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Better: A Surgeon’s Notes on Performance 

Anomalies, head cases and the education of Atul Gawande

Wednesday, Jun 6 2007

One of the best and worst parts of having parents who are both doctors is the stories they tell. From my mother and father, a dermatologist and a cardiologist, there were tales told at the dinner table — some thrilling, some gruesome or sad, all of them fascinating — that got me interested in how science, particularly medicine, plays out in our daily lives: the man who believed he had ants under his skin, or the American vets my dad treated during his internship at a Philippine naval base at the height of the Vietnam War. For those not similarly lucky and/or cursed enough to have grown up with stories like these, there is doctor and author Atul Gawande.

In the five years since his first book, Complications: A Surgeon’s Notes on an Imperfect Science, Gawande has been nominated for a National Book Award and won a MacArthur “genius” grant. His success in the world of letters is testament to the rarity of such gap-bridging works — part analytical journalism, part memoir, with lots of compelling real-world life-and-death problems to be solved. Like his last, Gawande’s new book, Better: A Surgeon’s Notes on Performance, is a collection of physicians’ clinical anecdotes, a form that languished for a spell until the acknowledged master of the genre — neurologist Oliver Sacks — resurrected it for modern times.

An intriguing example lifted straight out of Gawande’s own experience in the field is presented, then deftly teased apart with historical perspective or with informal numbers research. Each essay — on the campaign to eradicate polio in India, for instance, or on battlefield medicine in Iraq — is like a medical psalm, designed ultimately to enlighten as much as entertain, and shot through with Gawande’s gentle, self-deprecating humor. One need not be versed in medical jargon to enjoy Better, but only have an appreciation for the cerebral and the visceral. Gawande deconstructs what is essentially a mystifyingly complex and intractable system, one that everybody at some point in his or her life has partaken of, yet almost nobody understands. This in itself is extraordinary. But then the health care system in Gawande’s hands emerges as a landscape rich with human drama.

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The facts themselves are often so remarkable that it is simply a matter of getting out of the way in the telling of them. Here is a tasty bit from the chapter on the doctors who work in the death chambers: “Officials found that the electrical flow frequently arced, cooking flesh and sometimes igniting prisoners — postmortem examinations often had to be delayed for the bodies to cool.” Witnesses, he says, were often left “screaming in the gallery.” Reporters began to weep. An attorney general puked.

In part, the opportunity to relay such facts requires an access and an expertise plain old civilian authors don’t often have. Access in and of itself is not enough, however, and this is where Gawande’s real strength comes in, for he has the ability to take his insider’s perspective, turn it on its head, and look at things in the way a smart, curious outsider might. He talks about things not normally discussed in medicine. Things so routine or taken for granted as to be invisible, or so highly charged as to be taboo.

The essay “Piecework” was prompted by the first time Gawande had to negotiate his salary. Asked to come up with his own figure (and “if it’s reasonable,” that’s what the hospital would pay him), he began to investigate exactly how doctors and insurance companies put a price on care. Why, for instance, will insurers pay surgeons $492.35 for removing a bunion, and $1,662.34 for removing a lung? Is a lung (or the means of extracting it) worth three times as much as a bunion? Gawande asks great questions. In the era of malpractice suits, should doctors admit when they make mistakes? How long should a sick patient keep fighting to live? How long should his doctor keep struggling to cure him?

If the cathartic pleasures of clearly seeing that which is hidden in plain sight are the meat and bones of Better, it is the concept of the anomaly — that bump on the landscape you can’t help but notice, or that outlying tick of datum that just won’t fit onto the bell curve — that functions as the book’s connective tissue. Anomalies help us to understand how and why normal is normal. Throughout, Gawande argues for the value of “positive deviants,” peppering his text with examples of ingenuity to illustrate exactly what it takes to be pretty good, and what it takes to be outstanding. Virginia Apgar revolutionized obstetrics in the 1950s and ’60s. She treated babies that other doctors left to die, thinking they were too sick to survive. Gawande tells us that she used to carry around a scalpel and rubber tubing in her purse, you know, just in case the person beside her on the bus needed an emergency tracheotomy.

The most heartwarming positive deviants are a group of impoverished but resourceful surgeons in Nanded, India. Appalling things happen in Nanded. During Gawande’s visit, he saw a man die from an easily treatable collapsed lung. Patients had to rush out to purchase their own medical supplies, which were often unsanitary. However, “using just textbooks and advice from one another, the surgeons at this ordinary district hospital had developed an astonishing range of expertise.” Gawande observed a doctor perform makeshift brain surgery on a child who would otherwise have died. Fluid was building up in the boy’s head, and as there was no drill, no shunt and no neurosurgeon, the Nanded doctor simply ground a hole in the boy’s skull with a scissors tip. It sounds insane, but the boy lived.

Gawande, who is a professor at Harvard Medical School and a general surgeon at Brigham and Women’s Hospital in Boston, had gone to India thinking he might have something to teach his counterparts, as a hotshot, young, U.S.-educated doctor. But it is he who gets an education. “What is your preferred technique for removing bladder stones?” one of the Nanded surgeons asks him.

“My technique,” Gawande says, “is to call a urologist.”

Atul Gawande’s prose is uncluttered, elegant in a plainspoken way, even poetic at times. (He once said in an interview that he keeps a copy of Sylvia Plath’s poem “The Surgeon at 2 A.M.” taped to his office wall.) I blazed through Better in a single rapturous day. The narrative portrait that emerges is of a thoughtful, diligent and self-aware man, deeply in love with his profession, who even if he isn’t in possession of all the answers — isn’t entirely convinced that answers can be found — is nevertheless committed to searching for them. The heroes in Oliver Sacks’ classic works (like The Man Who Mistook His Wife for a Hat) were his idiosyncratic patients, who struggled to overcome their diagnoses and function in a world that regarded them as broken. In Gawande’s mythology, the heroes are without a doubt the doctors, flawed as they are.

BETTER: A Surgeon’s Notes on Performance | By ATUL GAWANDE | 288 pages | Metropolitan Books | $24 hardcover

Reach the writer at galimurung@laweekly.com
  • Anomalies, head cases and the education of Atul Gawande

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