Gawande Atul:Better. A surgeon’s notes on performance. New Delhi; Penguin Books: 2007. 222 pages. Paperback Rs 250.

The back cover shows Dr Gawande in his surgical scrubs, mask lowered to his neck and bleeper attached to his belt. He looks at you through thin-rimmed glasses, hands clasped together. One wonders whether there is the faintest trace of a smile on his face.

Those familiar with his earlier collection of essays, Complications, will know what to expect and welcome his accounts of interactions with patients, their families and his own colleagues.

The Introduction sets the tone with an account of the author’s experience as a medical student in the final year of his training. The senior resident told him to keep a close eye on a “wrinkled, seventy-something-year-old Portuguese woman” as he was worried about her condition. By the time Dr Gawande made his next call on this patient, she had been transferred to the intensive care unit under revised therapy as the senior resident had himself already examined her twice that morning, despite many other commitments, and found her condition worsening. “Because he checked on her, she survived,” Dr Gawande writes, quick to give credit to others for their sincerity of purpose and dedication to their patients even as he educates us on the lessons he learnt from them. In this case he asked himself, “What does it take to be good at something in which failure is so easy, so effortless?” and finds the answer in his senior resident’s competence, perseverance, hard work and precision.

Dr Gawande lists three requirements for success in medicine – diligence, doing what is right and ingenuity. It is his second requirement that concerns us in this journal so I will focus on part two of the book, ‘Doing Right’ (though I hasten to add that the other parts are at least as illuminating and worthy of study). “Medicine,” Dr Gawande writes, “is a fundamentally human profession. It is therefore forever troubled by human failings like avarice, arrogance, insecurity, misunderstanding.”

The first essay in this section, ‘Naked’, is especially relevant as I write this review, as our newspapers are full of accusations of “violating female modesty” by “cosmetic surgeon” Dr Vijay Sharma (1). Dr Gawande’s essay describes the examination of a female patient by a male physician in Afghanistan under the Taliban regime. A dark blanket-like screen separates doctor and patient. Behind it, the patient is covered from head to foot in a burkha. Doctor and patient do not talk to each other but address the patient’s young son, who is the go-between. An Iraqi surgeon told Dr Gawande that in his country, in addition to the presence of a family member accompanying the patient to the doctor, only a small portion of the patient’s body was uncovered for examination at any given time. In America, practices for the examination of a female patient by a male doctor, differ widely, whilst in Britain, a chaperone – a female member of the medical team – is mandatory and must be named in the medical notes.

Had it not been for Dr Vijay Sharma’s recent plight, the ruling by the Federation of State Medical Boards in America would have been stating the obvious: “touching a patient’s breasts or genitals for a purpose other than medical care is a sexual violation and a disciplinable offence. So are oral contact with a patient, encouraging a patient to masturbate in one’s presence, and providing services in exchange for sexual favours…”

Dr Gawande’s father, a urologist, advised him to keep the language strictly medical when talking to patients, explain each step of the physical examination and why it was necessary and bring in a female nurse if the patient is female or under eighteen years. Concludes Gawande fils: “His approach works. He has a busy practice. There have been no unseemly rumours. I grew up knowing many of his patients and they seemed to trust him completely.”

The next essay, ‘What doctors owe’, deals with accusations of malpractice against doctors, lawyers specialising in medical malpractice, and crazy lawsuits. Among the latter he describes how his mother, a paediatrician, was sued after a healthy two-month-old she had seen for a routine check-up died of sudden infant death syndrome (SIDS) a week later. As Dr Gawande points out, the defining characteristic of SIDS is that it occurs without warning.

The third essay deals with doctors’ fees. I shall merely quote some sentences from this essay to give you a flavour of the whole. “Doctors quickly learn that how much they make has little to do with how good they are. It largely depends on how they handle the business side of their practice.” Dr Gawande quotes a surgeon who makes over a million dollars a year: “I think doctors short-change themselves. Doctors are working for fees that are similar to or below those of plumbers or electricians.” In this surgeon’s view, doctors need to understand that they are businessmen – nothing less, nothing more. This doctor charges huge fees and has no shortage of patients.

‘The doctors of the death chamber’ deals with doctors who assist the State in execution of criminals. Though Dr Gawande is in favour of the death penalty, he regards involvement by physicians and nurses in executions as wrong.

The final essay in this section, ‘On fighting’, deals with the dying patient. Once again, I shall leave you to read the full text but stimulate your appetite with a quotation from a message sent by a patient’s mother: “We must eradicate from the soul all fear and terror of what comes to us out of the future.” This could well serve all of us as a credo.

After the publication of his first book, Dr Gawande was asked if his worst mistake appeared in this book. He replied: “Oh God, I’ve made so many terrible mistakes. I have no idea how I’d even begin to rank them. I mean, certainly my most vivid mistakes appear in the book, the ones that I’ve struggled with the most.”

Dr Gawande’s writings have, as expected, a heavy American bias and are more relevant to patients and doctors in that country. But there is much for all of us to ponder and learn from the honest, humane and reasoned manner in which he deals with important issues.

Let me conclude this review with a quotation from Dr Gawande’s introduction: “This is a book about performance in medicine… In medicine, as in any profession, we must grapple with systems, resources, circumstances, people – and our own shortcomings as well… Yet somehow we must advance, we must refine, we must improve. How we have and how we do is my subject here.”

Dr Gawande is a member of the group of young American doctors (that includes Dr Abraham Verghese and Dr Sandeep Jauhar) who excel in communicating their own experiences, hopes, fears and achievements in a manner that at once informs, educates and inspires (several of the chapters in this book appeared in the New Yorker and the New England Journal of Medicine). It is tempting to claim them as being of Indian origin but if we remain true to their ideals, we must confess that they are products of the best of American medicine. We await young Indian authors of their calibre.