I just finished Atul Gawande’s Better on a friend’s recommendation, and I owe that friend a drink (or perhaps one of those terrifying japanese sodas she likes).
Better‘s subtitle is “A surgeon’s notes on performance”, and that speaks directly to the hook. Gawande is a surgeon, and that fact shapes his perspectives and arguments as he makes the case that improvement comes from three main vectors: diligence, doing right and ingenuity. These are the three sections of his book, and each section is composed of a number of accounts which reflect the premise.
The section on diligence opens strong with the mundane seeming issue of hand washing. While it’s an interesting study on sanitation and infection, it is even more interesting as a portrait of how to go about solving a relentlessly mundane problem in a large scale environment. That focus on the mundane and practical drives the other two sections, one on a massive immunization campaign in India and the other on U.S. Army battlefield medicine, and the ways in which it has improved. While the nominal thread of these three is diligence, I would say the keyword is really logistics.
The next section, doing right, wanders the map a little bit, from malpractice, to doctor’s salaries, to how medicine is priced, to the death penalty (and the role of doctors in it) . This is, to my mind, the weakest section, but this probably speaks to my bias as a reader. I am less interested in the doctor’s perspective than I am in what it can tell me, so issues that are so strongly internal to the profession were not what I was looking for.
The last section, ingenuity, had been the one that had caught my interest, as I had been told about some of the findings about the treatment of cystic fibrosis, and I was curious to read more. This is where he absolutely knocks it out of the park, and these are the stories I’ll be thinking about for weeks.
First, he talks about the history of childbirth and medicine, and how deadly the process has been. This is interesting enough, but it takes a turn for the fascinating when he talks about the development of the Apgar score, a simple numeric rating of the health of a baby, taken one minute and five minutes after birth. In a magnificent example of getting what you measure for, the creation of a metric helped drive success by giving something to judge it against – how many children below a certain score can you save?
Next he talks about the treatment of cystic fibrosis and the bell curve. The kicker is this – when data became transparent, it became clear that there was a bell curve of outcomes in different treatment centers, with some vastly outperforming others. What’s more, when that data became available to all practitioners, they could look at the best practices of those best units and improve their own performance, thus improving the overall average.
Left at that, this would be a simple triumph of the virtues of transparency, but what gets very interesting is what happens next. Yes, the overall average improves, but the greatest improvement comes from the top group, not the bottom. Their improvement is so profound that the gap between the best and average becomes almost insurmountable. It seems those groups who were already on the lookout for any way they could improve applied that same drive to taking advantage of the new information.
The final bit, on doctor’s in India kind of ties it all together, and while it’s an illustration of a lot of the points in the book, one particular bit struck me, that these doctors in these sometimes terrible conditions still felt they had something to contribute to the wider medical world. That belief did not seem unfounded, but it also seemed that it was positively self-fufilling.
The book’s afterward, magnificently titled “How to be a Positive Deviant,” is composed of five simple points to follow, and it is probably the best such advice I’ve seen for the brilliant-yet-not-so-functional since Scott Berkun‘s section on office politics in The Art of Project Management (Now titled, Making Things Happen).
This is a book I would suggest to anyone who needs to do things which are bigger than themselves. While the premise may be medical, the bulk of the book is clearly applicable to almost any endeavor which requires diligence, judgement and ingenuity.