According to Dr. Gawande, the third component of being better is ingenuity, which he defines as “thinking anew… 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 constant searching for new solutions. Here I tell the stories of people in everyday medicine who have, through ingenuity, transformed medical care…. and I examine how more of us can do the same.”
In the chapter “The Score” he gives a brief overview of the history and advances in OB including knowledge and tools, culminating in the story of the Apgar Score. Takeaways from this include always measure, try things and see if results are impacted, then try and better those results. Why? Measuring is not just an objective measure of what you have done, but also to change your choices on how to do better.
- Why do you measure (or not measure)?
- What can you measure?
- Then, how can you better your measurement?
The next chapter “The Bell Curve” is about the state of treatment centers for cystic fibrosis. Dr. Gawande believes that improvement requires two types of ingenuity: finding a way to measure performance (described in “The Score”), and then doing something with that measure. We want to think that we are all pretty similar with a few leading the pack, the majority of us getting similar results and then a gradual drop off of others (like a shark fin, with ourselves being near the top of course), when in reality it is a bell curve with “a great indistinguishable middle.” How University of Minnesota Fairview leads the country in CF treatment is amazing, with the now former director pushing his patients, not being content with average values, understanding and explaining to patients how a small risk can compound over time (in skipping treatments), being creative in addressing impairments, and requiring “a degree of uniformity [for care of patients] that clinicians usually find intolerable.” Gawande writes “Even doctors with great knowledge and technical skill can have mediocre results; more nebulous factors like aggressiveness and diligence and ingenuity can matter enormously…. only if we know the results from all can we identify the positive deviants and learn from them.”
- Will being in the bottom part of the curve be used against us by payors? Will patients leave us?
- What if you are below average? Or average? Is there shame in being average? If you settle for it, yes. Would you want your doctor or physio settling for average if they were caring for you or a loved one?
- Using what you choose to measure, how can you push yourself and your patients to get to the front of the bell curve?
In “For Performance” Gawande tells of a visit to India, spending time with surgeons there. Even with the conditions in India they are making a difference. “True success in medicine is not easy. It requires will, attention to detail, and creativity. But the lesson I took from India was that it is possible anywhere and by anyone…. with a readiness to recognize problems and a determination to remedy them… better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.”
- What problem do you see in your own practice pattern or patients?
- How can you improve upon that?
Dr. Gawande finishes his book with five suggestions for being a positive deviant, summarized in this post which led me to reading the book. As healthcare professionals, we need to strive to do better – through diligence, doing right, and ingenuity. This is a great book to inspire, challenge, and encourage.