Better

A Surgeon’s Notes on Performance

Atul Gawande

Being better is a funny thing. We all want to do the best we can. We can even become devastated if we learn or feel that we aren’t. And yet, is there really an end point to this goal? Doesn’t everyone have room for improvement? But to improve we have to identify, acknowledge and address flaws. Tricky business, in’t it? 

As Dr. Gawande writes, “Betterment is a perpetual labor….. To complicate matters, we in medicine are also only humans ourselves. We are distractible, weak, and given to our own concerns…. The question… is not whether one accepts the responsibility. Just by doing this work, one has. The question is, having accepted the responsibility, how one does such work well.” 

Dr. Gawande explores what he considers three core components for success, in medicine, in risk and responsibility: diligence, doing right, and ingenuity. 

Before we dig in, let’s revisit the concept of a bell-curve. Most results follow a bell-curve. Most of our results and outcomes are probably average, and fall in the center of the bell curve. If you want to be better, you’ll compare your results to the bell-curve, by comparing our successes and failures to our peers, within our hospital or within the literature.

Diligence

Steady, earnest and energetic effort; persevering application. (Merriam Webster Dictionary) In other words, hard work, probably boring, and really easy to avoid. Pursue the concept of positive deviance- in other words, strive for the right of the bell-curve. As you try to move within the bell-curve, the smallest changes and habits will make the greatest differences. 

Acknowledge the problem, investigate the underlying causes (including asking those within the problem where they see contributions), and take action, consistently, persistently and patiently. 

Doing Right

Ethics are not always clear. There are many grey areas. There will be struggles, personally, professionally and amongst your profession. You may have to choose between the law, the practice, and your morals. Doing what everyone else does, if unethical, is not going to produce “better”. Do the hard thing. Do the right thing. 

Ingenuity

Ingenuity involves diligence in tracking the problems/weaknesses/errors, but also proactively taking measures to push up the bell-curve, not just accepting standard of care. A responsibility to ingenuity also involves the advancement of medicine overall. This necessitates being open about what we are doing. The Mayo brothers established one of the most advanced and sought after clinical practices in the countryside of remote Minnesota, in part, because of these practices. They openly accepted colleagues to observe them, and took every advantage to do likewise. They managed to advance medicine worldwide by example and ingenuity. (The Doctors Mayo, Helen Clapesattle)  

Dr. Gawande manages to challenge while inspiring, using medical examples and scenarios. This is most definitely worth the read, and is very readable. While the call to betterment is not an easy one, he outlines how impactful small actions can be in our profession and practice. 

So, where do you want to be Better? How can you apply these tactics to do so? And how are you going to manage the hit to your ego, or prevent letting your imposter syndrome from even starting?!

Further Reading/Resources:
For Better Or Worse
Book Rounds: Imposter Syndrome
Book Rounds: Feedback