Better by Atul Gawande: Book Review

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. Kathryn's articles are here.

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.
 

 
References

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