I’ve read several of Atul Gawande’s and while they aren’t along my typical thread of cognitive psychology, I do often find some very useful and insightful information from his books. Some of our lives are a continuous pursuit of improvement. Perfection is an unachievable and undesirable goal in my opinion. Looking at oneself and identifying reasons and ways to improve ourselves is a noble characteristic. This book is largely focused on medical improvements but the same principles can be applied by anyone looking to make incremental and continuous improvements in their life.

1. People often look to great athletes for lessons about performance. And for a surgeon like me, athletes do indeed have lessons to teach—about the value of perseverance, of hard work, and practice, of precision.
2. It’s not only the stakes but also the complexity of performance in medicine that makes it so interesting, and at the same time, so unsettling.
3. In medicine, as in any profession, we must grapple with systems, resources, circumstances, people—and our own shortcomings, as well. We face obstacles of seemingly unending variety. Yet somehow we must advance, we must refine, we must improve.
4. In any endeavor that involves risk and responsibility. The first is diligence, the necessity of giving sufficient attention to detail to avoid error and prevail against obstacle.
   1. Diligence is both central to performance and fiendishly hard.
5. The second challenge is to do right. Medicine is a fundamentally human profession. It is therefore forever troubled by human failings, failings like avarice, arrogance, insecurity, and misunderstanding.
6. The third requirement for success is ingenuity—thinking anew. 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.
7. Lloyd was bitten by the positive deviance idea—the idea of building on capabilities people already had rather than telling them how they had to change.
8. Diligence: it is defined as “the constant and earnest effort to accomplish what is undertaken.”
9. 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.
10. We can eradicate polio and do better on the other fronts. In reality, though, choices are made.
11. Still, you could make the same claim for almost any human problem that you decide to tackle—blindness or cancer or, for that matter, kidney stones. (If you’re starving, kidney pain certainly isn’t going to help.”) And then there is the issue of money.
12. Beneath the ideal is the gruelingly unglamorous and uncertain work. If the eradication of polio is our monument, it is a monument to the perfection of performance—to showing what can be achieved by diligent attention to detail coupled with great ambition.
13. And what they described revealed an intriguing effort to do something we in civilian medicine do spottily at best: to make a science of performance, to investigate and improve how well they use the knowledge and technologies they already have at hand. The doctors told me of simple, almost banal changes that produced enormous improvements.
14. Military doctors continued to transform their strategies for the treatment of war casualties. They did so through a commitment to making a science of performance, rather than waiting for new discoveries. And they did it under extraordinarily demanding conditions and with heroic personal sacrifices.
15. The paradox at the heart of medical care is that it works so well, and yet never well enough. It routinely gives people years of health that they otherwise wouldn’t have had.
16. But Hsiao came up with a formula. Work, he determined, was a function of time spent, mental effort and judgment, technical skill and physical effort, and stress.
17. Society has trusted us with power abilities, and the more willing we are to use these abilities against individual people, the more we risk and betray that trust.
18. The seemingly easiest and most sensible rule for a doctor to follow is: Always fight. Always look for what more you could do. I am sympathetic to this rule. It gives our best chance of avoiding the worst error of all—giving up on someone we could have helped.
19. The good doctors didn’t always get the answers right, she said. Sometimes they pushed too long or not long enough. But at least they stopped to wonder, to reconsider the path they were on. The asked colleagues for another perspective. The set aside their egos.
20. In the end, no guidelines can tell us what we have power over and what we don’t. In the face of uncertainty, wisdom is to err on the side of pushing, to not give up. But you have to be ready to recognize when pushing is only ego, only weakness. You have to be ready to recognize when the pushing can turn to harm.
21. There’s a paradox here. Ask most research physicians how a profession can advance, and they will tell you about the model of “evidence-based medicine”—the idea that nothing ought to be introduced into practice unless it has been properly tested and proved effective by research center, preferably through double blind, randomized controlled trial.
22. If a new strategy seemed worth trying, doctors did not wait for research trials to tell them if it was all right. They just went ahead and tried it, then looked to see if results improved. 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 that approach worked.
23. Finding a meaningful way to measure performance, as Virginia Apgar showed was possible in child delivery, is a form of ingenuity in itself. What you actually do with that measure involves another type of ingenuity, however, and improvement usually requires both kinds.
24. The bell curve is distressing for doctors to have to acknowledge. It belies the promise that we make to patients: that they can count on the medical system to give them their very best chance. It also contradicts the belief nearly all of us have that we are doing our job as well as it can be done. But evidence of the bell curve is starting to trickle out, to doctors and patients alike, and we are only beginning to find out what happens when it does.
25. As Berwick explained, the firefighters’ organization had unraveled. The men had lost their ability to think coherently, to act together, and to recognize that a lifesaving idea might be possible. This is what happens to all flawed organizations in a disaster, and, he argued, this is what is happening in modern health care. As medicine tries to cope with the advancing complexity of knowledge and treatment, it is failing short in performing even the simplest of tasks. To fix medicine, Berwick maintained, we need to do two things: measure ourselves and be more open about what we are doing. We should be routinely comparing the performance of doctors and hospitals, looking at everything from surgical complication rates to how often a drug ordered for a patient is delivered correctly and on time. And, he insisted, hospitals should give patients total access to the information. “No secrets is the new rule in my fire escape.”
26. He believed that excellence came from seeing, on a daily basis, the difference between 99.5 percent successful and being 99.95 percent successful. Many things human beings do are like that, of course: catching fly balls, manufacturing microchips, delivering overnight packages. Medicine’s distinction is that lives are lost in those slim margins.
27. In medicine, we have learned to appreciate the danger of ad hoc experimentation on patients—of cowboy physicians. We endeavor to stick to established findings. But with his unblinking focus on his patients’ actual results, Warwick has been able to innovate successfully.
28. Even doctors with great knowledge and technical skill can have mediocre results; more nebulous factors like aggressiveness and diligence and ingenuity can matter enormously.
29. What the best may have, above all, is a capacity to learn and change—and to do so faster than anyone else.
30. The hardest question for anyone who takes responsibility for what he or she does is, What if I turn out to be average?
31. Women themselves are often blamed, but the important underlying factors include how time-consuming, uncomfortable, and difficult it usually is to get a mammogram, how inconvenient the facilities often are, how expensive mammography is for those without insurance coverage, and how rarely reminders are given. The United States government and private foundations spend close to a billion dollars a year on research for discovery of new treatments in breast cancer, but little on innovations to improve the ease of and access to mammography screening.
32. Such machines have become the symbols of modern medicine, but to view them this way is to misunderstand the nature of medicine’s success. Having a machine is not the cure; understanding the ordinary, mundane details that must go right for each particular problem is.
33. New laboratory science is not the key to saving lives. The infant science of improving performance—of implementing our existing know-how—is.
34. True success in medicine is not easy. It requires will, attention to detail, and creativity.
35. 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 a willingness to try.
36. It can be hard not to feel that one is just a white-coated cog in a machine—an extraordinary successful machine, but a machine nonetheless. How could it be otherwise? The average American can expect to live at least seventy-eight years. But reaching, and surpassing, that age depends more on this system of millions of people than on any one individual within it. None of us is irreplaceable. So not surprisingly, in this work one begins to wonder: How do I matter?
37. My first suggestion came from a favorite essay by Paul Auster: As an unscripted question. Ours is a job of talking to strangers. Why not learn something from them?
38. Medicine is a trying profession, but less because of the difficulties of disease than because of the difficulties of having to work with other human beings under circumstances only partly in one’s control.
39. My third answer for becoming a positive deviant: count something. Regardless of what one ultimately does in medicine—or outside medicine, for the matter—on should be a scientist in this world. In the simplest terms, this means one should count something.
    1. If you count something you find interesting, you will learn something interesting.
40. My fourth suggestion: Write something. I do not mean this to be an intimidating suggestion. It makes no difference whether you write five paragraphs for a blog, a paper for a professional journal, or a poem for a reading group. Just write. What you write need not achieve perfection. It need only add some small observation about your world.
    1. Quoting the physicist John Ziman, “The invention of a mechanism for the systematic publication of ‘fragments’ of scientific work may well have been the key event in the history of modern science.” By soliciting modest contributions from many, we have produced a store of collective know-how with far greater power than any individual could have achieved. And this is as true outside science as inside.
41. My suggestion number five, my final suggestion for a life in medicine was: change. In medicine, just as in anything else people do, individuals respond to new ideas in one of three ways. A few become early adopters, as the business types call them. Most become late adopters. And some remain persistent skeptics who never stop resisting.
    1. Make yourself an early adopter. Look for the opportunity to change. I am not saying you should embrace every new trend that comes along. But be willing to recognize the inadequacies in what you do and to seek out the solutions.

Better: A Surgeon’s Notes on Performance