AAMC Reporter: February 2008

A Surgeon's Notes on Writing

Atul Gawande, M.D., M.A., M.P.H.

A surgeon and writer, Atul Gawande, M.D., M.A., M.P.H., is author of "Complications: A Surgeon's Notes on an Imperfect Science" and "Better: A Surgeon's Notes on Performance." On the staff of Brigham and Women's Hospital, Gawande uses real life patient scenarios as a platform to discuss some medical ethical questions. "Complications" was a 2002 finalist for the National Book Award.

Gawande also is a researcher, director of the World Health Organization's Global Challenge for Safer Surgical Care, a 2006 John D. and Catherine T. MacArthur Foundation Award winner, and a writer for The New Yorker. Both books are available in paperback from Picador.

Name one writer and one doctor who you feel have had a special influence on your career.

As far as a physician, the person who has helped me a ton is the chairman of surgery here, Michael Zinner, M.D. When I was a resident, The New Yorker asked if I would write an article for them, and I decided to write about a mistake I made that nearly killed a patient. I let him look at a draft of the article, and he didn't agree with everything I wrote by any means, but at the same time, he said, "Go ahead. Harvard is a big place. It will still be standing if you go down in flames."

A writer/physician who I can't imagine getting anywhere close to would be Chekov. His writing has that extremely focused physical high. He has that capacity for examination on the page that a physician has in the office. The writer that I try to weakly imitate—that I try to capture in economy and clarity—would be Hemingway. It's sort of old-fashioned, but his prose is so clean, and his capacity to make something clear is inexhaustible, so I am constantly turning back to Hemingway's novels.

Your books are intended for both medical professionals and lay people. Do you have a strategy for communicating with both groups?

I don't really. I don't shy away from technical terms. There is a kind of beauty to them, and people don't want to be treated like you are dumbing things down for them. I also think that in certain areas of professional expertise, our terminology hides the fact that we are not very clear on what we are talking about. So, when I use certain terms, I always ask myself if I even know what it is.

Physicians treat people individually, while writers reach a broader audience with their words. Describe the different rewards and challenges associated with each.

They are sort of inseparable for me. I am not sure I could manage the daily pain of medical practice—all of the ups and downs, the bureaucracy, and the headaches—without having a chance to step back from it and understand what it means. My writing lets me do that, my research lets me do that. I also find that if I only thought at the broader abstract level, that I would lose touch with the messy complexity of real life, and so I really feel like they go together.

What do you think the proper place is for humanities in medical education?

I don't buy the idea that reading "The Death of Ivan Ilyich" will make anybody a more humane and empathetic physician. Writing and looking carefully at literature gets you to step into other peoples' shoes, and understand how to see things from their positions. The place of humanities in medicine is mainly in trying to help us understand the question of whether it helps us get into other peoples' shoes. Humanities is there for us to have a place for discussing the questions, problems, and human realities that can't get captured in textbooks and studies.

In your second book, "Better," you focus on how doctors can improve themselves and their environment. How has the medical community's increased emphasis on quality helped improve this issue since the time your book was published?

I think it's helped enormously. The interesting thing is that now we have started to take the idea of producing better results for patients just as seriously as we take the idea of producing better financial results. And the puzzle of it is "OK, so you care. Now what do you do?" As a young surgeon coming out of my training into practice, it was the question that hits everyone square between the eyes. You can have all the skills, and still have a patient's care completely break down because the X-ray order didn't happen. And the complexity in medicine has increased so enormously, even just over the last decade, that we are all working much harder and feeling less effective. And that is what the book is about. It is about understanding where you can find a chance for any kind of victory— what is solvable and what isn't.

If you could tell every medical student and every medical educator to read one book, what would it be and why?

I assign one book to everyone who works in my research group. It may sound a little odd, but it's "Moneyball" by Michael Lewis. That book is a nonfiction account of the Oakland A's, a Major League Baseball team that has less money than a lot of the other teams. They can't buy star athletes, and yet get themselves into the playoffs year after year. And the interesting thing was how Billy Beane, the general manager, went about it. He tried to think of something as complex as an athlete's performance and a team's performance as being a solvable problem. Something you could dissect with statistics. He ended up going smack against the culture of baseball, which is that the talent scouts just know in their gut who is the best or what a good team looks like. Beane has proven over and over again that that kind of systematic approach to understanding something even as complex as baseball could be captured and explored. So then how does an average hospital of 3,000 employees get to the top of their bell curve?

—By Elissa Fuchs

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