Better: A Surgeon’s Notes on Performance

“Betterment is perpetual labor. The world is chaotic, disorganized, and vexing, and medicine is nowhere spared that reality. To complicate matters, we in medicine are also only humans ourselves. We are distractible, weak, and given to our own concerns. Yet still, to live as a doctor is to live so one’s life is bound up in others’ and in science and in the messy, complicated connection between the two. It is to live a life of responsibility.” 

Gawande wants to remind his readers that the world is not perfect. Because we are accustomed to living in ordered, structured, and modern societies, it is easy to forget that humans are flawed, and that reality is messy. Thus, doctors must strive to always be better because they are fighting against the chaotic nature of the world. People often forget that doctors are human, and they expect superhuman results in medicine. Gawande stresses that practicing medicine is a human task and that it is limited in ability, like every other human endeavor. 

“We always hope for the easy fix: the one simple change that will erase a problem in a stroke. But few things in life work this way. Instead success requires making a hundred small steps go right—one after the other, no slipups, no goofs, everyone pitching in.” 

The society that we currently live in is one of instant gratification. Thus, when people are faced with problems, they often want the problem to be solved right away. If it isn’t, they may become frustrated or annoyed and begin to lose hope. This is also true during the treatment of a disease or illness. Gawande stresses that success is a process that we must work towards. There are no shortcuts in life, and even the most immediate things are often the result of a long process that we may or may not have noticed. 

“Understood, however, as the prerequisite of great accomplishment, diligence stands as one of the most difficult challenges facing any group of people who take on tasks of risk and consequence. It sets a high, seemingly impossible, expectation for performance and human behavior.” 

According to Gawande, true diligence is an exhausting task because it does not allow room for rest. If someone rests, they cannot be diligent because diligence requires a person to be constantly moving forward and on the lookout for both pitfalls and new ways of doing things that can enhance one’s life and work. 

“Beneath the ideal is the gruelingly unglamorous uncertain work.”

We usually only see the final product of something, especially when it comes to success. However, for every minute of success, there were hours upon hours of unseen hard work that went into it. 

“But if mortality is low, the human cost remains high. The airman lost one leg above the knee, the other at the hip, his right hand, and part of his face. How he and others like him will be able to live and function remains an open question. His abdominal injuries prevented him from being able to lift himself out of bed or into a wheelchair. With only one hand, he could not manage his colostomy. We have never faced having to rehabilitate people with such extensive wounds. We are only beginning to learn what to do to make a life worth living possible for them.” 

In Chapter 3, Gawande recounts the massive strides that medicine, especially combat medicine, has made in saving lives. Though this appears to be a wonderful development, Gawande wonders how this new frontier that medicine has opened will proceed, as more and more people start living with injuries and conditions that previously would have resulted in their deaths. 

“Instead, the most important reason to consider tightening standards of medical protocol is simply to improve trust and understanding between patients and doctors. The new informality of medicine—with white coats disappearing and patient and doctor on a first name basis—has blurred boundaries that once guided us.” 

In a society that values informality, Gawande shows how formality is a good thing in certain fields, like medicine. Formality sets clear boundaries, which can be very helpful in awkward situations where either a patient or a doctor might feel vulnerable. 

“In such cases, don’t doctors owe something to patients and their families?” 

Here, Gawande asks a difficult question in medicine—what happens when things go wrong? While doctors do their best to help patients, they are human, and humans are flawed. In short, they make mistakes. So, what are a doctor’s responsibilities to a patient when he makes a mistake? It’s a tricky question that Gawande insists there is no clear-cut answer for. 

“Doctors quickly learn that how much they make has little to do with how good they are. It largely depends on how they handle the business side of their practice.” 

Usually, people assume doctors are altruistic people who practice medicine for the good of society. This may be true for most doctors, but modern medicine is also a business. Doctors need to be paid so that they can continue to help patients. Thus, one of the most complicated aspects of medicine is a doctor’s salary and how he or she receives it. This has become one of modern medicine’s biggest issues, especially as costs for both patients and doctors continue to rise. 

“It’s a war with insurance, every step of the way.” 

The relationship between modern medicine and medical insurance is adversarial. Doctors want to be paid, and insurance companies want to pay them as little as possible. Therefore, doctors often have to fight to receive payment for the things that they do. Unfortunately, if an insurer is asked to pay a doctor a lot of money, it will often deny coverage to a patient. Overall, it is a problematic system in which there are very few winners. 

“Execution has become a medical procedure in the United States. That fact has forced a few doctors and nurses, asked to participate in executions, to choose between the ethical codes of their professions and the desires of a broader society.” 

State-sanctioned executions are a gray area in modern medicine. While the Hippocratic Oath prohibits doctors from doing anything that might harm a patient, their medical knowledge is essential for ensuring that executions run smoothly and painlessly for the condemned. This ethical dilemma has yet to be resolved.

“I used to think that the hardest struggle of doctoring is learning the skills. But it is not, although just went you begin to feel confident that you know what you are doing, a failure knocks you down. It is not the strain of the work, either, though sometimes you are worn to your ragged edge. No, the hardest part of being a doctor, I have found, is to know what you have power over and what you don’t.” 

One of the most frustrating aspects of practicing any profession is realizing that no matter how good you become, you will never be perfect. This is especially true of medicine. Gawande insists that to be a good doctor or to live a good life, people have to learn to relinquish control in certain situations. 

“We have at our disposal today the remarkable abilities of modern medicine. Learning to use them is difficult enough. But understanding their limits is the most difficult task of all.” 

We are often under the impression that technology can solve any problem faced by man, but this is not always the case. It can be frustrating to come to this realization. Gawande reminds us that we are human, and to be human is to be limited in what one can do, even with the assistance of the most advanced technology. 

“The seemingly easiest and most sensible rule for a doctor to follow is: Always Fight. Always look for what more you could do. I am sympathetic to this rule. It gives us our best chance of avoiding the worst error of all—giving up on someone we could have helped.” 

The importance of never giving up is a point that Gawande returns to throughout the book. There is no limit to one’s will, and this is the greatest asset that humans have—their will to fight. If we can continue to fight in the face of adversity, we have a better chance of success than if we give up and rely on outside forces, people, or technology to do things for us. 

“For hospitals, deliveries are a good business. If mothers have a positive experience, they stay loyal to the hospital for years.” 

Here, Gawande reminds the reader of the business side of medicine. Everything in medicine is done for a reason but not always out of altruism. Regarding childbirth, the business side of medicine is especially important because a positive birth experience can add to a hospital’s patient list for a lifetime. 

“The Apgar Score changed everything. It was practical and easy to calculate, and it gave clinicians at the bedside immediate feedback on how effective their care was.” 

The Apgar Score is one of the few unified systems of measurement in medicine that allows doctors across the board to rate how well they have done something. Because doctors are often competitive people, their drive to improve their patients’ Apgar Scores has led to more babies being born healthy. This is an example of how established rubrics and metrics can help doctors assist patients. 

“The question facing obstetrics was this: Is medicine a craft or an industry?” 

Gawande dedicates a significant portion of the book to examining how modern medicine is viewed. If it is a craft, then it needs to be learned on an individual level. If it is an industry, it is one-size fits-all and exists to create the best products and services for the best price.

“The bell curve is distressing for doctors to have to acknowledge. It belies the promise that we make to patients: that they can count on the medical system to give them their very best chance. It also contradicts the belief nearly all of us have that we are doing our job as well as it can be done.” 

Patients do not always get the best care, and this cannot be helped because not every patient can be treated by the handful of doctors who are the absolute best practitioners in their respective fields. By illustrating this point, Gawande again shows how the human element of medicine impedes it. Not all doctors are created equal. 

“But the truth is, we have no reliable evidence about whether we’re as good as we think we are. Baseball teams have win-loss records. Businesses have quarterly earnings reports. What about doctors?” 

One of the issues that Gawande tries to both explain and understand is how doctors and those in the medical profession should be rated. He realizes that there is a need for the public to understand the quality of care that they will receive in relation to other options for care. However, no one has figured out how to implement such a system in medicine yet. 

“As medicine tries to cope with the advancing complexity of knowledge and treatment, it is falling short in performing even the simplest of its tasks. To fix medicine, [Don] Berwick maintained, we need to do two things: measure ourselves and be more open about what we are doing.”

Though it is difficult to fail, it is even more difficult to be criticized. This is why doctors never publicly discuss their methods. Gawande rejects the idea of practicing medicine in silence. He believes that if there were more transparency in the medical industry, there would be more advances in the field of medicine and the public would feel more comfortable dealing with medical professionals. 

“In this short speech, I realized, was the core of [Warren] Warwick’s worldview. He believed that excellence came from seeing, on a daily basis, the difference between being 99.5 percent successful and being 99.95 percent successful.” 

Perfection is impossible, but that doesn’t mean that one cannot strive for it. Although the difference between being 99.5 percent successful and being 99.95 percent successful may seem nominal, there is actually a huge difference between the two in the long run. If a person is truly diligent and striving to do right, he or she should always be finding small ways to improve.

“We are used to thinking that a doctor’s ability depends mainly on science and skill. The lesson from Minneapolis—and indeed from battlefield medical tents in Iraq, villages with outbreaks of polio, birthing rooms across the country, and all other places I have described in this book—is that these may be the easiest parts of care. Even doctors with great knowledge and technical skill can have mediocre results; more nebulous factors like aggressiveness and diligence and ingenuity can matter enormously.” 

This quotation illustrates the book’s main message: excellence is not something that most people are blessed with, but there is nothing to prevent people from fighting, working hard, and doing the best that they can to strive towards it. Perfection can never be achieved, but betterment can. It is the result of striving towards an unachievable goal and improving in the process. 

“What is troubling is not just being average but settling for it. Everyone knows that averageness is, for the most of us, our fate. And in certain matters—looks, money, tennis—we would do well to accept this. But in your surgeon, your child’s pediatrician, your police department, your local high school? When the stakes are our lives and the lives of our children, we want no one to settle for average.” 

Complacency is something that Gawande warns against. He also insists that though good is the enemy of best, we still have to learn to accept the things that we cannot change. Gawande believes that each individual has a moral duty to strive to be his or her absolute best and to help as many other people as possible in the process. 

“It can be hard not to feel that one is just a white-coated cog in a machine—an extraordinarily successful machine, but a machine nonetheless.” 

Gawande accepts the fact that in medicine a person is just one part of a larger system. One must be willing to accept this and one’s place in the system. However, one must also do everything possible to make his or her section of the system the best that it can be. This positively impacts other sections of the system, as well as the system as a whole.