Better A Surgeon's Notes on Performance

Atul Gawande




Trade Paperback

288 Pages



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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 his new 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, labor and delivery rooms in Boston, a polio outbreak in India, and 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 "a writer with a scalpel pen and an X-ray eye" (Time). 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.


Praise for Better

"Gawande provides a clear-eyed view of the medical profession that both resonates and gives pause. Once again, he spares no one, himself included. Gawande, a surgeon, manages to capture medicine in all of its complex and chaotic glory, and to put it, still squirming with life, down on the page . . . Gawande's meditation on performance is not only an absorbing collection of essays but also an exhilarating call for the rest of us to do the same . . . Gawande has the ability to deconstruct and explain the most difficult issues while preserving, even celebrating, their complexity. He applies a sly sense of humor to even the most unsettling topics. And his voice is so direct that at times it borders on painful (at least from the perspective of a fellow doctor) . . . With this book, Gawande inspires all of us, doctor or not, to be better."—Pauline W. Chen, The New York Times Book Review

"Atul Gawande is more interested in behavioural tendencies than emotional ones. His book is wider in scope and rich in fascinating detail."—The Economist

"Throughout Better, Gawande addresses the ethical and philosophical questions of medicine's role toward the common good . . . Gawande is unassuming in every way, and yet his prose is infused with steadfast determination and hope. If society is the patient here, I can't think of a better guy to have out back."—Gail Caldwell, The Boston Globe

"The three ingredients of good doctoring, according to the author, are ‘diligence,' ‘doing right' and ‘ingenuity.' He cited examples from a wide range of life-and-death situations to illustrate how these three key attributes save lives . . . Literary books by doctors are few, and important, given the complicated nature of the doctor-patient relationship. Gawande's insightful book illuminates the challenging choices members of the profession face every day."—Susan Salter Reynolds, Newsday

"Better is a masterpiece, a series of stories set inside the four walls of a hospital that end up telling us something unforgettable about the world outside."—Malcolm Gladwell, author of Blink

"Better is a mesmerizing book with fascinations on every page, told with mastery, insight, compassion, and humility by a surgeon who doesn't flinch from taboo subjects or self-examination. His topics range from the invisible to the unspeakable, and some chapters are exciting medical mysteries. On every page, one meets a candid and thoughtful man, who pays close attention, and who somehow manages to find the right balance between intimacy and respectfulness, in a world that can be inhospitable to both."—Diane Ackerman, author of An Alchemy of Mind

"It's hard to think of a writer working today who makes such good use of man's quest to avoid pain and death. Atul Gawande is not only adding to the small shelf of books by doctors that every layman should read. He's using medicine to help anyone who hopes to do anything better."—Michael Lewis, author of The Blind Side

"'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."—Kirkus Reviews

"Gawande, a Harvard-trained endocrine surgeon, contributor to The New Yorker, best-selling author, 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."—James Swanton, Library Journal

"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."—Publishers Weekly (starred review)

"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, Booklist

Reviews from Goodreads



Read an Excerpt


On Washing Hands
One ordinary December day, I took a tour of my hospital with Deborah Yokoe, an infectious disease specialist, and Susan Marino, a microbiologist. They work in our...

Read the full excerpt



  • Better by Atul Gawande--Audiobook Excerpt

    Listen to this audiobook excerpt from Atul Gawande's national bestseller Better: A Surgeon's Notes on Performance. The struggle to perform well is universal: each 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 may be on the line with any decision.



  • Atul Gawande

  • Atul Gawande, a MacArthur fellow, is a general surgeon at the Brigham and Women's Hospital in Boston, a staff writer for The New Yorker, an assistant professor at Harvard Medical School and the Harvard School of Public Health. His first book Complications, was a New York Times bestseller and a finalist for the National Book Award. Gawande lives with his wife and three children in Newton, Massachusetts.

  • Atul Gawande Tim Llewellyn
    Atul Gawande