Better: A Surgeon’s Notes on Performance

In Chapter 2, Gawande discusses something that might seem like a herculean task: the eradication of polio in India. He uses this discussion to examine “the importance of diligence as a virtue” (29). According to Gawande, “the prerequisite of great accomplishment [is] diligence [and it] stands as one of the most difficult challenges facing any group of people who take on tasks of risk and consequence” (29). Gawande believes diligence is exhausting because it must be practiced constantly.

To demonstrate an example of perseverance and diligence, Gawande recounts the story of Sunil Bahl, a worker for the World Health Organization. When Bahl learned about a polio outbreak in a province in southern India, he organized a “mop up,” or “targeted campaign to immunize all susceptible [patients] surrounding of new case [of infection]” (34). Bahl and his small team had to “go door to door to vaccinate more than 4.2 million children. In three days” (35). Although this seemed like an impossible task, Gawande argues that diligence and perseverance enabled doctors such as Bahl and Pankaj Bhatnagar to curb the outbreak of a polio epidemic. This incident also reveals the reality of practicing true diligence: “beneath the ideal is the gruelingly unglamorous and uncertain work” (47). Diligence means doing the hard drudgery without glamour.

In this chapter, Gawande turns his attention to the way medicine is practiced on the battlefield. He states that while “firepower has increased, lethality has decreased” (52). Gawande continues:

Although more U.S. soldiers have been wounded in combat in the current war than in the Revolutionary War, the War of 1812, and the Spanish-American War combined, and more than in the first four years of military involvement in Vietnam, we have had substantially few deaths. Just 10 percent of wounded American soldiers have died (53).

This fact illustrates the advancements that have been made in both medicine and the way combat casualties are treated. In combat, Gawande believes that those practicing medicine need “to make a science of performance, to investigate and improve how well they use the knowledge and technologies they already have at hand” (56). Gawande goes on to state that “almost banal changes […] produced enormous results” (56). In fact, “at the end of 2006, medical teams were still saving an unbelievable 90 percent of soldiers wounded in battle” through “a commitment to making a science of performance, rather than waiting for new discoveries” (68). Diligence here means doing all of the little things that will amount to lives saved without striving for the deus-ex-machina of scientific breakthroughs.

One of the most important concepts in combat medicine is the “Golden Hour,” during which most trauma victims can be saved if treatment is started. But battlefield injuries are usually so much more severe—especially in regard to blood loss—than normal trauma injuries that wounded soldiers have only a “Golden Five Minutes” (57). Because of this, the military started using Forward Surgical Teams to cut down on the transit time between battlefield injuries and surgery. These teams have saved countless soldiers from life-threatening injuries.

Despite all of the advances that have been made in modern combat medicine, “the human cost remains high” (61). More and more soldiers are returning with “such extensive wounds” (61) that rehabilitating them has become an entirely new project, which raises a new set of moral and ethical questions.