Better: A Surgeon’s Notes on Performance

In Chapter 5, Gawande discusses malpractice, a volatile topic in the medical industry. He begins with the story of Barbara Stanley, a woman who died of cancer after receiving conflicting diagnoses. Initially, Stanley was told that she had skin cancer and that she needed to have a cancerous nodule on her leg removed. Stanley sought a second opinion from a different doctor, who told her that she did not have skin cancer. This second opinion was incorrect, and Stanley eventually died from untreated cancer. Before her death, Stanley sued her doctor, Kenneth Reed, for malpractice.

Though it seems extreme, Gawande writes that “[t]he average doctor in a high-risk practice is sued about once every six years” (87). He claims that “providing medical care is difficult. It involves the possibility of any of a thousand missteps, and no doctor will escape making some terrible ones” (87). However, he wants to determine when a lawsuit for malpractice is valid, because doctors “owe something to patients and their families” (99). There is therefore tension between what is possible for a doctor to provide and what they should provide. 

In this chapter, Gawande discusses the salaries of doctors. He acknowledges that the public tends to view doctors who are concerned about making money “suspiciously” because “[d]octors aren’t supposed to be in it for the money” (113). Unfortunately for the medical industry, “doctors have been paid on a piecework basis since at least the Code of Hammurabi” (115). As such, everything in the healthcare system is itemized.

In the 1980s, “insurers, both public and private, began to agitate for more ‘rational’ fees” (115). While this seemed like a good idea at the time, it led to an arbitrary system that lacked uniformity. The federal government soon stepped in and created an organized system that attempted to calculate a doctor’s salary based on the “time spent, mental effort and judgment, technical skill and physical effort, and stress” (116) that went into his or her job.

Gawande claims that “doctors quickly learn that how much they make has little to with how good they are. It largely depends on how they handle the business side of their practice” (118). Because doctors must be businessmen to maintain their practices, some of them actually hire people to manage their practice’s finances. What further complicates things are insurance companies that do not want to pay more than they have to. Nonetheless, doctors need to be fairly compensated for their services. Gawande states that “[i]t’s a war with insurance every step of the way” (120). The Matthew Thornton Health Plan (MTHP) was created to try to solve this problem. Doctors in Nashua, New Hampshire, founded the MTHP to circumvent some of the issues surrounding doctor compensation and the costs of dispensing medical care. For a while, they were successful, but the MTHP eventually became too large to function properly. 

Chapter 7 delves into another controversial topic in the medical world: execution as a medical procedure. In this chapter, Gawande recounts the experiences of four doctors, given the monikers Doctors A, B, C, and D, who assisted or were present during state-sanctioned executions.

According to Gawande, “Execution has become a medical procedure in the United States” (132). However, the Hippocratic Oath forbids doctors from harming patients, and it compels them to help anyone in need. This would mean that they cannot in good conscience assist in killing someone. But what happens when a state sanctions an execution and the execution is handled by someone who is not a doctor? In that situation, can doctors sit on their hands and watch someone with less medical training than them inflict pain on the condemned? What if the executioner struggles to administer a lethal injection or cannot determine if the injection has been successful? Shouldn’t a doctor step in so that there will be as little pain as possible for the condemned? If so, it would make sense to involve doctors in the entire execution process. Gawande explores this moral dilemma throughout the chapter.

To illustrate the problem, Gawande tells the stories of four doctors who were involved in carrying out death penalties. The first doctor, Dr. A, claims that he “never would have gotten involved” (142) in the death penalty if he had known what his involvement would entail. Eventually, Dr. A joined the American Medical Associates’ stance against doctors being part of executions. The second doctor, Dr. B, continues to take part in executions, but does not have to perform them himself. The third doctor, Dr. C, believes that doctors should be aware of the role they will play in executions before they accept positions in correctional facilities. Lastly, Dr. D believes that his work in a correctional facility ultimately allowed him to assist patients even though it also required him to be involved in executions.

Gawande does not judge any of the four doctors involved in carrying out the death penalty. Though he admits that he is “in favor of the death penalty” (148), he also believes that doctors must not “follow rules and laws blindly” (153). According to Gawande, doctors must “be prepared to recognize when using [their] abilities skillfully comes into conflict with using them rightly” (153).

In Chapter 8—the final chapter dedicated to the topic of doing right—Gawande discusses the desire of both doctors and patients to fight against disease and illness. Gawande writes, “We have at our disposal today the remarkable abilities of modern medicine. Learning to use them is difficult enough. But understanding their limits is the most difficult task of all” (157). He urges doctors to consider when fighting is more harmful than helpful. Although “the seemingly easiest and most sensible rule for a doctor to follow is: Always fight” (161), doctors need to realize that they are only half of the equation and that they can only do so much. In the end, practicing medicine is not about their success as doctors, it is about their patients and what is best for them: “The good doctors didn’t always get the answers right…[but] they set aside their egos” (163-64). Gawande cautions doctors to always fight for their patients’ health, so that their desire for success won’t be fueled by ego or anything else that could cloud their medical judgment and keep them from giving their patients proper care: “In the end, no guidelines can tell us what we have power over and what we don’t…but you have to be ready to recognize when pushing is only ego, only weakness. You have to be ready to recognize when pushing can turn to harm” (164).