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Better: A Surgeon’s Notes on Performance
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Section 3: “Ingenuity”Chapter Summaries & Analyses
Chapter 9 Summary: “The Score”
In Chapter 9, Gawande begins his meditation on the book’s final section, “Ingenuity,” by examining the advancements that have been made to improve childbirth. Historically, childbirth has been hazardous for both babies and mothers: “For thousands of years, childbirth was the most common cause of death for young women and infants” (174). Although modern medicine has greatly improved the chances for survival for mothers and babies, there are still many complications that can arise during childbirth.
For many years, obstetricians labored to mitigate complications during childbirth, and they discovered “dozens” of maneuvers and advancements that greatly improved the outcome of problem births as a result (177). The invention of forceps and cesarean sections are two such advancements (177). However, despite these innovations, many babies still died after childbirth because there was no uniform system in place to gauge how healthy they were. One in 30 babies who were deemed too weak to live died right after birth. This statistic changed with the advent of Virginia Apgar’s method of rating a baby’s health.
Though Apgar was a brilliant doctor, her path to innovation was complicated by the fact that she was a woman in a mostly male profession. Still, she persisted and created the “Apgar score, as it became universally known” (186). The Apgar score allowed nurses to “rate the conditions of babies at birth on a scale from zero to ten” (187). Gawande goes on to say that “[t]he score turned an intangible and impressionistic clinical concept—the condition of new babies—into numbers that people could collect and compare” (187). Further, and because the test could be quantified, it drove doctors “to want to produce better scores—and therefore better outcomes for the newborns they delivered” (187).
After the “Apgar score changed everything” (190), it led to a fundamentally new way of thinking within the field of obstetrics. Today, because childbirth innovations like Cesareans are easy and functional, many hospitals are eschewing natural childbirth to make the process as convenient and practical as possible. Gawande claims that this forces doctors to consider whether medicine is a craft or an industry (192). He worries that hospitals and doctors have been so focused on perfecting the Apgar score and the process of childbirth that they have started to change something that nature already perfected (198). Gawande is also concerned that these innovations have been implemented without considering the impact they have on mothers (198). He warns doctors not to let blind faith in technology and innovation separate them from the fundamental aspects of medicine.
Chapter 10 Summary: “The Bell Curve”
Chapter 10 takes an honest look at the fact that most patients are not getting the best possible care available. Instead, their care falls along a bell curve, which is difficult for doctors to acknowledge. According to Gawande:
[The bell curve] belies the promise that we make to patients: that they can count on the medical system to give them their very best chance. It also contradicts the belief that nearly all of us have that we are doing our job as well as it can be done. But evidence of the bell curve is starting to trickle out, to doctors and patients alike, and we are only beginning to find out what happens when it does (207).
The bell curve is further complicated by the fact that doctors have no way of knowing for certain whether their care is as helpful as they hope it is: “[Doctors] have no reliable evidence about whether we’re as good as we think we are. Baseball teams have win-loss records. Businesses have quarterly earnings reports. What about doctors?” (207).
To show how the bell curve has inspired doctors to make advancements, Gawande tells the story of LeRoy Matthews. Matthews was a pediatrician from Cleveland who made massive strides in treating cystic fibrosis, a disease without a cure that limited patients to a life expectancy of around 20. By changing the way he treated the disease, Matthews revolutionized how the disease was managed: “Matthews viewed CF [cystic fibrosis] not as a sudden affliction but as a cumulative disease and provided aggressive preventative treatment to stave it off long before his patients became visibly sick” (210).
The bell curve also motivated Don Berwick, “a former pediatrician who runs a nonprofit organization in Boston” (212), to find ways to improve healthcare for patients. According to Berwick:
To fix medicine […] we need to do two things: measure ourselves and be more open about what we are doing. WE should be routinely comparing the performance of doctors and hospitals, looking at everything from surgical complication rates to how often a drug ordered for a patient is delivered correctly and on time. And […] hospitals should give patients total access to information (214).
Berwick believes that a more open healthcare system with greater transparency would greatly improve medicine for both doctors and patients alike.
Gawande worries that being in the bottom half of the bell curve will eventually be used against certain doctors. Overall, however, he believes that the bell curve does more good than harm because it holds doctors to higher standards and prevents them from becoming content with being average. According to Gawande, complacency has no place in healthcare because “when the stakes are our lives and the lives of our children, we want no one to settle for average” (230).
Chapter 11 Summary: “For Performance”
In the final chapter of Better, Gawande tries to determine if the best path for medicine’s future is “investment in laboratory science or in efforts to improve how existing medical care performs” (232). Although massive technological advances have helped to save many lives, he worries that doctors are too reliant on specialization and machinery and do not expand the scope of their own knowledge enough. Gawande offers this warning:
Such machines [like the MRI] have become the symbols of modern medicine, but to view them this way is to misunderstand the nature of medicine’s success. Having a machine is not the cure; understanding the ordinary, mundane details that must go right for each particular problem is (242).
Gawande uses a trip to India to highlight this point. In India, he witnesses Dr. Ashish Motewar, an Indian doctor who often lacks many of the modern appliances that Gawande has access to, become “among the most proficient ulcer surgeons in the world” (245). Once again, the desire to do better regardless of limitations is what is most essential to practice medicine properly.
Section 3 Analysis
In Chapters 9 and 10, Gawande insists that the goal of medicine should be to always advance towards some new breakthrough. He uses the advancements that have been made in childbirth as an example. Though these improvements have helped many patients, there are still deficiencies in the medical field that make overall progress difficult. For instance, doctors do not have standard metrics by which they can judge themselves. Therefore, they do not know how well they are practicing medicine in comparison to their peers.
Gawande demonstrates how the institution of the Apgar Score and the bell curve of healthcare helps doctors to understand where they fall in the larger spectrum of care. Because Gawande believes that doctors are competitive people, these metrics help motivate them to become better because nobody, especially no one in the medical industry, wants to be average, let alone below average. However, this desire for improvement can become all-consuming, which leads Gawande to consider whether medicine should be a craft or an industry.
Before the advent of medical technology, Gawande argues that medicine was a craft. To become skilled in the practice of medicine, doctors had to learn numerous techniques and be prepared for all sorts of contingencies. However, as advanced medical technology developed, Gawande believes that medicine slowly became an industry where a one-size-fits-all approach was taken to ensure that patients received the same quality of care. While this new approach to medicine may help doctors receive tangible results about their success as practitioners, Gawande worries about what doctors will lose when they completely forget the craft of medicine. After all, as the bell curve of healthcare clearly demonstrates, a one-size-fits-all approach to medicine has not guaranteed that all patients receive the same level of care.
Gawande continues to explore the theme of ingenuity in the final chapter of the book. Here, he insists that medicine needs to maintain its identity as a craft, rather than becoming a full-blown industry. He points out that doctors in India, who often lack basic medical materials, are still becoming worldwide leaders in their fields because they never stop searching for knowledge. For Gawande, to practice medicine properly, a doctor cannot rely on modern convenience. Instead, doctors must use their training and knowledge to provide the best possible care, even without modern equipment. Gawande especially admires doctors whose ingenuity was born out of necessity and, thus, outstrips his own. He acknowledges that this is due to a laziness on his part, a “laziness” not born from lack of desire for betterment but from being a victim of the privileges of the first world. In Gawande’s opinion, doctors need to keep moving the field of medicine forward without forgetting how to do things simply and efficiently.
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