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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OK. No problem. This happens once in a while. We’ll wait. By four o’clock, however, Magboo still had not been taken in. I called down to the OR desk to find out what was going on.

The recovery room had opened up, I was told, but Magboo was getting bumped for a patient with a ruptured aortic aneurysm coming down from the emergency room. The staff would work on getting us another OR.

I explained the situation to Magboo, lying on her stretcher in the preoperative holding area, and apologized. Shouldn’t be too much longer, I told her. She was philosophical. What will be will be, she said. She tried to sleep to make the time pass more quickly but kept waking up. Each time she awoke, nothing had changed.

At six o’clock I called again and spoke to the OR desk manager. They had a room for me, he said, but no nurses. After five o’clock, there are only enough nurses available to cover seventeen of our forty-two operating rooms. And twenty-three cases were going at that moment—he’d already made nurses in four rooms do mandatory overtime and could not make any more. There was no way to fit another patient in.

Well, when did he see Magboo going?

"She may not be going at all,” he said. After seven, he pointed out, he’d have nurses for only nine rooms; after eleven, he could run at most five. And Magboo was not the only patient waiting. “She will likely have to be canceled,” he said. Cancel her? How could we cancel her?

I went down to the control desk in person. One surgeon was already there ahead of me lobbying the anesthesiologist in charge. A second was yelling into the OR manager’s ear on the phone. Each of us wanted an operating room and there would not be enough to go around. A patient had a lung cancer that needed to be removed. Another patient had a mass in his neck that needed to be biopsied. “My case is quick,” one surgeon argued. “My patient cannot wait,” said another. Operating rooms were offered for the next day and none of us wanted to take one. We each had other patients already scheduled who would themselves have to be canceled to make room. And what was to keep this mess from happening all over again tomorrow, anyway?

I tried to make my case for Magboo. She had a breast cancer. It needed to be taken out. This had to happen sooner rather than later. The radioactive tracer, injected more than eight hours ago, was dissipating by the hour. Postponing her operation would mean she would have to undergo a second injection of a radioactive tracer—a doubling of her radiation exposure—just because an OR could not be found for her. That would be unconscionable, I said.

No one, however, would make any promises.

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.

The sections of this book examine three core requirements for success in medicine—or in any endeavor that involves risk and responsibility. The first is diligence, the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles. Diligence seems an easy and minor virtue. (You just pay attention, right?) But it is neither. Diligence is both central to performance and fiendishly hard, as I show through three stories: one about the effort to ensure doctors and nurses simply wash their hands; one about the care of the wounded soldiers in Iraq and Afghanistan; and one about the Herculean effort to eradicate polio from the globe.

Copyright © 2007 by Atul Gawande. All rights reserved.

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