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Summary
Summary
NATIONAL BESTSELLER
The New York Times bestselling author of Being Mortal and Complications examines, in riveting accounts of medical failure and triumph, how success is achieved in a complex and risk-filled profession
The struggle to perform well is universal: each one of us faces fatigue, limited resources, and imperfect abilities in whatever we do. But nowhere is this drive to do better more important than in medicine, where lives are on the line with every decision. In this book, Atul Gawande explores how doctors strive to close the gap between best intentions and best performance in the face of obstacles that sometimes seem insurmountable.
Gawande's gripping stories of diligence, ingenuity, and what it means to do right by people take us to battlefield surgical tents in Iraq, to labor and delivery rooms in Boston, to a polio outbreak in India, and to malpractice courtrooms around the country. He discusses the ethical dilemmas of doctors' participation in lethal injections, examines the influence of money on modern medicine, and recounts the astoundingly contentious history of hand washing. And as in all his writing, Gawande gives us an inside look at his own life as a practicing surgeon, offering a searingly honest firsthand account of work in a field where mistakes are both unavoidable and unthinkable.
At once unflinching and compassionate, Better is an exhilarating journey narrated by "arguably the best nonfiction doctor-writer around" ( Salon ). Gawande's investigation into medical professionals and how they progress from merely good to great provides rare insight into the elements of success, illuminating every area of human endeavor.
Author Notes
Atul Gawande is a surgical resident in Boston and staff writer on medicine and science for The New Yorker. A former Rhodes scholar, he received his M.D. from Harvard Medical School. He lives with his wife and three children in Newton, Massachusetts.
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Reviews (5)
Publisher's Weekly Review
Surgeon and MacArthur fellow Gawande applies his gift for dulcet prose to medical and ethical dilemmas in this collection of 12 original and previously published essays adapted from the New England Journal of Medicine and the New Yorker. If his 2002 collection, Complications, addressed the unfathomable intractability of the body, this is largely about how we erect barriers to seamless and thorough care. Doctors know they should wash their hands more often to avoid bacterial transfer in the ward, but once a minute does seem extreme. Using chaperones for breast exams seems a fine idea, but it does make situations awkward. "The social dimension turns out to be as essential as the scientific," Gawande writes-a conclusion that could serve as a thumbnail summary of his entire output. The heart of the book are the chapters "What Doctors Owe," about the U.S.'s blinkered malpractice system, and "Piecework," about what doctors earn. Cheerier, paradoxically, are the chapters involving polio and cystic fibrosis, featuring Dr. Pankaj Bhatnagar and Dr. Warren Warwick, two remarkable men who have been able to catapult their humanity into their work rather than constantly stumble over it. Indeed, one suspects that once we cure the ills of the health care system, we'll look back and see that Gawande's writings were part of the story. (Apr.) (c) Copyright PWxyz, LLC. All rights reserved
Booklist Review
Quick. What mundane practice, regularly propagated by generations of moms, could save the lives of thousands of hospital patients? To Brigham & Women's Hospital general surgeon and New Yorker staff writer Gawande, that question's answer is but one way to improve a profession where a C+ performance rating just isn't good enough. The follow-up to Gawande's critically acclaimed Complications (2002) is a sparkling collection of essays about medical professionals and places where better either has or is becoming the norm, where excellence is a journey rather than a destination. While acknowledging that varying levels of achievement are inevitable in any human endeavor, Gawande believes the medical profession must assume the burden of constant diligence to do better because lives hang in the balance. Rather than preaching about improving performance, Gawande bears witness to the remarkable levels of care that can be achieved by describing some incredibly innovative, adaptive, and even mundane (e.g., conscientious hand washing) practices in hospitals from Boston to the rural Indian village of Uti, from Pittsburgh to Iraqi battlefields. --Donna Chavez Copyright 2007 Booklist
New York Review of Books Review
DANA VACHON'S first novel begins with Tommy Quinn scanning the crowd gathered for the engagement party of his friend Roger Thorne. The 24-year-old casts his eyes on the investment bankers, the skinny women and their Botoxed mothers, the New York elite gathered at the Racquet & Tennis Club, a "limestone manse sitting like a sphinx on Park Avenue." Quinn applauds himself for being on "the most prosperous street in the most prosperous city in the most prosperous nation that ever lived." Standing on the club's terrace he feels he is "flying." The set-up is hoary - wide-eyed outsider comes to the vast metropolis. From it the novelist can go in two directions: he can give his character a sentimental education in big city life or he can make the world he enters so ridiculous that we can dismiss it without having to go. He can choose to be Thomas Wolfe, or Tom. At the novel's beginning it appears Vachon, himself a former investment banker, is going to give us Thomas. Quinn is sensitive: he is thinking of becoming a doctor and helping the poor - he would already have done so if his grades had gotten him into a better medical school. He had a brother who died young. His father has never recovered from not making partner at Cravath, Swaine & Moore and has become a serial joiner - a "great sycophantic dynamo," who has just become a member of his eighth country club. There, at the Fourth of July cocktail party, young Quinn meets the alluring Frances Sloan. Frances uses phrases like "beautifully brutal" and says "between cradle and grave, in the end, there was nothing" (in French, no less). She is blond and depressed, and Quinn is hooked. The tree has met its ax, Scott his Zelda. They become a couple. As her mental problems become more serious, she begins to deliberately cut herself. Quinn has not bargained on being her full-time nurse. Part of a generation of "desperate young materialists" he is about to start work at J.S. Spenser, a prestigious investment bank. In the bank's training program, which he wittily describes as "affirmative action for the already affirmed," he meets Thorne, who is mad for sex, drugs and money and determined to drain the '00s of every drop. Thorne, a descendant of the WASP establishment, guides Quinn through the labyrinth of Spenser divisions until they find the red hot center, the mergers and acquisitions department led by Terence Mathers. "This guy is a rock star," Thorne realizes. "Let's hook it up. We've gotta get into the M&A group." Because Mathers used to "dog" Thorne's sister at Princeton, they do. In the division Thorne shines and Quinn stumbles: he botches an early deal in which the firm is trying to sell off some oil fields. Thorne next draws a bead on the Latin American mergers and acquisitions team led by Manuel Oliveira Rodrigo Orjuela de Navarro. "I think we need to rock it with Miguel," Thorne tells Quinn. "In fact, I think we need to rock it with Miguel big time!" Manuel succumbs to Thorne's charms, too - they do shots at a trendy nightclub with some Fashion Week models - and includes him and Quinn in a conference in Cabo, where the firm has rented a resort for "just a bit under a million dollars" to pursue Latin America's finanical elite. Thorne relieves Manuel of his beautiful girlfriend - "you're such a fine babe, babe," he tells her - while Quinn, "glaringly useless even by J.S. Spenser's standards," tries to hold Frances' scarred hand long-distance. One night a Latin plutocrat invites the Spenser bankers to a "Pirates of the Caribbean" party on his yacht, to celebrate his daughter's 16th birthday. Early in the party the D.J. plays a song of homage to commemorate Manuel's kidnapped cousin, a great dancer. Shortly after, Zapatistas, initially confused with costumed guests, attack the yacht and capture Manuel too. In the middle of extensive gunplay, Quinn saves Thorne's life by dropping a "$20,000 bottle of Champagne" on a Zapatista aiming an Uzi in his direction. "The Cristal crashed down on him, leaving only a mangled corpse and bloody bubbles that surged across the deck in a red tide," Quinn notes. He and Thorne wind up overboard and are washed up on a remote beach, eventually making their way back to civilization. Quinn and Frances are reunited. What a strange scene. It doesn't fit the book Vachon seems to be writing. If it did, then Frédéric Moreau would have run a dragoon through with a bayonet in "Sentimental Education" and Nick Carraway would have taken George Wilson's revolver and shot him dead by the pool. There's no reason "Mergers & Acquisitions" shouldn't choose Tom over Thomas as a model. The absurd world of Manhattan moneymaking is always a good subject. But the scene highlights the problem "Mergers & Acquisitions" has from the beginning. Vachon's broad comic tendency keeps intruding on the novel of manners he seems to want to write. This tonal puzzlement defeats "Mergers & Acquisitions" long before the events on the yacht jump the shark. Quinn is, for example, throughout the book saddened by the death of his promising older brother at prep school. That's an honorable if hackneyed plot device, undercut by the number of times Vachon mentions that what killed him was an egg roll fried in peanut oil. And is it funny to have Quinn and Frances at a dinner at Cipriani in which the main comedy comes from one of the guests' being a midget? And is it really appropriate for the initials of some Latin characters to form naughty anagrams (cast your eyes back to Manuel's full name)? New York relishes novelty, and novels that convey its flavor must capture this. Does this cultural observation by Quinn feel fresh to you?: "You could produce 90 minutes of rhesus monkeys playing Nerf football, and as long as you got the damn thing screened at Cannes people would want to know you for having done it." Quinn and his father shop at Brooks Brothers and he and his friends eat at Smith & Wollensky and Le Bilboquet. They do cocaine in bathrooms as if the world stopped in 1985. They talk on Motorola Razrs when the guys selling fake watches on Fifth have them. Socially the '00s may be the '80s all over again, but even so, no book purporting to bring us cultural news should be set in an M&A division in 2007. If Vachon's signifiers seem drawn at leisure, his prose feels hurried. The night Quinn and Frances first try to make love, Quinn says: "The louver doors breathed seawater and night as amid the dying flowers of summer we tried again and again to climb into one another." Frances' skin is "like alabaster dipped in sun." When "coils of honeysuckle platinum ... escaped" her pulled-back hairdo, they "hung down her temples like laurels." I think she would forgive him these clichés - she's hardly an original creation herself - but I think he should promise her one thing. After they finally do consummate, he fondles "her firm B-cup breasts." If the space between birth and death is really as short as Frances says it is, he at least owes her another way to put that. Quinn, about to start work at a prestigious bank, is part of a generation of 'desperate young materialists.' D. T. Max is the author of "The Family That Couldn't Sleep: A Medical Mystery."
Kirkus Review
"What does it take to be good at something, when failure is so easy?" asks writer/physician Gawande in his follow-up to Complications (2002). Diligence, ingenuity and "doing right," he answers. Gawande illustrates each of these qualities with stories from his own experience, as well as his observations of and conversations with other physicians. Being diligent about the simple act of hand-washing dramatically reduces hospital infections, he demonstrates, and through diligence, army surgeons in Baghdad have greatly enhanced the survival rate among casualties in Iraq. The section on doing right tackles such troublesome moral issues as whether doctors should participate in executions and at what point treatment of a patient becomes mistreatment and should be stopped. Discussing ingenuity, Gawande shows how the rating scale devised by Virginia Apgar, neither an obstetrician nor a mother, transformed the practice of obstetrics. A similar rating scale for every medical encounter, he believes, would inform patients and improve the performance of doctors and hospitals. He lauds the innovative thinking of Don Berwick, head of the Institute for Health Care Improvement, who is challenging the medical profession to measure and compare the performance of doctors and hospitals and to give patients total access to that information. When such information is available, medical professionals can identify the best performance and learn from it, as Gawande illustrates with an account of exceptional results in treating cystic fibrosis at Babies and Children's Hospital in Cleveland. Monitoring and improving clinical performance would do more to save lives than advances in laboratory knowledge, he contends. For young doctors wondering how they can make an individual difference, Gawande suggests five strategies: Ask unscripted questions, don't complain, "count something" (be a scientist as well as a doctor), write something (to make yourself part of a larger world) and change in response to new ideas. A must-read for medical professionals--and a discerning, humanizing portrait of doctors at work for the rest of us. Copyright ©Kirkus Reviews, used with permission.
Library Journal Review
Gawande, a Harvard-trained endocrine surgeon, contributor to The New Yorker, best-selling author (Complications: A Surgeon's Notes on an Imperfect Science), and 2006 MacArthur fellow, examines the nature of how success and excellence are achieved in medicine and how diligence, doing right, and ingenuity can combine to do better-in not only medicine but also all other human endeavors. In a narrative style reminiscent of Oliver Sacks, Sherwin B. Nuland, and Abraham Verghese, Gawande candidly weaves a tapestry of essays on topics as varied as hospital hand washing, polio in India, surgical tents in the Iraq war, physicians' salaries, malpractice insurance, and doctors' roles in lethal injections. The essays are united, as they highlight opportunities for improvement within the medical community, which serves as a successful framework for Gawande's study of a profession predicated on betterment. These revealing, humanistic essays are highly recommended for all libraries. Gawande's varied accomplishments have been publicized, and this book is certain to be a best seller [For a Q&A with Gawande, see LJ 3/15/07.-Ed.]-James Swanton, Harlem Hosp. Lib., New York (c) Copyright 2010. Library Journals LLC, a wholly owned subsidiary of Media Source, Inc. No redistribution permitted.
Excerpts
Excerpts
Introduction Several years ago, in my final year of medical school, I took care of a patient who has stuck in my mind. I was on an internal medicine rotation, my last rotation before graduating. The senior resident had assigned me primary responsibility for three or four patients. One was a wrinkled, seventy-something-year-old Portuguese woman who had been admitted because--I'll use the technical term here--she didn't feel too good. Her body ached. She had become tired all the time. She had a cough. She had no fever. Her pulse and blood pressure were fine. But some laboratory tests revealed her white blood cell count was abnormally high. A chest X-ray showed a possible pneumonia--maybe it was, maybe it wasn't. So her internist admitted her to the hospital, and now she was under my care. I took sputum and blood cultures and, following the internist's instructions, started her on an antibiotic for this possible pneumonia. I went to see her twice each day for the next several days. I checked her vital signs, listened to her lungs, looked up her labs. Each day, she stayed more or less the same. She had a cough. She had no fever. She just didn't feel good. We'd give her antibiotics and wait her out, I figured. She'd be fine. One morning on seven o'clock rounds, she complained of insomnia and having sweats overnight. We checked the vitals sheets. She still had no fever. Her blood pressure was normal. Her heart rate was running maybe slightly faster than before. But that was all. Keep a close eye on her, the senior resident told me. Of course, I said, though nothing we'd seen seemed remarkably different from previous mornings. I made a silent plan to see her at midday, around lunchtime. The senior resident, however, went back to check on her himself twice that morning. It is this little act that I have often thought about since. It was a small thing, a tiny act of conscientiousness. He had seen something about her that worried him. He had also taken the measure of me on morning rounds. And what he saw was a fourth-year student, with a residency spot already lined up in general surgery, on his last rotation of medical school. Did he trust me? No, he did not. So he checked on her himself. That was not a two-second matter, either. She was up on the fourteenth floor of the hospital. Our morning teaching conferences, the cafeteria, all the other places we had to be that day were on the bottom two floors. The elevators were notoriously slow. The senior resident was supposed to run one of those teaching conferences. He could have waited for a nurse to let him know if a problem arose, as most doctors would. He could have told a junior resident to see the patient. But he didn't. He made himself go up. The first time he did, he found she had a fever of 102 degrees and needed the oxygen flow through her nasal prongs increased. The second time, he found her blood pressure had dropped and the nurses had switched her oxygen to a face mask, and he transferred her to the intensive care unit. By the time I had a clue about what was going on, he already had her under treatment--with new antibiotics, intravenous fluids, medications to support her blood pressure--for what was developing into septic shock from a resistant, fulminant pneumonia. Because he checked on her, she survived. Indeed, because he did, her course was beautiful. She never needed to be put on a ventilator. The fevers stopped in twenty-four hours. She got home in three days. What does it take to be good at something in which failure is so easy, so effortless? When I was a student and then a resident, my deepest concern was to become competent. But what that senior resident had displayed that day was more than competence--he grasped not just how a pneumonia generally evolves and is properly treated but also the particulars of how to catch and fight one in that specific patient, in that specific moment, with the specific resources and people he had at hand. People often look to great athletes for lessons about performance. And for a surgeon like me, athletes do indeed have lessons to teach--about the value of perseverance, of hard work and practice, of precision. But success in medicine has dimensions that cannot be found on a playing field. For one, lives are on the line. Our decisions and omissions are therefore moral in nature. We also 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. The steps are often uncertain. The knowledge to be mastered is both vast and incomplete. Yet we are expected to act with swiftness and consistency, even when the task requires marshaling hundreds of people--from laboratory technicians to the nurses on each change of shift to the engineers who keep the oxygen supply system working--for the care of a single person. We are also expected to do our work humanely, with gentleness and concern. 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. Recently, I took care of a patient with breast cancer. Virginia Magboo was sixty-four years old, an English teacher, and she'd noticed a pebblelike lump in her breast. A needle biopsy revealed the diagnosis. The cancer was small--three-quarters of an inch in diameter. She considered her options and decided on breast-conserving treatment--I'd do a wide excision of the lump as well as what's called a sentinel lymph node biopsy to make sure the cancer hadn't spread to the lymph nodes. Radiation would follow. The operation was not going to be difficult or especially hazardous, but the team had to be meticulous about every step. On the day of surgery, before bringing her to the operating room, the anesthesiologist double-checked that it was safe to proceed. She reviewed Magboo's medical history and medications, looked at her labs in the computer and at her EKG. She made sure that the patient had not had anything to eat for at least six hours and had her open her mouth to note any loose teeth that could fall out or dentures that should be removed. A nurse checked the patient's name band to make sure we had the right person; verified her drug allergies with her, confirmed that the procedure listed on her consent form was the one she expected. The nurse also looked for contact lenses that shouldn't be left in and for jewelry that could constrict a finger or snag on something. I made a mark with a felt-tip pen over the precise spot where Magboo felt the lump, so there would be no mistaking the correct location. Early in the morning before her surgery, she had also had a small amount of radioactive tracer injected near her breast lump, in preparation for the sentinel lymph node biopsy. I now used a handheld Geiger counter to locate where the tracer had flowed, and confirmed that the counts were strong enough to indicate which lymph node was the "hot" one that needed to be excised. Meanwhile, in the operating room, two nurses made sure the room had been thoroughly cleaned after the previous procedure and that we had all the equipment we needed. There is a sticker on the surgical instrument kit that turns brown if the kit has been heat-sterilized and they confirmed that the sticker had turned. A technician removed the electrocautery machine and replaced it with another one after a question was raised about how it was functioning. Everything was checked and cross-checked. Magboo and the team were ready. By two o'clock I had finished with the procedures for my patients before her and I was ready too. Then I got a phone call. Her case was being delayed, a woman from the OR control desk told me. Why? I asked. The recovery room was full. So three operating rooms were unable to bring their patients out, and all further procedures were halted until the recovery room opened up. OK. No problem. This happens once in a while. We'll wait. By four o'clock, however, Magboo still had not been taken in. I called down to the OR desk to find out what was going on. The recovery room had opened up, I was told, but Magboo was getting bumped for a patient with a ruptured aortic aneurysm coming down from the emergency room. The staff would work on getting us another OR. I explained the situation to Magboo, lying on her stretcher in the preoperative holding area, and apologized. Shouldn't be too much longer, I told her. She was philosophical. What will be will be, she said. She tried to sleep to make the time pass more quickly but kept waking up. Each time she awoke, nothing had changed. At six o'clock I called again and spoke to the OR desk manager. They had a room for me, he said, but no nurses. After five o'clock, there are only enough nurses available to cover seventeen of our forty-two operating rooms. And twenty-three cases were going at that moment--he'd already made nurses in four rooms do mandatory overtime and could not make any more. There was no way to fit another patient in. Well, when did he see Magboo going? "She may not be going at all," he said. After seven, he pointed out, he'd have nurses for only nine rooms; after eleven, he could run at most five. And Magboo was not the only patient waiting. "She will likely have to be canceled," he said. Cancel her? How could we cancel her? I went down to the control desk in person. One surgeon was already there ahead of me lobbying the anesthesiologist in charge. A second was yelling into the OR manager's ear on the phone. Each of us wanted an operating room and there would not be enough to go around. A patient had a lung cancer that needed to be removed. Another patient had a mass in his neck that needed to be biopsied. "My case is quick," one surgeon argued. "My patient cannot wait," said another. Operating rooms were offered for the next day and none of us wanted to take one. We each had other patients already scheduled who would themselves have to be canceled to make room. And what was to keep this mess from happening all over again tomorrow, anyway? I tried to make my case for Magboo. She had a breast cancer. It needed to be taken out. This had to happen sooner rather than later. The radioactive tracer, injected more than eight hours ago, was dissipating by the hour. Postponing her operation would mean she would have to undergo a second injection of a radioactive tracer--a doubling of her radiation exposure--just because an OR could not be found for her. That would be unconscionable, I said. No one, however, would make any promises. This is a book about performance in medicine. As a doctor, you go into this work thinking it is all a matter of canny diagnosis, technical prowess, and some ability to empathize with people. But it is not, you soon find out. In medicine, as in any profession, we must grapple with systems, resources, circumstances, people--and our own shortcomings, as well. We face obstacles of seemingly unending variety. Yet somehow we must advance, we must refine, we must improve. How we have and how we do is my subject here. The sections of this book examine three core requirements for success in medicine--or in any endeavor that involves risk and responsibility. The first is diligence, the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles. Diligence seems an easy and minor virtue. (You just pay attention, right?) But it is neither. Diligence is both central to performance and fiendishly hard, as I show through three stories: one about the effort to ensure doctors and nurses simply wash their hands; one about the care of the wounded soldiers in Iraq and Afghanistan; and one about the Herculean effort to eradicate polio from the globe. The second challenge is to do right. Medicine is a fundamentally human profession. It is therefore forever troubled by human failings, failings like avarice, arrogance, insecurity, misunderstanding. In this section I consider some of our most uncomfortable questions--such as how much doctors should be paid, and what we owe patients when we make mistakes. I tell the stories of four doctors and a nurse who have gone against medical ethics codes and participated in executions of prisoners. I puzzle over how we know when we should keep fighting for a sick patient and when we should stop. The third requirement for success is ingenuity--thinking anew. Ingenuity is often misunderstood. It is not a matter of superior intelligence but of character. It demands more than anything a willingness to recognize failure, to not paper over the cracks, and to change. It arises from deliberate, even obsessive, reflection on failure and a constant searching for new solutions. These are difficult traits to foster--but they are far from impossible ones. Here I tell the stories of people in everyday medicine who have, through ingenuity, transformed medical care--for example, the way babies are delivered and the way an incurable disease like cystic fibrosis is fought--and I examine how more of us can do the same. Betterment is a 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 that 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. The question, then, is not whether one accepts the responsibility. Just by doing this work, one has. The question is, having accepted the responsibility, how one does such work well. Virginia Magboo lay waiting, anxious and hungry, in a windowless, silent, white-lit holding area for still two hours more. The minutes ticked, ticked, ticked. At times, in medicine, you feel you are inside a colossal and impossibly complex machine whose gears will turn for you only according to their own arbitrary rhythm. The notion that human caring, the effort to do better for people, might make a difference can seem hopelessly naïve. But it isn't. Magboo asked me if there was any real prospect of her having her operation that night. The likelihood, I said, had become exceedingly small. But I couldn't bring myself to send her home, and I asked her to hang on with me. Then, just before eight o'clock, I got a text message on my pager. "We can bring your patient back to room 29," the display read. Two nurses, it turned out, had seen how backed up the ORs had gotten and, although they could easily have gone home, they volunteered to stay late. "I didn't really have anything else going on anyway," one demurred when I spoke to her. When you make an effort, you find sometimes you are not the only one willing to do so. Eleven minutes after I got the page, Magboo was on the operating table, a sedative going into her arm. Her skin was cleansed. Her body was draped. The breast cancer came out without difficulty. Her lymph nodes proved to be free of metastasis. And she was done. She woke up calmly as we put on the dressing. I saw her gazing upward at the operating light above her. "The light looks like seashells," she said. Copyright (c) 2007 by Atul Gawande. All rights reserved. Excerpted from Better: A Surgeon's Notes on Performance by Atul Gawande All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.