poor rural India, and with a few pieces of advice to newly-minted doctors. It's a hopeful ending. I can't decide whether this arrangement was deliberately obfuscating. Nor does Gawande spend much time explaining whether malpractice makes doctors better.
He's fair throughout, however, and his point is that doctors' work is hard. Understanding precisely why it's hard, and what they do to get their jobs done under trying conditions, is Better's job, and it succeeds admirably. It's a great, thought-provoking, fun read.
Modern business principles in the medical industry?
When I was an MBA student, I became fascinated with the continuous improvement philosophy espoused by Deming. This is the philosophy that drives Toyota and many other companies to achieve ever-higher levels of quality. Coincidentally, at that time in my life a coworker named Atul exemplified this philosophy in everything he did. So here we are with a book authored many years later by a person named Atul, and that book talks about improving performance.
In some areas of endeavor, constant improvements in performance are mandatory for a business to survive. A prime example is the online business world. Sites that don't constantly improve and innovate lose customers and die. We can go back to the Toyota example and see exactly why Toyota dominates the US auto market. While American automakers have been playing infighting games, Toyota has focused on making a better car. They have continually eliminated defects and instituted improvements, no matter how minor.
In other areas, improvement is completely at odds with the culture. A prime example is the typical government agency. "Customers" of government agencies have no choice in vendor. Bureaucrats continue to draw their salaries, while 20 or 100 people do the job of one person about as poorly as is humanly possible. This has led to countless jokes about the DMV. It's also responsible for the adage, "Government takes the path of least competence." Behavior that isn't tolerated in performance-driven companies is actually rewarded in many government organizations. There are exceptions, and I will note one of those in a moment.
In between these two ends of the spectrum, we find the medical care industry. And it's here were Atul Gawande lives and breathes. In this book, he shatters many myths about medical care. For example, it's simply not true that the quality of care is consistent from care center to care center. In fact, enormous variations exist and the consequences can be profound.
Gawande is obviously a clear thinker. This is evident in the fact that he so adroitly addresses so many facets of medical care in less than 300 pages. While this book isn't a page turner in the traditional sense--that is, it doesn't have cliff-hangers that make you keep reading--I was surprised at how well it maintained my interest and how quickly I finished reading it. The writing is clear and engaging, even though the author is discussing a very complex industry.
As Gawande points out, the real challenges before doctors today lay not in breakthrough technology but in the proper application of what they already have. This is not to say doctors are misapplying things. As the title implies, doctors (and all medical professionals) have room for improvement--for being better--at how they apply the tools they have.
This isn't just theory or some windbag expressing an unfounded opinion. As you have probably guessed, "Atul Gawande" isn't an Irish name. His family is originally from India, and Gawande gives us numerous examples of the amazing results Indian doctors obtain despite not having the tools and budgets we are accustomed to in the United States.
We don't have to travel to India to see how medical professionals can ratchet up the quality of care by using the constant improvement philosophy. Gawande brings us to one Cystic Fibrosis clinic in America and then another, so we can see how different approaches produce different results.
Earlier, I mentioned government agencies as examples of incompetence. Interestingly, the Veteran's Administration is way ahead of private industry when it comes to medical care. Gawande, who doesn't work in the VA, probably is not aware of the quality revolution that took place there.
Once the most dismal of medical care providers (following the typical government agency formula of focusing on bloated processes and ignoring results), the VA is now an example of productivity and quality that the private sector can only envy. In fact, the VA actually provides healthcare while the mainstream medical system has mostly limited itself to providing disease care and injury fixes.
"Better" is a book written by a practicing surgeon, and it looks inside the medical system. It can help medical professionals see ways to improve how they do things. But if you're not a medical professional, is this book worth reading? In my opinion, yes. The chapter on medicine's bell curve would justify that all by itself. Anyone who might need a specialist (for example, a neurologist) would benefit from understanding the points Gawande makes when he discusses the differences in quality of care at various centers.
This book reminds me of books that have been written about other industries and on business process improvement in general. Perhaps the most famous of the business process improvement books is Tom Peters' seminal work, "In Search of Excellence." Customers in a business to business relationship look to such books as "Lean Thinking" to better work with their vendors and suppliers. These books address many of the same fundamental issues Gawande covers in "Better."
One way to improve is to drive defects out. Another way is to look at what's working and adapt it to your situation. A third way, and Gawande provides plenty of examples, is to simply look for (and try) ways of doing things better. Just as books about Toyota's "quality miracle" have driven improvements in hundreds of other industries, so can the lessons learned in this book drive improvements in other industries.
So, in that sense it has very broad application in addition to providing insight into curing the ills of our medical care system. It's an excellent resource for any business person. But it's also an excellent resource for any consumer of medical services. You don't have to settle for "good enough." You can seek, and get, better.
Must Read - BE YOUR OWN ADVOCATE!!! 
The first surgery that I ever had was a c-section with my first child. I got an infection which resulted in two subsequent surgeries to clean the infection and remove a large hematoma. I wish I had read this book before. Its hard to tell your doctor or nurse to wash their hands and put new gloves on after touching something that is not sterile... but do it for your own good. I'm two months out from the c-section and I still have an open wound on my abdomen. You have no control over what goes on in a surgery, so talk to your doctor about PREVENTATIVE ANTIBIOTICS that you can take after surgery.
becoming more and more conceited 
I really liked Gawande's first book "Complications". That's why I was excited when I bought this one. It is still good with many interesting topics, however it seems that the success of his first book made the author more and more conceited which is reflected particularly in "How to become a positive deviant".
I am not sure if I will read a third book of Gawande.
reviews: 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, page 17
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