My notes from reading 'Better: A surgeon's notes on performance'


First off, this was a great read - a great window into the literal and figurative world of medicine.  Highly recommend it not just as a well-written book, but as it also has a lot of readily transposable ideas.  I read this at the recommendation of: https://leezukor.com/  and under the contextual influence of "how do OKRs work, anyhow?".

My own analysis & thoughts

  • Big theme of the systems principle 'make information visible' - publish results, don't hide results anywhere! (e.g. org-public OKRs)
  • Measuring "intangibles" can be a powerful innovation (e.g. How to measure anything, Hubbard)
  • Balanced KRs important everywhere (point/counterpoint)
  • "What the best may have, above all, is a capacity to learn and change - and to do so faster than everyone else."
  • Change is possible with just one person - be a positive deviant!  Note how a number of individuals were referenced below.
  • Diligence rang out loud and clear to me - Personal mastery (Fifth Discipline, Senge), "disciplined people who engage in disciplined thought and then take disciplined action" (Good to Great, Collins), 'character ethic' (7 Habits, Covey), etc -> i.e. it starts with people
What I'm taking away from this is that "find what matters and measure it" is a legitimate concern for change, and it's done by diligent people who leave ego at the door.  The so-called "learning culture" is not just an idealist dream, but a basic function of excellence, as my next book on the list supports.

The afterword section below (and most of my notes) are copied almost verbatim, but it's worth putting it at the forefront.  Take this and apply it to daily life, and read the book!

Afterword section - Suggestions for becoming a positive deviant

  1. "Ask an unscripted question." - Paul Auster.  If you ask a question, the machine begins to feel less like a machine.
  2. Don't complain.  Be prepared with something else to discuss: an idea you read about, an interesting problem you came across - even the weather.  See if you can keep the conversation going.
  3. Count something.  Be a scientist, just has to be interesting to you.  If you count something you find interesting, you will learn something interesting.
  4. Write something.  You should not underestimate the effect of your contribution, however modest.  You should not underestimate the power of the act of writing itself.  Most of all, by offering your reflections to an audience, even a small one, you make yourself part of a larger world.
  5. Change.  Make yourself an early adopter, look for the opportunity to change.  Be willing to recognize the inadequacies in what you do and seek out solutions.  Count how often you succeed and how often you fail.  Write about it.  Ask people what they think.  See if you can keep the conversation going.

Intro section

  • Three core requirements for success in medicine, or any endeavour that involves risk and responsibility:
    • Diligence - the necessity of giving sufficient attention to detail to avoid error and prevail against obstacles
      • Is not an easy or minor virtue
      • Central to performance and fiendishly hard
    • Do right - human profession forever troubled by human failings like avarice, arrogance, insecurity, misunderstanding
    • Ingenuity - thinking anew, but it is often misunderstood.  Not a matter of superior intelligence but of character
      • It demands, above all, a willingness to recognize failure and to change
      • It arises from deliberate (obsessive) reflection of failure and a constant searching for new solutions
  • NOTE: "Betterment is a perpetual labour.  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.  Just by doing this work, one has.  The question is, having accepted the responsibility, how one does such work well."

Diligence section

  • Anti-starvation program 'Save the Children', Jerry Sternin
    • Find the 'positive deviance' from within
      • get the villagers (i.e. everyone with a stake in it) to identify the best-fed children and, by themselves, find out why and apply these findings to their own families
        • POINT: You are getting the stakeholders to self-generate results, intentionally not actually doing anything yourself.
      • the program measured the results of this, found huge improvements consistently using this methodology
    • "We're here because of the ___ problem and we want to know what you know about how to solve it."
    • Dogma of the program: "Thou shalt not try to fix anything."
    • "We kept going through all the groups, because it was the first time those people had been heard, the first time they had a chance to innovate for themselves."
    • NOTE: Publicize the results!!!
  • Diligence: the constant and earnest effort to accomplish what is undertaken
    • Has a flavour of simplistic relentlessness
    • Understand it as the pre-requisite of great accomplishment
    • It sets a high (seemingly impossible) expectation for performance and human behaviour
  • Combat surgeons - make a science of performance, to investigate and improve how well they use the knowledge and technologies at hand
    • "simple, almost banal changes" made enormous improvements to the results
      • "wear the vests"
    • Trauma logs, no matter how much time it adds to things
      • i.e. Data collection is part of performance and improvement

Doing Right section

  • The systemic failures of health insurance system were abundant, yet still no great alternatives
  • Good doctors understand one key thing - it is not about them, it is always about the patient
    • They don't always get it right
    • But at least they stopped to wonder, to reconsider the path they were on - they asked colleagues for another perspective, they set aside their egos
  • NOTE: "When someone has come to you for your expertise, and your expertise has failed, what do you have left?  You only have your character to fall back upon - and sometimes it's only your pride that comes through."
  • In the face of uncertainty, wisdom is to err on the side of pushing, to not give up.  But you have to be ready to recognize when pushing is only ego, only weakness.
    • You have to be ready to recognize when the pushing can turn to harm

Ingenuity section

  • C-section, making a process requiring great skill & finesse into something very reliable & consistent
  • Apgar index -> turning intangibles into 'good enough' measurement
    • Intervals: +1minute, +5minutes
  • Making that information visible caused people to push for better scores and outcomes
  • Counterpoint: Fetal heart rate monitors make too much data visible leading to incorrect choices (i.e. interval of polling too short)
  • Apgar not only tells you how well you have done, it also changed the choices they made about how to do better
  • If you want to lift the results of every employee, sometimes you must choose reliability over perfection (e.g. forceps)
  • Apgar counterpoint: We don't rate the mother's side of things
  • Bell curve - hiding information blinded people to reality
    • i.e. the goal of 'give the very best chance' vs. reality of 'just average'
    • "I am doing the very best I can" vs. "I'm just average"
  • NOTE: Positive deviants push the bell curve ahead
    • Don Berwick + Wag Dodge - open info in healthcare (via 'Escape Fire' invention)
    • "no secrets!"
  • Warren Warwick - Excellence comes from seeing, on a daily basis, the difference between being 99.5% successful and 99.95% successful.
    • also, "We've failed, Janelle.  It's important to acknowledge when we've failed."
  • Fear of change in medicine due to cowboys
    • "With his unblinking focus on his patients' actual results, he has been able to innovate successfully."
  • Science & skill may be the easiest parts of the job; aggressiveness, diligence, and ingenuity can matter enormously
  • "You look at the rates of improvement in different quartiles, and it's the centers in the top quartile that are improving fastest.  They are at risk of breaking away.  What the best may have, above all, is a capacity to learn and change - and to do so faster than everyone else."
  • What if I turn out to be average?
    • What is troubling is not just being average but settling for it!
    • When the stakes are our lives and the lives of our children, we want no one to settle for average.

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