Excerpt from Better by Atul Gawande, plus links to reviews, author biography & more

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A Surgeon's Notes on Performance

by Atul Gawande

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  • First Published:
    Apr 2007, 288 pages
    Feb 2008, 288 pages

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People often look to great athletes for lessons about performance. And for a surgeon like me, athletes do indeed have lessons to each—about the value of perseverance, of hard work and practice, of precision. But success in medicine has dimensions that cannot be found on a playing field. For one, lives are on the line. Our decisions and omissions are therefore moral in nature. We also face daunting expectations. In medicine, our task is to cope with illness and to enable every human being to lead a life as long and free of frailty as science will allow. The steps are often uncertain. The knowledge to be mastered is both vast and incomplete. Yet we are expected to act with swiftness and consistency, even when the task requires marshaling hundreds of people—from laboratory technicians to the nurses on each change of shift to the engineers who keep the oxygen supply system working—for the care of a single person. We are also expected to do our work humanely, with gentleness and concern. It’s not only the stakes but also the complexity of performance in medicine that makes it so interesting and, at the same time, so unsettling.

Recently, I took care of a patient with breast cancer. Virginia Magboo was sixty-four years old, an English teacher, and she’d noticed a pebblelike lump in her breast. A needle biopsy revealed the diagnosis. The cancer was small—three-quarters of an inch in diameter. She considered her options and decided on breast-conserving treatment—I’d do a wide excision of the lump as well as what’s called a sentinel lymph node biopsy to make sure the cancer hadn’t spread to the lymph nodes. Radiation would follow.

The operation was not going to be difficult or especially hazardous, but the team had to be meticulous about every step. On the day of surgery, before bringing her to the operating room, the anesthesiologist double-checked that it was safe to proceed. She reviewed Magboo’s medical history and medications, looked at her labs in the computer and at her EKG. She made sure that the patient had not had anything to eat for at least six hours and had her open her mouth to note any loose teeth that could fall out or dentures that should be removed. A nurse checked the patient’s name band to make sure we had the right person; verified her drug allergies with her, confirmed that the procedure listed on her consent form was the one she expected. The nurse also looked for contact lenses that shouldn’t be left in and for jewelry that could constrict a finger or snag on something. I made a mark with a felt-tip pen over the precise spot where Magboo felt the lump, so there would be no mistaking the correct location. Early in the morning before her surgery, she had also had a small amount of radioactive tracer injected near her breast lump, in preparation for the sentinel lymph node biopsy. I  now used a handheld Geiger counter to locate where the tracer had flowed, and confirmed that the counts were strong enough to indicate which lymph node was the “hot” one that needed to be excised. Meanwhile, in the operating room, two nurses made sure the room had been thoroughly cleaned after the previous procedure and that we had all the equipment we needed. There is a sticker on the surgical instrument kit that turns brown if the kit has been heat-sterilized and they confirmed that the sticker had turned. A technician removed the electrocautery machine and replaced it with another one after a question was raised about how it was functioning. Everything was checked and cross-checked. Magboo and the team were ready.

By two o’clock I had finished with the procedures for my patients before her and I was ready too. Then I got a phone call.

Her case was being delayed, a woman from the OR control desk told me.

Why? I asked.

The recovery room was full. So three operating rooms were unable to bring their patients out, and all further procedures were halted until the recovery room opened up.

Copyright © 2007 by Atul Gawande. All rights reserved.

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