Atul Gawande Better Quotes

Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.

We always hope for the easy fix: the one simple change that will erase a problem in a stroke. But few things in life work this way. Instead, success requires making a hundred small steps go right - one after the other, no slipups, no goofs, everyone pitching in.

Are doctors who make mistakes villains? No, because then we all are.

The hardest question for anyone who takes responsibility for what he or she does is, What if I turn out to be average?

Betterment is perpetual labor. The world is chaotic, disorganized, and vexing, and medicine is nowhere spared that reality. To complicate matters, we in medicine are also only human ourselves. We are distractible, weak, and given to our own concerns. Yet still, to live as a doctor is to live so that one's life is bound up in others' and in science and in the messy, complicated connection between the two It is to live a life of responsibility. The question then, is not whether one accepts the responsibility. Just by doing this work, one has. The question is, having accepted the responsibility, how one does such work well.

There is a saying about surgeons, meant as a reproof: "Sometimes wrong; never in doubt." But this seemed to me their strength. Each day surgeons are faced with uncertainties. Information is inadequate; the science is ambiguous; one's knowledge and abilities are never perfect. Even with the simplest operation, it cannot be taken for granted that a patient will come through better off - or even alive. Standing at the table my first time, I wondered how the surgeon knew that he would do this patient good, that all the steps would go as planned, that the bleeding would be controlled and infection would not take hold and organs would not be injured. He didn't, of course. But still he cut.

A nurse has five seconds to make a patient like you and trust you. It’s in the whole way you present yourself. I do not come in saying, ‘I’m so sorry.’ Instead, it’s: ‘I’m the hospice nurse, and here’s what I have to offer you to make your life better. And I know we don’t have a lot of time to waste.

Do what is right, and do it now.

Nonetheless, what I saw was: better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.

Steps to become a positive deviant: 1. Ask unscripted questions 2. Don't complain 3. Count something that interests you 4. Write something... Anything 5. Change yourself. Change something

The possibilities and probabilities are all we have to work with in medicine, though. What we are drawn to in this imperfect science, what we in fact covet in our way, is the alterable moment-the fragile but crystalline opportunity for one's know-how, ability, or just gut instinct to change the course of another's life for the better.

People underestimate the importance of dilligence as a virtue. No doubt it has something to do with how supremely mundane it seems. It is defined as "the constant and earnest effort to accomplish what is undertaken."... Understood, however, as the prerequisite of great accomplishment, diligence stands as one of the most difficult challenges facing any group of people who take on tasks of risk and consequence. It sets a high, seemingly impossible, expectation for performance and human behavior.

We are used to thinking of doctoring as a solitary, intellectual task. But making medicine go right is less often like making a difficult diagnosis than like making sure everyone washes their hands.

The seemingly easiest and most sensible rule for a doctor to follow is: Always Fight. Always look for what more you could do.

To become a doctor, you spend so much time in the tunnels of preparation--head down, trying not to screw up, just going from one day to the next--that it is a shock to find yourself at the other end, with someone shaking your hand and offering you a job. But the day comes.

Our lives are inherently dependent on others and subject to forces and circumstances well beyond our control. Having more freedom seems better than having less. But to what end? The amount of freedom you have in your life is not the measure of the worth of your life. Just as safety is an empty and even self-defeating goal to live for, so ultimately is autonomy.

The seemingly easiest and most sensible rule for a doctor to follow is: Always Fight. Always look for what more you could do. (...) But our fight is not always to do more. It is to do right by our patients, even though what is right is not always clear.

At times, in medicine, you feel you are inside a colossal and impossibly complex machine whose gears will turn for you only according to their own arbitrary rhythm. The notion that human caring, the effort to do better for people, might make a difference can seem hopelessly naïve.

The power of checklists is limited, Boorman emphasized. They can help experts remember how to manage a complex process or configure a complex machine. They can make priorities clearer and prompt people to function better as a team. By themselves, however, checklists cannot make anyone follow them. I

An audience is a community. The published word is a declaration of membership in that community and also of a willingness to contribute something meaningful to it. So choose your audience. Write something.

A study led by the Harvard researcher Nicholas Christakis asked the doctors of almost five hundred terminally ill patients to estimate how long they thought their patient would survive, and then followed the patients. Sixty-three per cent of doctors overestimated survival time. Just seventeen per cent underestimated it. The average estimate was five hundred and thirty per cent too high. And, the better the doctors knew their patients, the more likely they were to err.

Arriving at meaningful solutions is an inevitably slow and difficult process. Nonetheless, what I saw was: better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes willingness to try.

Equally worrying, and far less recognized, medicine has been slow to confront the very changes that it has been responsible for—or to apply the knowledge we have about how to make old age better. Although the elderly population is growing rapidly, the number of certified geriatricians the medical profession has put in practice has actually fallen in the United States by 25 percent between 1996 and 2010. Applications to training programs in adult primary care medicine have plummeted, while fields like plastic surgery and radiology receive applications in record numbers. Partly, this has to do with money—incomes in geriatrics and adult primary care are among the lowest in medicine. And partly, whether we admit it or not, a lot of doctors don’t like taking care of the elderly.

THIS IS NOT, to say the least, an appealing prospect. People naturally prefer to avoid the subject of their decrepitude. There have been dozens of bestselling books on aging, but they tend to have titles such as Younger Next Year, The Fountain of Age, Ageless, or—my favorite—The Sexy Years. Still, there are costs to averting our eyes from the realities. We put off dealing with the adaptations that we need to make as a society. And we blind ourselves to the opportunities that exist to change the individual experience of aging for the better.

You do not imagine that a mere matter of etiquette could foil you. But the social dimension turns out to be as essential as the scientific—matters of how casual you should be, how formal, how reticent, how forthright. Also: how apologetic, how self-confident, how money-minded.

My third answer for becoming a positive deviant: Count something. Regardless of what one ultimately does in medicine—or outside medicine, for that matter—one should be a scientist in the world....If you count something you find interesting, you will learn something interesting.

Several years ago, researchers at the University of Minnesota identified 568 men and women over the age of seventy who were living independently but were at high risk of becoming disabled because of chronic health problems, recent illness, or cognitive changes. With their permission, the researchers randomly assigned half of them to see a team of geriatric nurses and doctors—a team dedicated to the art and science of managing old age. The others were asked to see their usual physician, who was notified of their high-risk status. Within eighteen months, 10 percent of the patients in both groups had died. But the patients who had seen a geriatrics team were a quarter less likely to become disabled and half as likely to develop depression. They were 40 percent less likely to require home health services. These were stunning results. If scientists came up with a device—call it an automatic defrailer—that wouldn’t extend your life but would slash the likelihood you’d end up in a nursing home or miserable with depression, we’d be clamoring for it. We wouldn’t care if doctors had to open up your chest and plug the thing into your heart. We’d have pink-ribbon campaigns to get one for every person over seventy-five. Congress would be holding hearings demanding to know why forty-year-olds couldn’t get them installed. Medical students would be jockeying to become defrailulation specialists, and Wall Street would be bidding up company stock prices. Instead, it was just geriatrics. The geriatric teams weren’t doing lung biopsies or back surgery or insertion of automatic defrailers. What they did was to simplify medications. They saw that arthritis was controlled. They made sure toenails were trimmed and meals were square. They looked for worrisome signs of isolation and had a social worker check that the patient’s home was safe. How do we reward this kind of work? Chad Boult, the geriatrician who was the lead investigator of the University of Minnesota study, can tell you. A few months after he published the results, demonstrating how much better people’s lives were with specialized geriatric care, the university closed the division of geriatrics.

Ingenuity is often misunderstood. It is not a matter of superior intelligence but of character. It demands more than anything a willingness to recognize failure, to not paper over the cracks, and to change. It arises from deliberate, even obsessive, reflection on failure and a constant searching for new solutions.

It is unsettling to find how little it takes to defeat success in medicine. You come as a professional equipped with expertise and technology. You do not imagine that a mere matter of etiquette could foil you. But the social dimension turns out to be as essential as the scientific--matters of how casual you should be, how formal, how reticent, how forthright. Also: how apologetic, how self-confident, how money-minded. In this work against sickness, we begin not with genetic or cellular interactions, but with human ones. They are what make medicine so complex and fascinating. How each interaction is negotiated can determine whether a doctor is trusted, whether a patient is heard, whether the right diagnosis is made, the right treatment given. But in this realm there are no perfect formulas.

Indeed, the scientific effort to improve performance in medicine—an effort that at present gets only a miniscule portion of scientific budgets—can arguably save more lives in the next decade than bench science, more lives than research on the genome, stem cell therapy, cancer vaccines, and all the other laboratory work we hear about in the news.

Even with the simplest operation, it cannot be taken for granted that a patient will come through better off—or even alive.

Doctors quickly learn that how much they make has little to do with how good they are. It largely depends on how they handle the business side of their practice. Many

I do not come in saying, ‘I’m so sorry.’ Instead, it’s: ‘I’m the hospice nurse, and here’s what I have to offer you to make your life better. And I know we don’t have a lot of time to waste.

as people’s capacities wane, whether through age or ill health, making their lives better often requires curbing our purely medical imperatives—resisting the urge to fiddle and fix and control.

When someone has come to you for your expertise and your expertise has failed, what do you have left? You have only your character to fall back upon—and sometimes it’s only your pride that comes through.

The striking thing is that WHO doesn't really have the authority to do any of this. It can't tell governments what to do. It hires no vaccinators, distributes no vaccine. It is a small Geneva bureaucracy run by several hundred international delegates whose annual votes tell the organization what to do but not how to do it.…The only substantial resource that WHO has cultivated is information and expertise.

They belong to the connected and the knowledgeable, to insiders over outsiders, to the doctor’s child but not the truck driver’s. If choice cannot go to everyone, maybe it is better when it is not allowed at all.

International organizations are fond of grand-sounding pledges to rid the planet of this or that menace. They nearly always fail, however. The world is too vast and too various to submit to dictates from on high.

Two-thirds of the terminal cancer patients in the Coping with Cancer study reported having had no discussion with their doctors about their goals for end-of-life care, despite being, on average, just four months from death. But the third who did have discussions were far less likely to undergo cardiopulmonary resuscitation or be put on a ventilator or end up in an intensive care unit. Most of them enrolled in hospice. They suffered less, were physically more capable, and were better able, for a longer period, to interact with others. In addition, six months after these patients died, their family members were markedly less likely to experience persistent major depression. In other words, people who had substantive discussions with their doctor about their end-of-life preferences were far more likely to die at peace and in control of their situation and to spare their family anguish.

One American in seven has no coverage, and one in three younger than sixty-five will lose coverage at some point in the next two years. These are people who aren't poor or old enough to qualify for government programs but whose jobs aren't good enough to provide benefits either.

...where they had control--their skills, for example--these doctors sought betterment. They understood themselves to be part of a larger world of medical knowledge and accomplishment. Moreover, they believed they could measure up in it...partly...a function of...camaraderie as a group.

MODERN SCIENTIFIC CAPABILITY has profoundly altered the course of human life. People live longer and better than at any other time in history. But scientific advances have turned the processes of aging and dying into medical experiences, matters to be managed by health care professionals. And we in the medical world have proved alarmingly unprepared for it.

Human birth...is a solution to an evolutionary problem: how a mammal can walk upright, which requires a small, fixed, bony pelvis, and also possess a large brain, which entails a baby whose head is too big to fit through that small pelvis...in a sense, all human mothers give birth prematurely. Other mammals are born mature enough to walk and seek food within hours; our newborns are small and helpless for months.

In medicine, we have long faced a conflict between the imperative to give patients the best possible care and the need to provide novices with experience. Residencies attempt to mitigate potential harm for supervision and graduated responsibility. And there is reason to think patients actually benefit from teaching. Studies generally find teaching hospitals have better outcomes than non teaching hospitals. Residents may be amateurs, but having them around checking on patients, asking questions, and keeping faculty on their toes seems to help. But there is still no getting around those first few unsteady times a young physician tries to put in a central line, remove a breast cancer, or sew together two segments of colon. No matter how many protections we put in place, on average these cases go less well with a novice then with someone experienced.

We always hope for the easy fix: the one simple change that will erase a problem in a stroke. But few things in life work this way. Instead, success requires making a hundred small steps go right - one after the other, no slipups, no goofs, everyone pitching in. We are used to thinking of doctoring as a solitary, intellectual task. But making the medicine go right is less often like making a difficult diagnosis than like making sure everyone washes their hands.

For those who had no interest in moving into such places—Alice Hobson, for instance—it became acceptable and feasible to remain in their own homes, living as they wanted to live, autonomously. That fact remains something to celebrate. There is arguably no better time in history to be old. The lines of power between the generations have been renegotiated, and not in the way it is sometimes believed. The aged did not lose status and control so much as share it. Modernization did not demote the elderly. It demoted the family. It gave people—the young and the old—a way of life with more liberty and control, including the liberty to be less beholden to other generations. The veneration of elders may be gone, but not because it has been replaced by veneration of youth. It’s been replaced by veneration of the independent self.

Five years later, Albert Sabin published the results of an alternative polio vaccine he had used in an immunization campaign in Toluca, Mexico, a city of a hundred thousand people, where a polio outbreak was in progress. His was an oral vaccine, easier to administer than Salk’s injected one. It was also a live vaccine, containing weakened but intact poliovirus, and so it could produce not only immunity but also a mild contagious infection that would spread the immunity to others. In just four days, Sabin’s team managed to vaccinate more than 80 percent of the children under the age of eleven—26,000 children in all. It was a blitzkrieg assault. Within weeks, polio had disappeared from the city. This approach, Sabin argued, could be used to eliminate polio from entire countries, even the world. The only leader in the West who took him up on the idea was Fidel Castro. In 1962, Castro’s Committee for the Defense of the Revolution organized 82,366 local committees to carry out a succession of weeklong house-to-house national immunization campaigns using the Sabin vaccine. In 1963, only one case of polio occurred in Cuba.

The third requirement for success is ingenuity—thinking

When I was a child, the lessons my father taught me had been about perseverance, never to accept limitations that stood in my way. As an adult, watching him in his final years, I also saw how to come to terms with limits that couldn't simply be wished away. When to shift from pushing against limits to making the best of them is not often readily apparent. But it is clear that are times when the cost of pushing exceeds its value. Helping my father through the struggle to define that moment was simultaneously among the most painful and most privileged experiences of my life. Part of the way my father handled the limits he faced was by looking at them without illusion. Though his circumstances sometimes got him down, he never pretended they were better than they were. He always understood that life is short and one's place in the world is small. But he also saw himself as a link in a chain of history.

Research has found that loss of bone density may be an even better predictor of death from atherosclerotic disease than cholesterol levels.

Paul O’Neill, the former secretary of the Treasury and CEO of the aluminum giant Alcoa, agreed to take over as head of a regional health care initiative in Pittsburgh, Pennsylvania. And he made solving the problem of hospital infections one of his top priorities.

Whether insurance is provided by the government or by corporations, there is no reason to think that the battles—over the fees charged, the bills rejected, the preapproval contortions—will ever end.

Each year, according to the U.S. Centers for Disease Control, two million Americans acquire an infection while they are in the hospital. Ninety thousand die of that infection. The

The average doctor in a high-risk practice like surgery or obstetrics is sued about once every six years. Seventy percent of the time, the suit is either dropped by the plaintiff or won by the doctor in court. But the cost of defense is high, and when doctors lose, the average jury verdict is half a million dollars. General

Obstetrics went about improving the same way Toyota and General Electric went about improving: on the fly, but always paying attention to the results and trying to better them. And

The author suggests we aren’t taking advantage of the opportunity to make the experience of aging better. In what ways could we improve aging in our daily lives and as a culture? 6. Did you read Alice Hobson’s story as an inspiring one, or as a cautionary tale? 7. Even with diminishing capacities, Felix found ways to give his life in a retirement community purpose by helping fellow residents, mentoring younger doctors, and caring for his wife. What activities might you envision doing that would bring you fulfillment in your retirement when you might face some physical limitations?

...litigation has proved to be a singularly unsatisfactory solution. It is expensive, drawn out, and painfully adversarial. It helps very few people.

How do we reward this kind of work? Chad Boult, the geriatrician who was the lead investigator of the University of Minnesota study, can tell you. A few months after he published the results, demonstrating how much better people’s lives were with specialized geriatric care, the university closed the division of geriatrics. “The university said that it simply could not sustain the financial losses,” Boult said from Baltimore, where he had moved to join the Johns Hopkins Bloomberg School of Public Health. On average, in Boult’s study, the geriatric services cost the hospital $1,350 more per person than the savings they produced, and Medicare, the insurer for the elderly, does not cover that cost. It’s a strange double standard. No one insists that a $25,000 pacemaker or a coronary-artery stent save money for insurers. It just has to maybe do people some good.

WHAT DOES IT take to be good at something in which failure is so easy, so effortless?

People often look to great athletes for lessons about performance. ... But success in medicine has dimensions that cannot be found on a playing field.

The rest of the night went no better.

Studies generally find that teaching hospitals have better outcomes than non-teaching hospitals.

doctors need to understand that we are businessmen—nothing less, nothing more—and the sooner we accept this the better.

The reason has to be that doctors remain at least partly motivated by the hope of doing meaningful and respected work for people and society.

the social dimension turns out to be as essential as the scientific—matters of how casual you should be, how formal, how reticent, how forthright. Also: how apologetic, how self-confident, how money-minded. In this work against sickness, we begin not with genetic or cellular interactions, but with human ones.

It used to be ‘Two hip replacements today—yay!’” he recalled. “Then it became ‘Two hip replacements today—ugh.

That’s why doctors are convinced that they’d better stick with their well-honed instincts when they’re making a diagnosis.

the studies show that you’re better off sticking with the computer’s judgment.

I offered no excuses. I promised to be better prepared for such cases and to be quicker to ask for help.

No matter how accomplished, surgeons trying something new got worse before they got better, and the learning curve proved longer, and affected by a far more complicated range of factors, than anyone had realized. It’s all stark confirmation that you can’t train novices without compromising patient care.

No one was thinking of any better options,

MODERN SCIENTIFIC CAPABILITY has profoundly altered the course of human life. People live longer and better than at any other time in history. But scientific advances have turned the processes of aging and dying into medical experiences, matters to be managed by health care professionals

perfect their skills, and move on to a better position.

In a year, fewer than three hundred doctors will complete geriatrics training in the United States, not nearly enough to replace the geriatricians going into retirement, let alone meet the needs of the next decade. Geriatric psychiatrists, nurses, and social workers are equally needed, and in no better supply.

When someone has come to you for your expertise and your expertise has failed, what do you have left? You have only your character to fall back upon—and

People live longer and better than at any other time in history. But scientific advances have turned the processes of aging and dying into medical experiences, matters to be managed by health care professionals. And we in the medical world have proved alarmingly unprepared for it.

The medical officer’s microplan was a sheaf of ragged paper, with marker-drawn maps and penciled-in tables. The first page said that he had recruited twenty-two teams of two vaccinators each to cover a population of 34,144 people. “How do you know this population estimate is right?” Pankaj asked. The officer replied that he’d done a house-to-house survey.

That’s how a doctor earns money, she told me. It’s a war with insurance, every step of the way.

In this work against sickness, we begin not with genetic or cellular interactions, but with human ones. They are what make medicine so complex and fascinating. How

In this work against sickness, we begin not with genetic or cellular interactions, but with human ones. They are what make medicine so complex and fascinating.

A study led by the sociologist Nicholas Christakis asked the doctors of almost five hundred terminally ill patients to estimate how long they thought their patient would survive and then followed the patients. Sixty-three percent of doctors overestimated their patient’s survival time. Just 17 percent underestimated it. The average estimate was 530 percent too high. And the better the doctors knew their patients, the more likely they were to err.

And the insight was that as people’s capacities wane, whether through age or ill health, making their lives better often requires curbing our purely medical imperatives—resisting the urge to fiddle and fix and control. It was not hard to see how important this idea could be for the patients I encountered in my daily practice—people facing mortal circumstances at every phase of life.