Atul Gawande, a general surgeon at the Brigham and Women’s Hospital in Boston, wrote a bestseller in 2002 entitled “Complications.” His follow-up book, “Better,” is another volume of essays and stories about healthcare quality. Quality in healthcare is the darling of reform gurus because there is widespread agreement that the easiest way to save money in healthcare is to improve quality.
Gawande is a gentle and compelling storyteller who has the wonderful gift of grabbing your attention and not letting go. His argument for quality improvement is divided into three sections: Diligence, Doing Right, and Ingenuity. These sections describe important components for success in medicine, and he fleshes them out with anecdotes. “Diligence” is illustrated by stories of hand-washing, care of wounded soldiers from Iraq and Afghanistan, and the effort to eradicate polio. He defines “doing right” as doing the right thing at the right time for the right patient, actions that, he suggests, often are countered by avarice, arrogance, insecurity and misunderstanding. He holds that “ingenuity” depends more on character than intelligence, and his stories confirm it.
I love the way Gawande frames the problem: “Our decisions and omissions are therefore moral in nature,” he writes. “We face daunting expectations. In medicine, our task is to cope with illness and to enable every human being to lead a life as long and free of frailty as science will allow.” And then he concludes, “It’s not only the stakes but also the complexity of performance in medicine that makes it so interesting and, at the same time, so unsettling.”
I particularly appreciate his afterword, in which he makes a plea for each of us to become a “positive deviant.”
He asks that we all do these five simple things:
1. Ask an unscripted question. When interacting with patients, find out something trivial that will make your understanding of the patient better.
2. Don’t complain. The practice of medicine can be boring and trying but don’t let it get you down. Don’t let yourself become part of the “ain’t it awful” crowd.
3. Count something. Never lose your intent to be a scientist. Document your observations
4. Write something. Put something on paper or on your computer that you can share.
5. Change. Be an early adapter. Be willing to recognize the inadequacies in what you do and seek out solutions.
Read this book as a reminder: We are not perfect, but we can get better.
Gary D. VanderArk, MD, is clinical professor of neurosurgery at the University of Colorado Health Sciences Center, Denver, Colo. He is the 2001 AANS Humanitarian Award recipient. The author reported no conflicts for disclosure.