Book Review of Better: A Surgeon's Notes on Performance

Better: A Surgeon's Notes on Performance

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Review of Better, by Atul Gawande (Hardcover, 2007)

Reviewer: Mark Lamendola, author of over 6,000 articles.

When I was an MBA student, I became fascinated with the continuous improvement philosophy espoused by Deming. This is the philosophy that drives Toyota and many other companies to achieve ever-higher levels of quality. Coincidentally, at that time in my life a coworker named Atul exemplified this philosophy in everything he did. So here we are with a book authored many years later by a person named Atul, and that book talks about improving performance.

In some areas of endeavor, constant improvements in performance are mandatory for a business to survive. A prime example is the online business world. Sites that don't constantly improve and innovate lose customers and die. We can go back to the Toyota example and see exactly why Toyota dominates the US auto market. While American automakers have been playing infighting games, Toyota has focused on making a better car. They have continually eliminated defects and instituted improvements, no matter how minor.

In other areas, improvement is completely at odds with the culture. A prime example is the typical government agency. "Customers" of government agencies have no choice in vendor. Bureaucrats continue to draw their salaries, while 20 or 100 people do the job of one person about as poorly as is humanly possible. This has led to countless jokes about the DMV. It's also responsible for the adage, "Government takes the path of least competence." Behavior that isn't tolerated in performance-driven companies is actually rewarded in many government organizations. There are exceptions, and I will note one of those in a moment.

In between these two ends of the spectrum, we find the medical care industry. And it's here were Atul Gawande lives and breathes. In this book, he shatters many myths about medical care. For example, it's simply not true that the quality of care is consistent from care center to care center. In fact, enormous variations exist and the consequences can be profound.

Gawande is obviously a clear thinker. This is evident in the fact that he so adroitly addresses so many facets of medical care in less than 300 pages. While this book isn't a page turner in the traditional sense--that is, it doesn't have cliff-hangers that make you keep reading--I was surprised at how well it maintained my interest and how quickly I finished reading it. The writing is clear and engaging, even though the author is discussing a very complex industry.

As Gawande points out, the real challenges before doctors today lay not in breakthrough technology but in the proper application of what they already have. This is not to say doctors are misapplying things. As the title implies, doctors (and all medical professionals) have room for improvement--for being better--at how they apply the tools they have.

This isn't just theory or some windbag expressing an unfounded opinion. As you have probably guessed, "Atul Gawande" isn't an Irish name. His family is originally from India, and Gawande gives us numerous examples of the amazing results Indian doctors obtain despite not having the tools and budgets we are accustomed to in the United States.

We don't have to travel to India to see how medical professionals can ratchet up the quality of care by using the constant improvement philosophy. Gawande brings us to one Cystic Fibrosis clinic in America and then another, so we can see how different approaches produce different results.

Earlier, I mentioned government agencies as examples of incompetence. Interestingly, the Veteran's Administration is way ahead of private industry when it comes to medical care. Gawande, who doesn't work in the VA, probably is not aware of the quality revolution that took place there.

Once the most dismal of medical care providers (following the typical government agency formula of focusing on bloated processes and ignoring results), the VA is now an example of productivity and quality that the private sector can only envy. In fact, the VA actually provides healthcare while the mainstream medical system has mostly limited itself to providing disease care and injury fixes.

"Better" is a book written by a practicing surgeon, and it looks inside the medical system. It can help medical professionals see ways to improve how they do things. But if you're not a medical professional, is this book worth reading? In my opinion, yes. The chapter on medicine's bell curve would justify that all by itself. Anyone who might need a specialist (for example, a neurologist) would benefit from understanding the points Gawande makes when he discusses the differences in quality of care at various centers.

This book reminds me of books that have been written about other industries and on business process improvement in general. Perhaps the most famous of the business process improvement books is Tom Peters' seminal work, "In Search of Excellence." Customers in a business to business relationship look to such books as "Lean Thinking" to better work with their vendors and suppliers. These books address many of the same fundamental issues Gawande covers in "Better."

One way to improve is to drive defects out. Another way is to look at what's working and adapt it to your situation. A third way, and Gawande provides plenty of examples, is to simply look for (and try) ways of doing things better. Just as books about Toyota's "quality miracle" have driven improvements in hundreds of other industries, so can the lessons learned in this book drive improvements in other industries.

So, in that sense it has very broad application in addition to providing insight into curing the ills of our medical care system. It's an excellent resource for any business person. But it's also an excellent resource for any consumer of medical services. You don't have to settle for "good enough." You can seek, and get, better.