Iowa Writing Project

Atul Gawande, Better: A Surgeon’s Notes on Performance.

Posted on Wednesday, October 26th, 2016

 Introduction: From his junior resident experience with a dedicated senior resident, Gawande generates a key question: What does it take to be good at something in which failure is so easy, so effortless? (P.3) Later he suggests complex dimensions of success: Lives are on the line. Our decisions and omissions are therefore moral in nature… 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. (P.4) 1 (Also true in teaching?)

In medicine, as in any profession, we must grapple with systems, resources, circumstances, people – and our own shortcomings as well. (p.8) 2

The core requirements for success in medicine or in any endeavor that involves risk and responsibility:

Diligence – giving sufficient attention to detail to avoid error and prevail against obstacles – central to performance & fiendishly hard. 3

Doing right – despite working in a fundamentally human enterprise, therefore troubled by human failings, it is difficult to know when “right” is to keep striving and when it is to stop. (Reason for sustained reflection?) 4

Ingenuity – thinking anew is not a matter of superior intelligence but of character and demands a willingness to recognize failure (not paper over the cracks) and to change; it arises from deliberate, obsessive reflection on failure and a constant search for new solutions. 5

Betterment is a perpetual labor. The world is chaotic, disorganized and vexing, and medicine (education?) is nowhere spared that reality. To complicate matters, we…are also only human ourselves…Yet 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 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. (p.9) 6

In Better, ten essays are organized to illustrate the core requirements, and the first essay, “On Washing Hands,” explores the incredible difficulty, the diligence demanded, in getting medical practitioners to be meticulous in a basic practice, the one thing that consistently halts the spread of infections. (p.14) (We doctors and nurses wash our hands one-third to one-half as often as we are supposed to.)

The essay explores persistent system and human impediments to improving practice, at which success requires making a hundred small steps go right. (p.21) 7 Ironically, the version appearing in The Essay Connection, a college writing anthology where I first encountered Gawande and adapted from the version which first appeared in the New England Journal of Medicine in 2004, does not include a section I found most meaningful and hopeful when I read the book. Throughout the essay, Gawande shifts between using “compliance” and “adherence” for what is lacking in the use of “know-how” to stop epidemic infections. (I greatly prefer adherence and its sense of response to a galvanizing vision of possibility over compliance and its image of submission to imposed leverage.) 8 Late in the essay he describes an engineering effort to eliminate impediments and time wasters in order to make it easier for hospital staff to comply with the hand washing protocol. In two years, however, improved practice in the “unit” of focus had spread minimally elsewhere in the hospital. The leaders, not medical practitioners, left in frustration. Then the missing segment…

Importantly, the initial effort spawned another. An involved and interested surgeon serendipitously encountered a story from another field, an effort to save malnourished children in Viet Nam. 9 Facing resistance to change based on what “outsiders” said, a nutritionist team focused on finding solutions from insiders. Asking small groups of poor villagers to identify who among them had the best-nourished children (p.25) (those demonstrating positive deviance from local norms), then getting villagers to visit those mothers in their homes to see exactly what they were doing, they achieved revolutionary change. Malnutrition dropped 65-85% in two years – in every village where the team had worked! The surgeon, Jon Lloyd, focused on the positive deviance idea – building on capacities people already had rather than telling them how they had to change. Wisely seeing a key aspect of the approach (and involving the original nutritionist team), he held small group discussions with health care workers at every level; each meeting began with “We’re here because of the hospital infection problem and we want to know what you know about how to solve it.” (p.26) 10 Even when iterations meant they were hearing mostly the same things, they kept going: it was the first time those people had been heard, the first time they had a chance to innovate for themselves. 11 Converting input into procedure, monitoring implementation and posting results, after one year they saw wound infections – intractable for years – drop to zero. Gawande acknowledges the risk of premature acceptance of the initiative; results might not last and it might not be successfully duplicable on a large scale, but nothing else has worked, and this is the most fascinating idea anyone has had to solve the problem in a century. (p.27)

Numerous essays in Better are worth close reading, and in the Afterword, Gawande offers suggestions for becoming a positive deviant, despite how small one’s place in the world inevitably proves to be. (p.249) In a lecture to medical school students, generated from the question how do I really matter (p.250), 12 he poses five ways one might make a worthy difference:

  • Ask an unscripted question – listen, learn something, make a human connection, keep conversations going – If you ask a question, the machine begins to feel less like a machine. (p.252) 13

  • Don’t complain – the profession is trying due to working with other human beings under circumstances one only partly controls; resist the pull into a litany of woes; be prepared with something else – and idea you read about, a problem you find fascinating. 14

  • Count something – be a scientist; count some phenomena you find interesting – you will learn something interesting. 15

  • Write something – you need not achieve perfection, only add some small observation about your world (p.255); do not underestimate the power of the act of writing itself – it lets you step back & think through, to achieve a degree of thoughtfulness; sharing writing with an audience makes you part of a larger world, declares membership… a willingness to contribute. 16

  • Change – as possible, choose early adoption over persistent skepticism; be willing to recognize inadequacies in practice and seek solutions; choices are imperfect but alter lives, thus it seems safer to do what everyone else is doing – a doctor must not let that happen, nor should anyone who takes on risk and responsibility in society (p.257). 17

Of each of these, ask others what they think & keep the conversation going.

I find Gawande’s stewardship of medicine, his profession, consistent with the better functions of teacher-leaders: stewardship of education. It’s not position.

  1. Work load in medicine is an issue; equally, workload affects teaching. The number of “others” one serves is a factor, but the complexity of the serving is equally so – nuanced and “unsettling.” What a “moral” context/question!

  2. Gawande reflects by writing…this external-internal tension, this self – with shortcomings – in context should demand reflection by doctors & teachers.

  3. “Fiendishly hard” must resonate; teachers - so often submerged in details.

  4. Writing today, Gawande might well address the influence on medicine of “affordable care”; how do teachers handle outside determiners of “right”?

  5. Ingenuity – deliberate, obsessive, constant – feels so at odds with most student-teacher ratios, despite a century of NCTE advocacy for change?

  6. Betterment is also a perpetuating labor…improving, transforming fosters transforming. A truly professional life becomes bound up in “better.”

  7. I wonder if ensuring success through small steps invokes the nuanced difference between leadership and stewardship?

  8. Cultivating “adherence” takes a strong vision, and a longer more complex investment; administrators often seem to settle for (prefer) “compliance.”

  9. What if this surgeon had not been involved, or if he had not read widely?

  10. This concept, positive deviance, gets at the essence of my resistance to imposed standards and practices. If collaboratively pondering standards, preferably from diverse sources, can inform teacher chosen direction and cultivation of sound practices (locally contextualized), then perhaps the even more valuable role of positive deviance can operate.

  11. How important is it to see the process behind the data and source integrity as crucial, not just the data?

  12. Teachers, I think, especially at the end of a year, often pose this question.

  13. Truly important in many arenas; at odds with scripted teaching! Might authentic teacher leadership prize tough questioning within the system?

  14. Yes, complaining (I’m often guilty) is easier than doing the work of having something to offer. What if we don’t read, talk, reflect, think, write?

  15. Too easy to ignore when teachers are awash in futile “countings”… What potential in counting more important things? Sourcing better data?

  16. Gawande makes a powerful case for writing in professions.

  17. Facing the real nature of our choices, coming to terms with the tension between imperfection and life-altering consequences, is professionalism!

New York, NY:    
Picador/ Metropolitan Books/Henry Holt & CO. 2007
ital = quoted; otherwise paraphrased.                           
(# = JSD question or comment on p.4)