Doctor: Medical World Flawed

At the ripe age of 41, surgeon and writer Atul Gawande has a lot to brag about. In addition to joining the faculty at the Brigham and Women’s Hospital in 2003, he has been a staff writer for the New Yorker since 1998, served as a senior health policy advisor in the Clinton administration from 1992 to 1993, and is currently an assistant professor at both Harvard Medical School and the Harvard School of Public Health.

His 2002 book “Complications: A Surgeon’s Notes on an Imperfect Science” was a finalist for the National Book Award, and in 2006 he received the MacArthur “genius grant” for his research and writing.

But despite this success, Gawande is anything but complacent.

TAKING ON THE ODDS

“Medicine is a world where we have a 97 percent likelihood of succeeding in avoiding complications,” Gawande says in a phone interview with The Crimson. “Most people would look at that and think that’s pretty good, but there are people out there who look at that 3 percent, recognize that it occurs with tens of millions of patients, and see that it translates into a lot of deaths.”

The shortcomings that Gawande struggles to overcome in the field of medicine are the subject of his new book, “Better: A Surgeon’s Notes on Performance,” which consists mostly of essays previously published in the New Yorker.

“I was trying to understand why medicine is imperfect and how one navigates that world either as a doctor who is trying to learn the skills along the way or as someone just trying to think about what should happen in medicine from any vantage point,” he says.

In “Better,” Gawande looks critically at a host of problems in healthcare that range from hand washing in hospitals to eradicating polio in India.

“It’s really hard to solve these problems and it takes a kind of attention to detail that we’re not used to thinking about in our system,” he explained.

Gawande is adamant about the need for doctors to be critical of their own performance.

“In order to really know if you’re succeeding, you have to measure how you’re doing,” he says. “Being willing to be transparent about your failures is something we all find hard to do.”

POSITIVE DEVIATION

Central to this principle is his concept of the “positive deviant” in medicine—a person who simply outperforms others in his or her field. It is Gawande’s project in “Better” to understand why some people or institutions in medicine are great while others are just, well, okay.

“The answer wasn’t in how smart, necessarily, people were,” he says. “It had much more to do with how they approached their own fallibility. There are some at the top of the bell curve who have abilities to look at their flaws and ask hard questions not only about their flaws, but at the systems around them, and then to continually focus effort and resources on how to overcome those flaws.”

He identifies three qualities of the positive deviant—diligence, ingenuity, and moral strength—and structures his essays around these principles. In the last chapter, he offers suggestions for how individuals can strive to become positive deviants themselves.

One suggestion is that doctors learn to ask questions.

“I suggested from something I saw in other people who are great at what they do, that they take the time to ask something unexpected,” he says. “It could be as simple as asking how they thought that Red Sox game went or asking a colleague in the elevator what they think of a certain idea.”

BRINGING PEOPLE TOGETHER

Gawande’s career as a writer, which began in 1997 when he started writing a short column for the Internet magazine “Slate,” has always emphasized the human side of medicine.

“There is an undervalued component of making good hospitals, good organizations, good clinics work, and it is that effort to bring people together in teams,” he says. “Medicine is now a team effort in a way it just wasn’t, as recently as twenty years ago.”

But working in a modern bureaucracy presents its own set of problems and challenges, which Gawande tackles in his writing.

“The thing is that I work in a hospital that has 10,000 employees throughout the system. You will naturally disappear as a cog in the machine. The pressure is to simply get through your day,” he says. “But we all need human interaction to be effective at what we do.”

The theme of human interaction is central to the essays in “Better,” many of which tell the story of ordinary individuals and the work they do to improve care on a case-by-case basis.

“You see people who have energy and optimism despite the chaos, despite the flaws and disasters, and you recognize that a fundamental component of that is a curiosity about the world around them.”

That curiosity is paramount for Gawande in the pursuit of personal and professional success. Despite his officially-deemed “genius” status, Gawande continues searching for better solutions to medicine’s many flaws.

As he is careful to add, “I don’t pretend to have clear answers.”

—Staff Writer Claire J. Saffitz can be reached at csaffitz@fas.harvard.edu.