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‘Better’ Healthcare

By Sara Calabro

New York magazine’s latest cover story, on the impending financial doom of many New York City hospitals, is just one more reason to read Better: A Surgeon’s Notes on Performance by Atul Gawande.

Insurance red tape and the high costs associated with caring for underserved populations have put many inner city hospitals in a dire position. Better does not provide the answers, but rather, the inspiration for improvement that’s too easily lost in today’s challenging healthcare environment.

Gawande’s book will appeal to readers beyond just those who work in hospitals. It’s about what it means to be a good doctor, but also about the universal human drive to rise to the occasion and exceed expectations.

Through 11 heartfelt stories, plus a moving afterward that includes a lecture Gawande once gave to med students, the author respectfully conveys both the miracles and shortcomings of modern medicine. A number of seemingly different subjects—from hospital hand-washing protocols to trauma surgery in Iraq to physician pay—are pulled together into a cohesive book that reads more like a novel than a collection of separate stories.

The book is organized into three sections, named after what Gawande says are “three core requirements for success in medicine”—diligence, doing right, and ingenuity. Each has its pronounced bent but all contain a common theme: A situation’s imperfection is no excuse to quit trying to improve it.

Gawande, a surgeon at Brigham and Women’s in Boston who is also a staff writer for the The New Yorker, does not talk about acupuncture. But he advocates adoption of a less-is-more attitude in certain medical situations where excess is too often the go-to mentality.

Our healthcare system, says Gawande, would benefit more from looking closely at what we already have than from putting more money toward new technology:

We have not effectively used the abilities science has already given us. And we have not made remotely adequate efforts to change that….[T]he 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.

The world is full of opinions about what it means to “improve performance in medicine.” But certainly one form of improvement is an openness to multiple perspectives. Regardless of your definition of science or interpretation of non-mainstream medicines like acupuncture, it’s hard to deny that healthcare has gotten too expensive for the people providing and receiving it.

A popular argument in favor of pouring dollars into medical equipment and research is that better technology ultimately saves money. In many cases this is true. But moving forward does not need to exclude looking back. Preventative care and relatively affordable modalities have helped keep people healthy for thousands of years. Of course we should not ignore technological advances in favor of inferior healthcare. But too often we are too quick to usher out the old to make way for the new without fully reaping the predecessor’s benefits.

Performance improvement in medicine requires that all healthcare players take a hard, nonjudgmental look at the best of what’s currently available, regardless of whether it falls within their immediate level of expertise or comfort zone. It demands at least a basic level of knowledge about these options—or at minimum, a willingness to admit to not understanding them, which is not the same as dismissing them.

Gawande says in Better, “People should be able to learn about anything that affects their lives.”

Underlying all of Gawande’s tales of impressive medical feats is an awareness of context and a willingness to adapt. To accomplish this, the doctors of Better step outside their own frames of reference, let go of preconceived notions, and adjust for the betterment of patients. Neither diligence, doing right, nor ingenuity can happen without listening.

Photo by Sara Calabro


Carl Balingit

I haven’t read the book, but your review highlights a valuable point: that we must strive to improve not only our understanding of disease but also our methods of treatment.

In regards to improving performance in medicine, Integrative Medicine (IM) seems like one way to answer this call. Yet, I believe that healthcare — in terms of IM — is still in its gestation period.

To take it further, I believe we should celebrate the birth of IM only if we can uphold the autonomy of each school of medicine as we integrate the various treatment modalities.

Using acupuncture as an example, this is what I mean:

As acupuncture migrates into mainstream care, there are growing efforts to define it in terms of its mechanism of action. For ‘mechanism of action’ is Western medicine’s understanding of disease intervention, and it’s a very linear approach to treatment. For example: if the liver is diseased, then treat the liver.

In contrast, traditional acupuncture is very non-linear in its approach to healing. For example, it doesn’t just see jaundice as a symptom of hepatitis; it sees hepatitis as a symptom as well. This means that treating just the liver could equate to symptomatic treatment and not necessarily true healing.

Currently, it seems like Western medicine’s acceptance of acupuncture in the integrative field is largely based on its intent to define acupuncture using Western terminology. However, this neglects the context in which acupuncture is practiced effectively.

The risk in trying to fit acupuncture within the existing borders of Western thought — rather than expanding the borders to accommodate new perspectives — is that IM may remain undeveloped. Or, to use the analogy I started, healthcare may miscarry.

This same rationale would apply to other treatment modalities as well.


Great points, Carl. If you haven’t already, you might want to check out a piece we did last month on adrenal fatigue. It addresses some of what you mention here, particularly the issue of language.

Thanks for reading.

Tom Williams

Atul Gawande has lots of great things to say. “Quality control” measures are lacking in most Oriental medicine clinics and I am always challenged by Gawande’s articles to improve this important part of my practice.

Alright, so he is a Western medical doctor. But anybody who agrees to be interviewed by Stephen Colbert is OK by me!

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