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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.



About these reviews

You may be wondering why the reviews here are any different from the hundreds of "reviews" posted online. Notice the quotation marks?

I've been reviewing books for sites like Amazon for many years now, and it dismays me that Amazon found it necessary to post a minimum word count for reviews. It further dismays me that it's only 20 words. If that's all you have to say about a book, why bother?

And why waste everyone else's time with such drivel? As a reader of such reviews, I feel like I am being told that I do not matter. The flippancy of people who write these terse "reviews" is insulting to the authors also, I would suspect.

This sound bite blathering taking the place of any actual communication is increasingly a problem in our mindless, blog-posting Webosphere. Sadly, Google rewards such pointlessness as "content" so we just get more if this inanity.

My reviews, contrary to current (non) standards, actually tell you about the book. I always got an "A" on a book review I did as a kid (that's how I remember it anyhow, and it's my story so I'm sticking to it). A book review contains certain elements and has a logical structure. It informs the reader about the book.

A book review may also tell the reader whether the reviewer liked it, but revealing a reviewer's personal taste is not necessary for an informative book review.

About your reviewer

  • Books are a passion of mine. I read dozens of them each year, plus I listen to audio books.
  • Most of my "reading diet" consists of nonfiction. I think life is too short to use your limited reading time on material that has little or no substance. That leads into my next point...
  • In 1990, I stopped watching television. I have not missed it. At all.
  • I was first published as a preteen. I wrote an essay, and my teacher submitted it to the local paper.
  • For six years, I worked as an editor for a trade publication. I left that job in 2002, and still do freelance editing and authoring for that publication (and for other publications).
  • No book has emerged from my mind onto the best-seller list. So maybe I'm presumptuous in judging the work of others. Then again, I do more describing than judging in my reviews. And I have so many articles now published that I stopped counting them at 6,000. When did I stop? Probably 20,000 articles ago! (It's been a while).
  • I have an engineering degree and an MBA, among other "quant" degrees. That helps explain my methodical approach toward reviews.
  • You probably don't know anybody who has made a perfect or near perfect score on a test of Standard Written English. I have. So, a credential for whatever it's worth.

About reading style

No, I do not "speed read" through these. That said, I do read at a fast rate. But, in contrast to speed reading, I read everything when I read a book for review.

Speed reading is a specialized type of reading that requires skipping text as you go. Using this technique, I've been able to consistently "max out" a speed reading machine at 2080 words per minute with 80% comprehension. This method is great if you are out to show how fast you can read. But I didn't use it in graduate school and I don't use it now. I think it takes the joy out of reading, and that pleasure is a big part of why I read.

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