Excerpts from the book: Better: A Surgeon's Notes on Performance

Excerpts from the book: Is my series where I share some highlights and notes I made while reading some book that I think is good, thought provoking and worth sharing.

Better: A Surgeon's Notes on Performance
The struggle to perform well is universal, but nowhere is this drive to do better more important than in medicine. 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.

• Here are the 3 requirements for success:
• The first is diligence, the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles.
• 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.
• 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.
• When you make an effort, you find sometimes you are not the only one willing to do so.
• People underestimate the importance of diligence as a virtue. No doubt this has something to do with how supremely mundane it seems. It is defined as “the constant and earnest effort to accomplish what is undertaken.” There is a flavor of simplistic relentlessness to it. And if it were an individual’s primary goal in life, that life would indeed seem narrow and unambitious.
• Beneath the ideal is the gruelingly unglamorous and uncertain work. If the eradication of polio is our monument, it is a monument to the perfection of performance—to showing what can be achieved by diligent attention to detail coupled with great ambition.
• Have tried to emulate the spirit of my father’s visits—the decorum in language and attire, the respect for modesty, the precision of examination.
• Choices must be made. No choice will always be right. There are ways, however, to make our choices better.
• There is a legal definition of negligence (“when a doctor has breached his or her duty of care”), but I wanted to know his practical definition of the term. Lang said that if he finds an error that resulted in harm and the doctor could have avoided it, then, as far as he is concerned, the doctor was negligent.
• But what if I have a good record among surgeons, with generally excellent outcomes and conscientious care? That wouldn’t matter, he said. The only thing that matters is what I did in the case in question. It’s like driving a car, he explained—I could have a perfect driving record, but if one day I run a red light and hit a child, then I am negligent, he said.
• 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. It gives us our best chance of avoiding the worst error of all—giving up on someone we could have helped.
• Good doctors, she finally said, understand one key thing: “This is not about them. It’s about the patient.” The good doctors didn’t always get the answers right, she said. Sometimes they still pushed too long or not long enough. But at least they stopped to wonder, to reconsider the path they were on. They asked colleagues for another perspective. They set aside their egos.
• In the end, no guidelines can tell us what we have power over and what we don’t. In the face of uncertainty, wisdom is to err on the side of pushing, to not give up. But you have to be ready to recognize when pushing is only ego, only weakness. You have to be ready to recognize when the pushing can turn to harm. In a way, our task is to “Always Fight.” But our fight is not always to do more. It is to do right by our patients, even though what is right is not always clear.
• True success in medicine is not easy. It requires will, attention to detail, and creativity. But the lesson I took from India was that it is possible anywhere and by anyone. I can imagine few places with more difficult conditions. Yet astonishing successes could be found. And each one began, I noticed, remarkably simply: with a readiness to recognize problems and a determination to remedy them. Arriving at meaningful solutions is an inevitably slow and difficult process. Nonetheless, what I saw was: better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.
• MY FIRST SUGGESTION came from a favorite essay by Paul Auster: Ask an unscripted question. Ours is a job of talking to strangers. Why not learn something about them? If you ask a question, the machine begins to feel less like a machine.
• MY SECOND SUGGESTION was: Don’t complain. But resist it. It’s boring, it doesn’t solve anything, and it will get you down. You don’t have to be sunny about everything. Just be prepared with something else to discuss: an idea you read about, an interesting problem you came across— even the weather if that’s all you’ve got. See if you can keep the conversation going.
• MY THIRD ANSWER for becoming a positive deviant: Count something.
• If you count something you find interesting, you will learn something interesting.
• MY FOURTH SUGGESTION was: Write something
• MY SUGGESTION NUMBER five, my final suggestion for a life in medicine, was: Change.
• So find something new to try, something to change. Count how often you succeed and how often you fail. Write about it. Ask people what they think. See if you can keep the conversation going.