Friday, July 3, 2009


A friend at work recommend the book Better to me a while back and I finally got to it this weekend (the book queue is deep here). The book is written by Atul Gawande a surgeon and he provides some interesting insights into how the medical profession and particular parts of medicine have gotten better or are getting better.

The first part of the book talks about surgery in military hospitals in Iraq and Afghanistan. The key insight is that despite being understaffed and overwhelmed with work, the surgeons and teams are fanatical about measuring everything in order to spot trends and in order to find out what works and where things aren't working.

Later in the book, there is some great material on obstetrics and how they have had a richer tendency over the years to try new things in order to improve their Apgar scores. Once Virginia Apgar invented the scoring systems to measure the health of a newborn and it was widely adopted, doctors and hospitals immediately began tracking the scores and find ways to improve the scores. Things that led to improvement were adopted and things that didn't help were discarded. A measurement system was in place, a simple one, and the players in the field learned and got better as a result. A great line is attributed to her in the book, "Do what is right and do it now."
The Apgar effect wasn't just a matter of giving clinicians a quick objective read of how they had done. The score also changed the choices they made about how to do better.
Another section is on Cystic Fibrosis and "how the Cystic Fibrosis Foundation has gathered detailed data form the country's cystic fibrosis centers." LeRoy Matthews in Cleveland in the 1960s claimed to have better results than others were achieving and once measurements were done, he was proven right. Furthermore, his improvement continued going forward and fortunately, his methods and better methods from others were spread elsewhere. Again, measurements are made and better practices surface. Care for CF afflicted patients improved.

The chapter on CF also talks about the 'bell curve' of medicine and there are always going to be better and worse doctors/surgeons/hospitals, etc. Interesting reading.

Where I work, we've used the Six Sigma methods to improve our processes in manufacturing, IT, HR and elsewhere. The overall process consists of the steps: Define, Measure, Analyze, Improve and Control. One has to define the problem, but then measurements are critical. You can't improve something you don't measure. Whatever your problems in whatever line of work you do, measurements are key to getting better.

The author closes the book with 5 suggestion that might make a difference. How to become a positive deviant. They are:
  1. Ask an unscripted questions. In medicine or anywhere, talk to people. Connect with the people around you.
  2. Don't Complain. "Resist it. It's boring, it doesn't solve anything, and it will get you down."
  3. Count something. "be a scientist... If you count something you find interesting, you will learn something interesting."
  4. Write something. "add some small observation about your world.... make yourself part of a larger world."
  5. Change. Do something different. Follow a new idea.

I really liked this book. Perhaps more than many I've read recently. Recommended for anyone, whether in medicine or not. I'd like to meet the author someday.

Thanks Fred Bross for recommending it to me.


  1. Thanks Mark, for recommending it to me :) This is a very interesting book. I find it fascinating how compelled people are to improve when they can see through measurements the possibility exists to be better.

  2. Just finished and yes it was a great book. Transparency seemed like another key point especially on the CF issue. The closing chapter really helps tie to together. Count something seems to be something I wish my org would do more of.
    Thanks for the recomendation