Sunday, January 20, 2008

Book Review (1/34) Better: A Surgeon's Notes on Performance

I have a subscription to the New Yorker. Some weeks I read the entire thing cover to cover. Other weeks (notably the week where fashion is a huge topic) I hardly read anything between "Talk of the Town" and the Review Section in the back. Usually, there will be one or two articles in the magazine that will intrigue me. What's really amazing is that chances are one of these articles is about a topic I have never really thought about or cared about. The fact that I enjoy these articles as much as I do is a tribute to the staff and writers of the New Yorker.

Every now and then an article strikes me so much that I scan in it so I'll always have access to it. This occurred a few weeks back when I encountered an article called "The Checklist" by Atul Gawande. Gawande is a surgeon, however, he is also an excellent writer. The article revolved around how much the infection rate in hospitals could be lowered by the inclusion of checklists. Not new drugs. Not new surgeries. Just a simple ole checklist. This type of innovation is the exact type of innovation the field of Human Factors should be making. However, once again the innovation has come from the inside.

Based on how intellectually stimulating I found the article to be I quickly turned to the "Contributors" page of the New Yorker and found that Gawande had a new book out entitled Better: A Surgeon's Notes on Performance. After looking up a few reviews online I decided that this book would be perfect for me and after I created this list of 101 Things I knew this would be book number 1.

As much as I learn from the fiction books I read (some have really made me think ... Evolution by Stephen Baxter, Replay by Ken Grimwood) I've found that I really get my rocks off with a great nonfiction book. I think it is much more difficult to make a readable nonfiction book because it is so easy to get lost in the jargon of one's field (that's a topic for another day). But when people nail it (Jared Diamond, James Surowiecki, Daniel Dennett, James Gleick) the results are wonderful. For whatever reason I often end up sidetracked and fail to read as much non-fiction as I should. That's why I've decided to shoot for one a month on this list.

This book definitely lived up to my expectations. It's around 250 pages and I picked it up around 7 today and here I am writing my review already. It is a page turner. Gawande's writing is crisp, clear, and very thought provoking. The question he poses is simple, How can we (referring to the medical industry) be better? The solution for him is through diligence, doing the right thing, and ingenuity. The book is divided into 3 sections that discuss various case studies of how those 3 traits (or lack thereof) have affected the goal of saving lives.

The results are fascinating. One would imagine that medical staff would be diligent in following the simple mantra of "Wash Your Hands". But for various reasons compliance is not 100%, leading to the spread of all sorts of nasty germs throughout a hospital. Gawande goes on to discuss the extraordinary efforts to eradicate polio and the way in which doctors and surgeons in Iraq adapted to make the Iraq War have the lowest injured/death ratio of any American War.

He continues into the second section with a fascinating discussion on ethics. What are the guidelines for examining patients? What do the doctors owe if they make a mistake? How much money should a doctor make? Is it ethical to be present for an execution? And finally, how hard should a doctor fight for a patient? This question in particular is very interesting. Gawande presents the case that the fatality rate of babies decreased when doctors began to fight for premature babies rather than just making the assumption that there wasn't anything they could do for them.

The final section on ingenuity is the one that resonated with me the most. Gawande discusses innovations in childbirth, cystic fibrosis treatment, and improvisation amongst the poorly equipped hospitals of India that have resulted in extending people's lives. I loved his discussion of the bell curve and how some cystic fibrosis centers were always exceptional no matter how much the overall average improved. In trying to explain the success of these "positive deviants" Gawande stated "What the best may have, above all, is a capacity to learn and change -- and do so faster than anyone else"

When you combine this statement with the diligence recommended in the first part of the book I believe you have a recommendation for the optimal control strategy. You need enough flexibility to change your control when the system has actually changed, yet you need enough stability in the system to not chase the noise. From the reading of Gawande's book I get the sense that each of these two traits have their proponents and the major success stories have both qualities.

Dr. Warrick, the director of the leading cystic fibrosis treatment center, was both an innovator and someone dedicated to diligence based on Gawande's description. As much as I am a fan of the concepts of decentralization and bottom up processing I continue to be amazed at what the efforts of one determined individual can make in a large organization. Chalk this up as another victory for the hybrid organization favored by the book The Starfish And the Spider: The Unstoppable Power of Leaderless Organizations

Gawande concludes his book with 5 ways to become a positive deviant (one of those people on the better than average side of the bell curve). 1.)Ask an unscripted question - this is getting at building camaraderie among team members 2.)Don't Complain 3.)Count Something -- basically an attempt to get one to notice patterns in the world 4.)Write Something -- even if it is just a blog. and 5.)Change. I love all these recommendations, but change is something I am really fond of.

I try to keep my mind open. I try not to, as Phillip Wylie says in The Disappearance, read a book with the assumption that I am already the master of what it contains and that the author has written it soley that I can prove him wrong. The ability to change is something that is vital in a world that is constantly changing.

So that's a wrap for the first non-fiction book of the month! I highly recommend it to anyone who is interested in learning about complexity and how people deal with dynamic environments. Though set in the medical field (which I and many others believe is the next frontier for Human Factors) I believe the lessons learned can be applied across many domains. I'm taking Gawande's advice and every time I see this word change I'm counting. I'm also sure Gawande's other book: Complications: A Surgeon's Notes on an Imperfect Science will be on my list.

Next up: I'm not sure. I have a few ideas floating around (an autobiography of a kamikaze pilot, one of the presidential candidate's books) but I haven't decided yet. Stay tuned sportsfans!

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