‘A searing, deeply humane collection of essays about medical
practice that has all the makings of a modern classic’
‘Rich in fascinating detail … as engaging to the layman as to
the practising or studying doctor’ Economist
‘Reading him is rewarding’ TLS
‘An introspective, enthusiastic, gifted and thoughtful
storyteller … A brilliant diagnosis of medicine’s ills’
British Medical Journal
‘A fascinating study’ Irish Tatler
‘Gawande is an accomplished author and doesn’t shy away
from hot topics like malpractice, while his writing is clear and
refreshingly free from off-putting medical jargon.’
‘Riveting’ Irish Examiner
Atul Gawande is one of the world’s most distinguished
doctors. A 2006 MacArthur Fellow, he is a general surgeon at
the Brigham and Women’s Hospital in Boston, a staff writer
for the New Yorker, an associate professor at Harvard Medical
School and the bestselling author of Complications: A Surgeon’s
Notes on an Imperfect Science, also published by Proﬁle. He lives
with his wife and children in Newton, Massachusetts.
a l s o b y At u l G awa n d e
A Surgeon’s Notes on an Imperfect Science
A S u r g e o n ’ s N ot e s
o n Pe r f o r m a n c e
This paperback edition published in 2008
First published in Great Britain in 2007 by
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First published in the United States of America in 2007 by
Copyright © Atul Gawande, 2007, 2008
Several of these chapters have appeared, in different form,
in the New Yorker and the New England Journal of Medicine
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For my parents and sister
Part I Diligence
On Washing Hands
Casualties of War
Part II Doing Right
What Doctors Owe
The Doctors of the Death Chamber
Part III Ingenuity
The Bell Curve
Afterword: S uggestions for
B ecoming a P ositive D eviant
Notes on Sources
everal years ago, in my ﬁnal year of medical school, I
took care of a patient who has stuck in my mind. I was
on an internal medicine rotation, my last rotation before
graduating. The senior resident had assigned me primary responsibility for three or four patients. One was a wrinkled,
seventy-something-year-old Portuguese woman who had been
admitted because—I’ll use the technical term here—she didn’t
feel too good. Her body ached. She had become tired all the
time. She had a cough. She had no fever. Her pulse and blood
pressure were ﬁne. But some laboratory tests revealed her
white blood cell count was abnormally high. A chest X-ray
showed a possible pneumonia—maybe it was, maybe it wasn’t.
So her internist admitted her to the hospital, and now she was
under my care. I took sputum and blood cultures and, following the internist’s instructions, started her on an antibiotic for
this possible pneumonia. I went to see her twice each day for
the next several days. I checked her vital signs, listened to her
lungs, looked up her labs. Each day, she stayed more or less the
same. She had a cough. She had no fever. She just didn’t feel
good. We’d give her antibiotics and wait her out, I ﬁgured.
She’d be ﬁne.
One morning on seven o’clock rounds, she complained
of insomnia and having sweats overnight. We checked the vitals sheets. She still had no fever. Her blood pressure was normal. Her heart rate was running maybe slightly faster than
before. But that was all. Keep a close eye on her, the senior resident told me. Of course, I said, though nothing we’d seen
seemed remarkably different from previous mornings. I made
a silent plan to see her at midday, around lunchtime. The senior resident, however, went back to check on her himself
twice that morning.
It is this little act that I have often thought about since. It
was a small thing, a tiny act of conscientiousness. He had seen
something about her that worried him. He had also taken the
measure of me on morning rounds. And what he saw was a
fourth-year student, with a residency spot already lined up in
general surgery, on his last rotation of medical school. Did he
trust me? No, he did not. So he checked on her himself.
That was not a two-second matter, either. She was up on
the fourteenth ﬂoor of the hospital. Our morning teaching
conferences, the cafeteria, all the other places we had to be
that day were on the bottom two ﬂoors. The elevators were
notoriously slow. The senior resident was supposed to run one
of those teaching conferences. He could have waited for a
nurse to let him know if a problem arose, as most doctors
would. He could have told a junior resident to see the patient.
But he didn’t. He made himself go up.
The ﬁrst time he did, he found she had a fever of 102 degrees and needed the oxygen ﬂow through her nasal prongs
increased. The second time, he found her blood pressure had
dropped and the nurses had switched her oxygen to a face
mask, and he transferred her to the intensive care unit. By the
time I had a clue about what was going on, he already had her
under treatment—with new antibiotics, intravenous ﬂuids,
medications to support her blood pressure—for what was developing into septic shock from a resistant, fulminant pneumonia. Because he checked on her, she survived. Indeed,
because he did, her course was beautiful. She never needed to
be put on a ventilator. The fevers stopped in twenty-four
hours. She got home in three days.
What does it take to be good at something in which failure is
so easy, so effortless? When I was a student and then a resident, my deepest concern was to become competent. But
what that senior resident had displayed that day was more
than competence—he grasped not just how a pneumonia generally evolves and is properly treated but also the particulars of
how to catch and ﬁght one in that speciﬁc patient, in that speciﬁc moment, with the speciﬁc resources and people he had at
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. But success in medicine has dimensions that cannot be found on a playing ﬁeld. For one, lives
are on the line. Our decisions and omissions are therefore
moral in nature. We also face daunting expectations. In medicine, our task is to cope with illness and to enable every human
being to lead a life as long and free of frailty as science will allow. The steps are often uncertain. The knowledge to be mastered is both vast and incomplete. Yet we are expected to act
with swiftness and consistency, even when the task requires
marshaling hundreds of people—from laboratory technicians
to the nurses on each change of shift to the engineers who keep
the oxygen supply system working—for the care of a single
person. We are also expected to do our work humanely, with
gentleness and concern. 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.
Recently, I took care of a patient with breast cancer. Virginia Magboo was sixty-four years old, an English teacher, and
she’d noticed a pebblelike lump in her breast. A needle biopsy
revealed the diagnosis. The cancer was small—three-quarters
of an inch in diameter. She considered her options and decided on breast-conserving treatment—I’d do a wide excision
of the lump as well as what’s called a sentinel lymph node
biopsy to make sure the cancer hadn’t spread to the lymph
nodes. Radiation would follow.
The operation was not going to be difﬁcult or especially
hazardous, but the team had to be meticulous about every
step. On the day of surgery, before bringing her to the operating room, the anesthesiologist double-checked that it was safe
to proceed. She reviewed Magboo’s medical history and medications, looked at her labs in the computer and at her EKG.
She made sure that the patient had not had anything to eat for
at least six hours and had her open her mouth to note any
loose teeth that could fall out or dentures that should be removed. A nurse checked the patient’s name band to make sure
we had the right person; veriﬁed her drug allergies with her,
conﬁrmed that the procedure listed on her consent form was
the one she expected. The nurse also looked for contact lenses
that shouldn’t be left in and for jewelry that could constrict a
ﬁnger or snag on something. I made a mark with a felt-tip pen
over the precise spot where Magboo felt the lump, so there
would be no mistaking the correct location. Early in the
morning before her surgery, she had also had a small amount
of radioactive tracer injected near her breast lump, in preparation for the sentinel lymph node biopsy. I now used a handheld
Geiger counter to locate where the tracer had ﬂowed, and
conﬁrmed that the counts were strong enough to indicate
which lymph node was the “hot” one that needed to be excised. Meanwhile, in the operating room, two nurses made
sure the room had been thoroughly cleaned after the previous
procedure and that we had all the equipment we needed.
There is a sticker on the surgical instrument kit that turns
brown if the kit has been heat-sterilized and they conﬁrmed
that the sticker had turned. A technician removed the electrocautery machine and replaced it with another one after a
question was raised about how it was functioning. Everything
was checked and cross-checked. Magboo and the team were
By two o’clock I had ﬁnished with the procedures for my
patients before her and I was ready too. Then I got a phone
Her case was being delayed, a woman from the OR control desk told me.
Why? I asked.
The recovery room was full. So three operating rooms
were unable to bring their patients out, and all further procedures were halted until the recovery room opened up.
OK. No problem. This happens once in a while. We’ll
wait. By four o’clock, however, Magboo still had not been
taken in. I called down to the OR desk to ﬁnd out what was
The recovery room had opened up, I was told, but Magboo was getting bumped for a patient with a ruptured aortic
aneurysm coming down from the emergency room. The staff
would work on getting us another OR.
I explained the situation to Magboo, lying on her
stretcher in the preoperative holding area, and apologized.
Shouldn’t be too much longer, I told her. She was philosophical. What will be will be, she said. She tried to sleep to make
the time pass more quickly but kept waking up. Each time she
awoke, nothing had changed.
At six o’clock I called again and spoke to the OR desk
manager. They had a room for me, he said, but no nurses. After ﬁve o’clock, there are only enough nurses available to
cover seventeen of our forty-two operating rooms. And
twenty-three cases were going at that moment—he’d already
made nurses in four rooms do mandatory overtime and
could not make any more. There was no way to ﬁt another
Well, when did he see Magboo going?
“She may not be going at all,” he said. After seven, he
pointed out, he’d have nurses for only nine rooms; after
eleven, he could run at most ﬁve. And Magboo was not the
only patient waiting. “She will likely have to be canceled,” he
said. Cancel her? How could we cancel her?
I went down to the control desk in person. One surgeon
was already there ahead of me lobbying the anesthesiologist
in charge. A second was yelling into the OR manager’s ear on
the phone. Each of us wanted an operating room and there
would not be enough to go around. A patient had a lung cancer that needed to be removed. Another patient had a mass in
his neck that needed to be biopsied. “My case is quick,” one
surgeon argued. “My patient cannot wait,” said another. Operating rooms were offered for the next day and none of us
wanted to take one. We each had other patients already scheduled who would themselves have to be canceled to make
room. And what was to keep this mess from happening all
over again tomorrow, anyway?
I tried to make my case for Magboo. She had a breast
cancer. It needed to be taken out. This had to happen sooner
rather than later. The radioactive tracer, injected more than
eight hours ago, was dissipating by the hour. Postponing her
operation would mean she would have to undergo a second
injection of a radioactive tracer—a doubling of her radiation
exposure—just because an OR could not be found for her.
That would be unconscionable, I said.
No one, however, would make any promises.
* * *
This is a book about performance in medicine. As a doctor,
you go into this work thinking it is all a matter of canny diagnosis, technical prowess, and some ability to empathize with
people. But it is not, you soon ﬁnd out. 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. How we
have and how we do is my subject here.
The sections of this book examine three core requirements for success in medicine—or 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 obstacles. Diligence seems an easy and minor virtue. (You just pay attention, right?) But it is neither.
Diligence is both central to performance and ﬁendishly hard,
as I show through three stories: one about the effort to ensure
doctors and nurses simply wash their hands; one about the
care of the wounded soldiers in Iraq and Afghanistan; and
one about the Herculean effort to eradicate polio from the
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, misunderstanding. In this section I consider some of our most uncomfortable questions—such as how much doctors should be
paid, and what we owe patients when we make mistakes. I tell
the stories of four doctors and a nurse who have gone against
medical ethics codes and participated in executions of
prisoners. I puzzle over how we know when we should keep
ﬁghting for a sick patient and when we should stop.
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. These are difﬁcult traits to foster—but they are far
from impossible ones. Here I tell the stories of people in
everyday medicine who have, through ingenuity, transformed
medical care—for example, the way babies are delivered and
the way an incurable disease like cystic ﬁbrosis is fought—and
I examine how more of us can do the same.
Betterment is a perpetual labor. The world is chaotic,
disorganized, and vexing, and medicine is nowhere spared that
reality. To complicate matters, we in medicine are also only
humans ourselves. We are distractible, weak, and given to our
own concerns. Yet still, to live as a doctor is to live so that
one’s life is bound up in others’ and in science and in the
messy, complicated connection between the two. It is to live a
life of responsibility. The question, then, is not whether one
accepts the responsibility. Just by doing this work, one has.
The question is, having accepted the responsibility, how one
does such work well.
Virginia Magboo lay waiting, anxious and hungry, in a windowless, silent, white-lit holding area for still two hours more.
The minutes ticked, ticked, ticked. At times, in medicine, you
feel you are inside a colossal and impossibly complex machine
whose gears will turn for you only according to their own arbitrary rhythm. The notion that human caring, the effort to
do better for people, might make a difference can seem hopelessly naïve. But it isn’t.
Magboo asked me if there was any real prospect of her
having her operation that night. The likelihood, I said, had become exceedingly small. But I couldn’t bring myself to send
her home, and I asked her to hang on with me. Then, just before eight o’clock, I got a text message on my pager. “We can
bring your patient back to room 29,” the display read. Two
nurses, it turned out, had seen how backed up the ORs had
gotten and, although they could easily have gone home, they
volunteered to stay late. “I didn’t really have anything else going on anyway,” one demurred when I spoke to her. When
you make an effort, you ﬁnd sometimes you are not the only
one willing to do so.
Eleven minutes after I got the page, Magboo was on the
operating table, a sedative going into her arm. Her skin was
cleansed. Her body was draped. The breast cancer came out
without difﬁculty. Her lymph nodes proved to be free of metastasis. And she was done. She woke up calmly as we put on the
dressing. I saw her gazing upward at the operating light above
“The light looks like seashells,” she said.
On Washing Hands
ne ordinary December day, I took a tour of my hospital with Deborah Yokoe, an infectious disease specialist, and Susan Marino, a microbiologist. They
work in our hospital’s infection-control unit. Their full-time
job, and that of three others in the unit, is to stop the spread of
infection in the hospital. Th ...
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