If you have already read Complications by Atul Gawande, I will not need to convince you to read Better. The book is a collection of articles but flows as if they are chapters. Medical writers have the advantage of writing about issues which interest a large segment of the population. Gawande has the additional advantage of writing well and sensitively. He makes you ponder. He raises questions which are ignored by many (and he doesn’t have all the answers). Life, and healthcare, are messy. I rate Better as interesting and as well-written as How Doctors Think by Jerome Groopman.

While Gawande almost always writes from a positive perspecitve, he does not hide uncomfortable facts. He appreciates the role of science in healthcare but understands that there is much more to healing than the mechanical application of science. For example: “Each year, according to the U. S. Centers for Disease Control, two million Americans acquire an infection while they are in the hospital. Ninety thousand die of that infection.” “Our hospital’s statistics show what studies everywhere else have shown – that we doctors and nurses wash our hands one-third to one-half as often as we are supposed to.” Continuing to do what has been done before to solve this problem, even doing more of it, will not tend to improve outcomes over the long-term. Behavior has to be observed and understood. Then modifications can be made which will have a greater chance of success.

“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 to it. And if it were an individual’s primary goal in life, that life would indeed seem narrow and unambitious. Understood, however, as the prerequisite of great accomplishment, diligence stands as one of the most difficult challenges facing any group of people who take on tasks of risk and consequence.” Many of us have come to understand that while “don’t sweat the small stuff” sounds great and lets up on the pressures we feel, very often “the devil is in the details.” We are functioning best when we can both step back to see the long-range goals and also persevere through the necessary details to bring the goals to fruition. Under this topic he discusses the amazing success of the world effort to eliminate polio, including the role of Rotary International, and how difficult it will be to reach that goal. Ridding the world of small pox was much easier, by comparison, and polio is only one of many devastating diseases which continues to flourish.

Among the issues he discusses is the challenge of sensitively performing a physical examination to a variety of people with widely differing standards of what is acceptable physical contact. The nature of doctors fees and income. Malpractice and what should be done when mistakes are made. The role of doctors in executions. On question of how heroic efforts should be to save someone’s life and who should make those decisions. It can be hard for doctors to remember that this is not about them. It is about the patient. Their egos and expertise are on the line. “You have only our character to fall back upon – and sometimes it’s only your pride that comes through.”

He uses obstetrics to show how decisions are made in medicine. “There’s a paradox here. Ask most research physicians how a profession can advance, and they will tell you about the model of ‘evidence-based medicine’ – the idea that nothing ought to be introduced into practice unless it has been properly tested and proved effective by research centers, preferably through a double blind, randomized controlled trial. But in a 1978 ranking of medical specialties according to their use of hard evidence from randomized clinical trials, obstetrics came in last. Obstetricians did few randomized trials, and when they did they largely ignored the results…. Yet almost nothing else in medicine has saved lives on the scale that obstetrics has.” “In obstetrics, if a new strategy seemed worth trying, the doctors did not wait for research trials to tell them if it was all right. They just went ahead and tried it, then looked to see if results improved.”

“The Apgar score changed everything. It was practical and easy to calculate, and it gave clinicians at the bedside immediate feedback on how effective their care was. In the rest of medicine, we are used to measuring dozens of specific things: blood counts, electrolyte levels, heart rates, viral titers. But we have no routine measure that puts the data together to grade how the patient as a whole is faring.” He goes on to explain how the Apgar score changed the whole culture of care. Forceps, for example, can be an excellent tool, but they take a lot more skill to use well and safely than does a Caesarian and, therefore, have gone out of use.

He uses cystic fibrosis as an example of how measurement and exact protocols can improve outcomes, but that even with everyone technically doing the same procedures with the same protocols, outcomes will vary widely in the hands of one person or one team compared with another.

Gawande also speaks of the amazing results some surgeons have in parts of the world in which they face terrible medical conditions in worse physical circumstances and achieve what appear to be miracles. Human ingenuity and dedication can be very inspiring. He concludes with the recommendation that we become “positive deviants”. We can all make things better. This does not happen without trying something new and without a positive attitude.