What we can learn about performance from this legendary surgeon and Harvard professor

On November 9, President Joe Biden appointed surgeon, writer, and public health researcher, Atul Gawande to the White House’s COVID-19 Advisory Board. The team has got their work cut out for them no doubt, though Gawande’s inclusion speaks well of their resolve. 

In his 2007 book, Better: A Surgeon’s Notes on Performance, the decorated physician draws from the past to illustrate failings of the present. This framing suggests that medical professionals possess a privileged insight into effective decision making because of the risk and responsibility associated with their work.

“It’s trying to understand medicine as a kind of performance. By looking at how people do their job in medicine, you begin to have ideas and lessons for how performance really works at something that’s high risk, at something that’s difficult, and in a job that’s very human. It pushes us in ways that we’re not necessarily pushed in other walks of life,” Gawande said of the book’s intentions.

“Medicine is fundamentally a human profession. It is, therefore, forever troubled with human failings, failings like avarice, arrogance, insecurity, and misunderstanding. So, the solutions/problems/issues are interwoven with human traits. It is not a matter of superior intelligence, but of character. It demands more than anything, a willingness to recognize failure, to not paper over the cracks, and to change it. It arises from deliberate, even obsessive reflection on failure and a constant searching for new solutions.”

Gawande more explicitly contends that diligence, ingenuity, and a genuine desire to do right by patients are the three most important qualities in his profession via a collection of medical essays. Some of these were written years before Better’s release, which itself occurred more than 13 years ago. Still, the first chapter (titled Washing Hands) couldn’t feel any more prescient 

We learn that 2 million people contract infections at hospitals every year because their practitioners fail to adequately wash their hands. In the same chapter, Gawande chronicles the World Health Organization’s struggle to distribute polio vaccines to millions of people in an organized manner.

Not unlike what’s happening now with COVID vaccine candidates, the organization had to instruct clinicians on how to properly administer and preserve doses. The process was kind of a mess. 

A similar flavor of mistrust from the public dogged health systems just like it dogs efforts to inoculate the world against the novel coronavirus (SARS-CoV-2) today. Gawande recalled a woman who refused to give her child a pollio vaccine only for that very child to become paralyzed from the condition not long thereafter.

It was at once frustrating and consoling to be made aware of the cycle of conflict and gratitude that defines the pedestrian doctor relationship. 

Every generation believes that their crisis is uniquely challenging or that their peers are uniquely flawed. But Better demonstrates that humans have never been immune to defeat or incapable of success against the odds. 

As we get into the middle section of the bookafter we’ve learned about the pressures of being a medic in the war, a physician with a pioneering addition to the field or an ordinary citizen trying to cope with the social disruption inspired by sickness, the lessons premised by medical procedures broaden to quotidian life. Which is to say, we can appreciate the same principles that lead to success in medicine as guiding stars in our own lower stake endeavors. 

Gawande does a good job avoiding the kind of platitudes that typically anchor self-help literature. 

It helps that expertise gives shape to the majority of the maxims here, accompanied by references to formative voices in antiseptic research. Some of the more dense medical language must feel more accessible to readers picking up the book for the first time this year.  

There are two anecdotes found within that reflect this strength pretty well. The first revolves around Ignaz Philipp Semmelweis, a 19th-century Hungarian physician who practiced when death rates were unusually high among newborns. The hospital where Semmelweis worked saw about 3,000 mothers give birth a year but 20% of the babies perished.

Semmelweis suspected poor sanitation to be the culprit. When he required surgeons to wash their hands with chlorine and a nail brush before each and every procedure, the newborn death rate dropped from 20% to 1%. Semmelweis was deemed a controversial figure in his time because of his introduction of this life-saving protocol.

In one anecdote, three parallels to the modern-day are made apparent.

  1. Poor hygiene has always been a predictive element of the transmission of infectious diseases.
  2. We’ve been interacting with bacteria and pathogens since the beginning of time, but have only begun to truly understand the depth of their risk in the last few centuries. 
  3. Lastly, new prescriptive concepts are bound to draw criticism. No matter how logical, people do not like being instructed on how to do things in a new way

Gawande also writes about the techniques senior residents use to encourage proper sterilization practices. In one such instance, he references the 30-minute checkup, wherein medical staff is gathered together to discuss their hygiene habits for half an hour.

The simple expectation that public scrutiny is on the table dramatically increases the likelihood of exceptional conduct. The same can be said of convenient methods of sterilization. Gawande goes on to reveal that routine handwashing increased by 30% with the invention of alcohol hand gels.

The second anecdote that speaks to Better’s central message is a personal one. Early in his career, the then med-student was made responsible for a woman in her 70’s who was admitted with body aches, a cough, and a high white blood cell count. The woman did not have a fever and blood culture samples did not reveal anything noteworthy.  “Each day she stayed more or less the same.  She just didn’t feel good.”

It was only when a senior resident took over that the woman’s condition improved. The doctor checked in on the patient twice a morning; retesting vitals and reviewing the data that had been logged on her thus far.  

“A tiny act of consciousness. He’d seen something about her that worried him. So he checked on her himself. That was no two-second matter. She was up on the 14th floor of the hospital. The elevators were notoriously slow,” Gawande continued.

The senior doctor determined that she was on the verge of septic shock before transferring her to the intensive care unit. He set her up with a regimen of antibiotics and she was home in 3 days.

COVID-19 has produced index cases that take on a comparable ambiguity. Some patients express characteristic symptoms while others exhibit effects that have yet to be recorded by academicians.  Survivors often express appreciation for the health care providers that didn’t throw up their hands and submit to inconclusive test results.

“People underestimate the importance of diligence as a virtue. Defined as the constant and earnest desire to accomplish what is undertaken. Diligence stands as one of the most difficult challenges facing any group of people who take on tasks of risk and consequence. It sets a high, seemingly impossible  expectation for performance and human behavior yet some in medicine have delivered on that expectation on an almost unimaginable scale.”

Gawande credits his understanding of the gravity of his role with why he likes to equate himself to a performer: there are practices that need to be maintained in order for a surgeon to live on the tips of their toes, not unlike a musician or a dancer. The only meaningful differences concern the outcome of failure.

Ultimately, Better is a roundup of medical stories that implores people from all walks of life to measure themselves against their objectives. It’s a perfect read for those looking to feel optimistic about a new era of Covid-19 countermeasures.