[This review was published in the Summer 2007 issue of the Mankind Quarterly, pp. 118-120.]


Book Review 


Better: A Surgeon’s Notes on Performance

Atul Gawande

Metropolitan Books, 2007 


            We have no hesitation in saying that this book will be both edifying and fascinating to all readers.  It is an example of writing at its best—unpretentious, thoughtful, easily readable without undue informality, full of morals without moralizing, important in its subject-matter, and intriguing in its details.

            Atul Gawande is more than a general surgeon at a Boston hospital, although being a surgeon would in itself be enough when we consider the intelligence he brings to his craft.  He adds an academic side as a member of the faculty at the Harvard Medical School and the Harvard School of Public Health, and as a “frequent contributor” to the New England Journal of Medicine, certainly one of the leading (if not the leading) medical journals in the world.  His down-to-earth intellectuality comes to bear, too, as an author for a wider audience: his first book was Complications: A Surgeon’s Notes on an Imperfect Science, and he is a staff writer for the New Yorker.

             Any passage in Better would serve to illustrate the simple directness of Gawande’s narrative, but this one from the Introduction has the advantage also of summarizing what the book is about:  “This is a book about performance in medicine.  As a doctor, you go into this work thinking it is all a matter of canny diagnosis, technical prowess, and some ability to empathize with people.  But it is not, you soon find out.  In medicine, as in any profession, we must grapple with systems, resources, circumstances, people—and our own shortcomings, as well.  We face obstacles of seemingly unending variety.  Yet somehow we must advance, we must refine, we must improve.  How we have and how we do is my subject here.”

            This reviewer bought the book to give to his oldest grandson, a fourteen-year-old who at present aspires to become a surgeon.  I thought I would read a page or two to assure myself that it is written at a level suitable to his understanding.  That was enough to hook me, and the reading led me on from one engaging medical situation to another until, all too soon, the book was finished.  My grandson will receive the book, no doubt, but not before his grandmother has had time to read it, too.

            Gawande’s chapter about his two-month visit to hospitals in India is one of the many captivating narratives.  He tells of the squalor, the lack of equipment and resources, the relentless overcrowding, and the low numbers of medical personnel—all at the same time he marvels at the ingenuity and expertise of the few surgeons, who don’t have the luxury of calling in specialists and have to do everything themselves.  Another engaging subject is his chapter on the role of medical personnel in the execution of criminals.  Yet another has to do with the procedures that have been discovered to allow ninety percent of casualties’ lives to be saved in Iraq—a marked improvement over all prior wars.

            One of the book’s characteristics is that Gawande doesn’t drop a subject while it is half-explored.  He carries his inquiry into the subject’s many nuances, including human and policy issues.  One of the many issues that come to the fore is whether there needs to be a rethinking of the time-honored medical premise that everything possible should be done to extend a patient’s life, no matter what the circumstances.  Do, say, the war casualties who survive but who are now condemned to reside for the rest of their lives in bodies that are mangled and reduced beyond belief have a prospect of a “life worth living”?  This is an issue that is growing ever-more acute in medicine.  Should CPR be used to resuscitate a drowning victim whose brain has long been deprived of oxygen?  Should “assisted suicide” become acceptable in light of an aging population that is subject to all sorts of end-of-life pain and misery?   Gawande cannot, of course, presume to resolve so vast an issue himself; in fact, he tends to hold fast to the traditional medical ethic, even while understanding the human implications.  But neither does he avoid broaching the hard questions.

            Better is laid out in sections that consider certain of what we might call “life lessons” that can be learned from a surgeon’s experiences: the importance of “diligence,” of “doing right,” and of “ingenuity.”  It ends with “suggestions for becoming a ‘positive deviant’” (i.e., someone who departs from the norm in a constructive way).  Although these are “copybook maxims” of the sort so much appreciated in the United States more than a century ago, there is nothing “preachy” about how Gawande presents them.  There’s much for my grandson—or anyone else, for that matter—to learn from them.

            Beyond these, however, there is a subtext that carries what is perhaps Gawande’s central message.  He readily acknowledges the value of new discoveries and technologies, but above all he wants to stress how, through careful observation and measurement, medical “delivery systems” can be made much more effective than they now are.  The mentality that infuses the book is one of scientific objectivity—an ability to back off mentally from an activity enough to see it dispassionately and to note the differences between what works well and what doesn’t.  His discussion is entirely in the realm of medicine, but one can easily see how invaluable this mentality can be in many other human endeavors.

                                                                                                                                                                                                                                                                                                            Dwight D. Murphey