Home All Better by Atul Gawande: Book Review

Better by Atul Gawande: Book Review

written by Kathryn Britton 16 March 2008

Kathryn Britton, MAPP '06, is a former software engineer and executive coach. She is now a writing coach and editor with a focus on helping people write books, blogs, and articles that contribute to the greater good (Theano Coaching LLC). She has been facilitating writing workshops since 2013. Her own books include Sit Write Share on how to get writing done well, Smarts and Stamina on using positive psychology principles to build strong health habits, and Character Strengths Matter: How to Live a Full Life. Full bio. Her Sit Write Share website has resources for writers. Kathryn's articles are here.

Cover of Better After I turned down the corner on the fifth page that I wanted to share with my positive psychology peers, I decided that a review of Better: A Surgeon’s Notes on Performance by Atul Gawande made sense for Positive Psychology News Daily.

Dr. Gawande is a surgeon and a columnist for the New Yorker. In Better, he writes about performance in medical settings, in particular about what it takes to get better — at washing hands to avoid spread of infection, at childbirth, at care for the wounded from the battlefield, at vaccinating children in India, at dealing with medical mistakes, at treating chronic disease such as cystic fibrosis, and so on.

In the preface, he tells a story of a senior resident taking care of patient, “But what that senior resident had displayed that day was more than competence–he grasped not just how pneumonia generally evolves and is properly treated but also the particulars of how to catch and fight one in that specific patient, in that specific moment, with the specific resources and people he had at hand” (p. 3). That sums up for me the challenge of applying positive psychology. It’s not just knowing principles of human flourishing. It’s also understanding how to apply them with particular people in particular settings with particular resources at hand.

The book is divided into 3 sections, one for each of the three core requirements that he sees for success in medicine. Each of these is relevant for success with positive psychology:

  1. Diligence: giving sufficient attention to avoid error and prevail against obstacles. His stories show how it is both “central to performance and fiendishly hard” (p. 8).
  2. Doing right: Dealing with medicine as a human profession troubled by human failings with difficult ethical questions such as whether to participate in executions, how much money doctors should make, how they should deal with mistakes, and when they should stop fighting for the life of particular patients.
  3. Ingenuity: reflecting on failure and constantly searching for new answers. The way medicine is practiced may have more potential for improving health than bench science. For example, he attributes great improvement in performance during childbirth to Virginia Apgar’s score for evaluating the condition of newborns — a simple score that “turned an intangible and impressionistic clinical concept — the condition of new babies — into numbers that people could collect and compare” (p. 187).

In the chapter about getting clinicians to wash their hands always (a fiendishly difficult problem), he introduces the idea of positive deviance, a term introduced by Jerry and Monique Sternin in their efforts to improve child nutrition in Vietnam. “Although the know-how to reduce malnutrition was long established… most people proved reluctant to change such fundamental matters as what they fed their children and when just because outsiders said so” (p. 25). The Sternins started looking for solutions from insiders: Who already had the best-nourished children? What were they doing that others in the same circumstances could adopt? Positive deviance is thus “the idea of building on capabilities that people already had rather than telling them how they had to change.” Sounds familiar, right?

The chapters about improvements in childbirth and treatment of cystic fibrosis made me think about the tension between having new ideas and empirically testing them. We often talk about positive psychology as if we were following the model of developing new medicines that have to be empirically tested before they are widely used. But some of the medical treatment changes with the most impact have been made up as people have gone along. The important thing is to collect data so that over time the treatments that make the most difference can be replicated widely.

That brings me to the afterword where Dr. Gawande makes 5 suggestions for becoming a positive deviant:

  • Ask an unscripted question. This involves getting to know patients and colleagues as people. “If you ask a question, the machine begins to feel less like a machine” (p. 252).
  • Don’t complain. Complaining starts the downward spiral.
  • Count something. “If you count something interesting, you will learn something interesting” (255).
  • Write something. “By soliciting modest contributions from the many, we have produced a store of collective know-how with far greater power than any individual could have achieved” (p. 256).
  • Change. Find something new to try.

I think these make sense for all of us, not just those in medicine.


Gawande, A. (2007). Better: A surgeon’s notes on performance. New York: Picador Books. Page numbers are from the paperback version.

Positive Deviance Initiative, Presentations.  Retrieved March 16, 2008 from http://www.positivedeviance.org/materials/presentations.html

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Jeff Dustin 16 March 2008 - 11:11 am

Better is one of your finest articles. How fascinating!

Kathryn Britton 16 March 2008 - 2:57 pm


I recently wrote a posting in my blog about what makes positive feedback effective.

Your comment has two out of three of the characteristics — it’s specific and it’s praise for the work, not for the person.

But the third is missing — insight into what’s good.

What makes this review one of my finest articles? I like it — I am glad to read over it again. But I don’t see where the comparison comes in.

Ah, thanks for giving me a chance to practice these thoughts about feedback.


Kathryn Britton 16 March 2008 - 2:58 pm

One other thing – I added links to the Sternin’s Positive Deviance site since I first posted the review.


Jeff Dustin 16 March 2008 - 6:44 pm

I’ll tell you why the article was outstanding, actually one of the very finest you have written here. First, the topic appeals to me. I’m a high school teacher/graduate student/human fascinated with performance. Sherri F.’s writing along with John’s always seem to hit that certain note.

Yet your article explores an issue we had talked about briefly. The second great/wonderful aspect of this piece was its focus on application v theory. I know, I know theories are practical & basic research is the substrate for all the rest. Whatever, the cutting edge stuff, while riskier, will always, always, always outpace theoretical, untested research. In your review of Better, context takes center stage. A positive psychologist-practitioner MUST tailor interventions to the specific milieu.

I told you once that I hated some of the positive exercises. I believe that one of the biggest stumbling blocks to acceptable and practice of PP by the public is the cheese factor.

What I mean is that if an exercise is 100 percent certain to make you extremely happy, it won’t get off the ground with people or become popular and accepted without massaging it to suit the target audience.

Take a gratitude exercise like counting your blessings. Great. How does that name sound to an atheist? To a narcissist who believes that all of his/her accomplishments are self-derived? To a neurotic who when thinking of blessings considers 5 curses right alongside them? (I’m sorry for using labels, but they are indeed briefer). How about a teen who thinks that PP is “gay” and just wants to rebel? Or how about someone with extremely low IQ? How about someone who feels macho and thinks Gratitude is for “wimps”?

I think that Better showcases the need for good marketing by PP’ers. I hope this post helps illustrate some of your piece’s strong points.

Psychology book lover 17 March 2008 - 7:06 am

What a great review, it is always good to see positive psychology being used (albiet in a different manner) in other fields. That has always been one of my stumbling blocks as I come from anthropology – the cross over with psychology is so great but seems little tapped into. This is especially true in terms of positive psychology – there are all sorts of similar tricks that indigenous peoples and cultures have set up around the world that help an individual become a positive deviant.

Jeff Dustin 18 March 2008 - 2:01 am

The Positive Deviance website has made a template for thinking about problems similar to some of the appreciate inquiry literature. I enjoyed looking at the slide shows. I love the 6 D’s of positive deviance:


Now if I could remember the missing two!

Editor K.H.B. 18 March 2008 - 10:21 am

Define the problem, related current practices, and successful outcome
Determine if there are individuals or groups (Positive deviants, PDs) that already exhibit desired behavior or status
Discover uncommon practices that enable PDs to outperform others
Design activities enabling others to practice the uncommon practices
Discern the effectiveness through ongoing evaluation
Disseminate successful practices – scale up

Kathryn Britton 18 March 2008 - 10:46 am

Thanks for taking the time to write out why you particularly liked this article.

Your reasons are very close to the reasons I liked the book — the particularity of successful practice (context) and the interesting outlook on the tension between evidence-based practices and what’s needed in application.

Dr. Gawande has a very interesting discussion of obstetrics. “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 until it has been properly tested and proved effective by research centers, preferably through double blind, randomized, controlled trial” (p. 188). According to him, obstetricians do few randomized trials. “Yet almost nothing else in medicine has saved lives on the scale that obstetrics has.”

He then talks about the importance of the Apgar score because it enables obstetricians to see if results improved when they tried things. “The Apgar changed everything. It was practical and easy to calculate, and it gave clinicians at the bedside immediate feedback on how effective their care was. … The score also changed the choices they made about how to do better” (p. 190).

Perhaps one of the things we need in positive psychology is an analog to the Apgar score — something that is quick and easy to determine, that gives us the feedback to know what practices really do make things better.


Wayne Jencke 18 March 2008 - 1:48 pm

What about the ultimate positive psychology intervention as applied to medicine – the placebo (hope)?


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