There's a very good chapter near the end of the book about how the practice of obstetrics has dramatically improved outcomes for mothers and children over the past 100 years. He tells us that most of the changes did not come down to randomised controlled trials, double-blinded studies etc, but rather keen observations of outcomes and comparisons. The practice, he writes, was changed forever with the introduction of the Apgar score. This gave a score of the outcome of new born babies immediately after birth. This score allowed for comparisons between outcomes (outcome measures). In the next chapter about cystic fibrosis, he tells us about how all CF specialist centers make their outcomes and patient results (ie. average life expectancy of their patients) known to each other. Apparently in medicine, most outcomes form a 'bell-curve' distribution, so there are always some poor performers and some exceptionally good performers. Although comparison of outcomes increases competition, it drives improvement and change.
In the final afterword, Atul Gawande sets out his five suggestions on how to become a positive deviant (part of a lecture he gives medical students each year):
1. Ask an unscripted question. Medicine can feel at times like a machine with the doctor and patient small cogs in the process. Asking a patient (or indeed a colleague) a simple question, such as 'what do you do for a living?', 'did you watch the game last night?' makes a human connection.
2. Don't complain. Nothing is more dispiriting than hearing doctors complain. I agree with this point. Resist it it because it is boring, be prepared to have other things to discuss, such as something interesting which you saw, or even the weather if nothing else.
3. Count something. If you count something interesting, you will find something interesting.
4. Write something. Whether it is a few paragraphs in a blog, a paper for a journal or even a piece of creative writing. Make your reflections available to a wider audience, because an audience is a community and the published word is a declaration of membership of this community, as well as a willingness to contribute to it.
5. Change. The final suggestion for a successful life in medicine. Become an early adopter. Some of the best ideas and revolutionary concepts in medicine initially met large resistance. Be willing to recognise inadequacies of what you do and try to find solutions.
So always try to be better. Find something new to try, count how often it fails, or succeeds, and write about it. I think these sound like good words of advice. To anyone who finds these ideas interesting, I'd highly recommend this book.
