Book: Better by Atul Gawande

Very good series of essays on medicine by a surgeon

Atul Gawande
Better: A Surgeon's Notes on Performance
Metropolitan Books, 2007
ISBN-13: 978-0-8050-8211-1
ISBN-10: 0-8050-8211-5
257 pages (main text)

Better: A Surgeon's Notes on Performance is a series of eleven essays (plus an introduction and an afterword) by the Brooklyn-born surgeon Atul Gawande. The book is divided into three parts with several essays in each of "Diligence", "Doing Right", and "Ingenuity". The essays are generally good or very good but the organization feels like it was invented after most of them were written. Regarding the book's title, what essay isn't about making things better somehow? And for the subtitle, the essays are about performance only in the broadest sense of the term. There are few over-arching themes. I suppose that Eleven and a Bit Miscellaneous Essays About Medicine might have sold fewer books, but it would have been a trifle more accurate.

Regardless of the book's organization, the essays are good and they're likely to be informative since they're about subjects that few general readers will know much about. Still, they're likely to be of varying degrees of interest to most readers. The first essay "On Washing Hands" is about how to get doctors to wash their hands as often as they should when going from patient to patient. (It turns out that making hand washing less time-consuming by providing alcohol wipes helps.) In the essay, Dr Gawande spends some time pondering the nature of medicine and the nature of problem-solving but there isn't much in it that's exciting. The second essay "The Mop-Up" was considerably more interesting to me. It's about the enormous resources and complex logistics that are brought to bear on a polio outbreak in India. Equally interesting is "The Doctors of the Death Chamber" which is based on conversations Dr Gawande had with four doctors and one nurse who give the lethal injections by which the death penalty is administered these days in the United States. Their justifications for setting aside temporarily the life-saving aspect of their work are interesting reading. "The Score" is largely about the delivery of babies. Among other interesting things in it is that delivery by scheduled Cesarian section may actually be safer than ordinary delivery. There's a that's interesting to learn in this book.

But while Dr Gawande's reporting is sparklingly clear and almost always interesting, his analysis is sometimes less good. The essay "Piecework" is about how, and how much, doctors are paid. Near the end, there is some not-unexpected criticism of the American system of health insurance. Dr Gawande says, "Our byzantine insurance system leaves gaps at every turn. Some day soon that must change." (p. 128) There's noting wrong with that sentiment, but it would have been much more interesting to hear from Dr Gawande what he thinks it should be changed to. In "The Score", Dr Gawande says, regarding the increase in Cesarian sections, "We are losing our connection to yet another natural process of life." (p. 198) That something is a natural process of life is a poor argument that it is good. We pay doctors to prevent plenty of perfectly natural processes. And in the essay "On Fighting", Dr Gawande says:

    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.
    (p. 161)

(Later in the essay he moderates that stance a bit.) The essay would have been more interesting if he had discussed the expensive consequences of that rule in relation to the gaps he notes in America's insurance system. At the end of "Doctors of the Death Chamber", Dr Gawande gives his opinion that taking part in executions is unethical for medical professionals. Alas, Dr Gawande doesn't say much to justify his opinion and so his position ends up looking less carefully considered than the position of the people he disagrees with.

Though the book's organization is a bit over-sold and some of the analysis is weak, the book's virtues outweigh those flaws. There are interesting stories here and we get to meet some proper heroes of medicine.

There's a tiny editing error in that "Navy" would have been better as lowercase on page 48.

Posted: Tue - April 24, 2007 at 07:35 PM   Main   Category: