Better: A Surgeon's Notes on Performance

Better: A Surgeon's Notes on Performance by Atul Gawande

My rating: 4 of 5 stars


I have had a lot of doctors in my life. The best one I ever had was the surgeon who failed. Before I went under, he told me it would take about 2 hours and had an 85% success rate. When I woke up, nearly five hours had passed, I was in far more pain than I had been led to expect, and he was waiting to tell me that I was in the 15%, that he hadn’t saved my eye, and that he would be ready to talk to me as soon as I was back on my feet.

When he retired several years later, I wrote him a thank you note. Because he did his best, and it wasn’t enough, and he knew it, and he told me so honestly and in great detail as many times as I needed to hear it, and he held his office trash can for me to throw up in, and he waived thousands of dollars in bills so he could keep seeing me when I was in law school with the horrible useless insurance, and he cared whether I was having a good life. A surgeon – can you imagine?

This book isn’t really about that sort of failure, the kind where current technology and understanding isn’t enough. It’s about designing behavioral triggers to save lives by increasing compliance with hand-washing drills, and it’s about the massive manpower efforts necessary to eliminate infectious diseases from the world, and it’s about what a patient is owed after a failure of any kind. It struck a huge cord with me, because one of the things that medicine and the practice of law at my level have in common is an expectation of a 0% error rate. Seriously – I am explicitly and implicitly told on a daily basis that anything less than perfection is failure. There are no stupid slip-ups, and there are no impossible situations that no one could solve.

Which has nothing to do with reality, of course. Learning to live under these conditions is, uh, let’s call it emotionally taxing and leave it at that. Anyone who has ever been through a medical residency is probably nodding right now.

So I thought this book – I got there! – was great. Not just for the case studies of Polio outbreaks and third-world surgery, though they’re pretty interesting. But because this book is thinking specifically about that. About the difference between an expectation of infallible perfection, and the seldom-acknowledged reality that our brains are imperfect and even the very best of us sometimes aren’t good enough. “When someone has come to you for your expertise, and your expertise has failed, what do you have left? You have only your character to fall back upon, and sometimes it’s only your pride that comes through.” Succinctly put, and so very true. Ask me about something I fucked up this past summer sometime, and how the surgeon who failed was on my mind in the aftermath, when all I had left to do was take it the best I could.

Anyway, rambling. I was intellectually engaged here on multiple levels, the way you are when you’re always thinking and reacting, even when it isn’t always good. Insert a whole rebuttal essay here on Gawande’s ablism in the section on improved rates of survival for devastating combat injuries and all his musing on whether life with this and that disability is actually “worth living,” whatever the fuck that is supposed to mean. Scrub that, I know exactly what that’s supposed to mean, and I think it’s crap. Also, the business of the disabled person in question, not an able-bodied columnist for The New Yorker. /snide.

And insert a whole other essay on the execution section, and how Gawande and I have differing opinions on the death penalty – he is for it and I am not – but how fascinating it was that when presented with the ethical dilemma of doctor participation in executions, he concluded that if executions cannot be conducted safely without doctors they shouldn’t happen, and I concluded doctors should be permitted to compromise their oaths.

Engaged, like I said.




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