The AAOS Medical Liability Committee believes that orthopaedic surgeons who embrace and practice the principles of performance improvement, patient communication, and self-monitoring will lower their liability exposure. Reading this book will help accomplish these goals. Along the way, you may also develop a new appreciation for and increased self-satisfaction with your role in today’s complex healthcare system.


Published 2/1/2008
John Harp, MD

Lessons for lowering your liability exposure

Atul Gawande’s latest book is well worth reading

Better: A Surgeon’s Notes on Performance by Atul Gawande. Metropolitan Books, Henry Holt and Company, LLC, New York, 2007, 273 pages. ISBN-13: 978-0-8050-8211-1

Atul Gawande, MD, a general surgeon at the Brigham and Women’s Hospital in Boston, examines several current medical topics of interest in his latest book, Better: A Surgeon’s Notes on Performance, a follow-up to his Complications: A Surgeon’s Notes on an Imperfect Science.

Written for the general, nonmedical public, Better: A Surgeon’s Notes on Performance examines how to improve health care by providing better service and outcomes to patients with existing technology. The three sections address what Dr. Gawande considers are core values: diligence, doing right, and ingenuity.

The section on diligence provides three examples: hand washing in hospital infection control, controlling polio in India, and reducing battlefield casualties. With the current media focus on methicillin-resistant Staphylococcus aureus infections it is also a good introduction to the complexities and interconnections in providing high quality health care in a real-world setting.

Stopping hand contact as a source of nosocomial infections requires the successful execution of myriad small steps by all hospital personnel and medical staff. The basic science is elementary; compliance is the elusive key.

Dr. Gawande also introduces the concept of reinforcing “positive deviance” behaviors. Human performance operates along a bell-shaped curve. People who are at the positive end of the curve can serve as models or teachers for the rest of the population, showing how they use existing resources to get outstanding results.

Dr. Gawande also examines the attention to detail and prompt, proactive mobilization of resources in controlling polio outbreaks in India, where compliance issues in the target populations have historically hampered success. Finally, he addresses innovations in treating Iraq battlefield casualties that have decreased the mortality rate to historic low levels.

Doing right
In the second section of the book, Dr. Gawande addresses medical liability issues in an easy-to-read, plain-language narrative. He shares several stories, including his own experience as a first-year medical student.

Dr. Gawande’s interview with a pediatric orthopaedic surgeon turned medical liability lawyer discloses what factors make a particular case attractive enough for the attorney to front the $40,000 to $50,000 required to bring a case to trial. Considerations include both negligence and harm to the patient, as well as the potential settlement and the character of the plaintiff with respect to the prospective jury pool. This lawyer defines negligence as an avoidable error that resulted in harm, which is likely what a jury would use on a subconscious level.

Another attorney points out that negative comments about a physician’s care from allied healthcare workers often form the nidus of lawsuits. The chapter ends with a brief discussion of alternatives to the current malpractice system and the acknowledgement that compensating every patient actually injured by adverse events would bankrupt the healthcare system.

The chapter titled “On Fighting” examines the dilemma faced by physicians who work for a cure, even if it appears that all is lost or the cause is hopeless.

A long chapter on issues in obstetrics begins this section, which includes a biography of Virginia Apgar, MD, that shows how relatively simple systems can be used to measure and improve outcomes. The increasing number of births by Cesarean section is related to the technical difficulties of training physicians to use the less invasive, but more complex technique of forceps delivery, and raises a number of questions.

Are surgical skills an art to be passed from mentor to apprentice? Has society rejected techniques with rare disastrous complications as associated outcomes? Should surgical skills be approached as industrial-type technical procedures that can be easily monitored as they are performed? Have societal expectations changed to emphasize consistent repeatable results at the expense of natural physiology and the occasional disastrous result? In addressing these issues, the chapter serves as a springboard for discussion.

“The Bell Curve” chapter focuses on measuring clinical performance, using the variations in outcomes of patients with cystic fibrosis as an introductory model. Despite widely disseminated standard clinical treatment guidelines, results vary significantly among national treatment centers.

In “For Performance,” the author argues that research budgets should be invested in improving clinical performance rather than in basic or “bench” science, because the benefits would be much greater for a larger number of people.

Making an exceptional career
In his afterword, Dr. Gawande advises medical students on how to give personal meaning to a career in medicine and how to have an exceptional career. Elegant in their simplicity, these sage suggestions are applicable to anyone at any stage of a medical career. This last chapter alone is well worth the small cost and the hour or two you’ll spend reading.

Dr. Gawande raises several timely medical ethics issues, including capital punishment, dignity, and justice, specifically allocation of resources. As a surgeon himself, Dr. Gawande discusses and frames these topics in terms that are very comfortable to an orthopaedist.

Although an easy read rather than a rigid scientific treatise, this book raises many excellent questions and makes cogent observations about our current healthcare system and problems inherent in the performance issue. It is a useful guide to general perceptions about challenges facing the system today—one any physician who wants to feel the public pulse is well advised to read.

John Harp, MD, is a member of the AAOS Medical Liability Committee. He can be reached at

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