Better, by

Atul Gawande

By Kristen Ashworth

Apositive deviant is a person that takes individual action—outside ‘the norm’—to better a pre-existing system in small increments, so that, over time, big changes ensue. Positive deviants have continuously instigated significant progress in healthcare for faster diagnoses, greater treatment success, and improved patient quality of life. In a collection of stories from the bedside, Better, by surgeon and New York Times best-selling author Dr. Atul Gawande, explores the actions of a few physicians – unsung heroes – who have conscientiously gone against the grain as positive deviants to create big changes in medicine.1 Gawande illustrates what it means to be a positive deviant through anecdotal evidence from his own clinical experience and that of his colleagues, underpinning his stories with three main themes: diligence, doing right, and ingenuity. Though Better is written from the perspective of a surgeon, the larger learnings extend far beyond the walls of the hospital and can be applied to us as researchers on the precipice of bettering progress in scientific discovery.

Gawande begins his book by elucidating the importance of diligence—an often overlooked virtue in medicine. “Diligence is both central to performance and fiendishly hard,” Gawande explains. He expounds on this thought by discussing the challenges of infection control in hospitals due to a lack of diligence in hand hygiene by medical teams. Gawande then uses anecdotes from medical staff on the frontlines to demonstrate how a small yet diligent commitment for improvement in triage and treatment strategies has significantly reduced the mortality rate of soldiers in the last century. Most touching, perhaps, was Gawande’s recounting of his journey to India in the early 2000s to help implement an emergency eradication of polio in a region of 4.2 million people in just three days. Working with an almost impossible time constraint, the team remained committed to knocking on every door, in every village, to ensure no child was missed. The inoculation campaign was a success.

The duty of ‘doing right’ was the next theme covered by Gawande, using ethical topics such as medical malpractice and physician-assisted dying to explore what a doctor owes to a patient. Though many of his stories speak to American healthcare, litigation, and government processes, the key takeaway still rings true: when handed great responsibility (for physicians, the responsibility of human lives), moral principles must guide deviance. That’s in part what makes positive deviance, positive. Gawande concludes his book by speaking of ingenuity and innovation in medicine, and the importance of applying a scientific mindset to improve clinical care. He illustrates the introduction of obstetric tools, such as the C-section and the Apgar score, to explain the power of initially radical, yet relatively simple, ingenuity in medicine that has significantly improved both child and maternal outcomes.Overall, Better was a thought-provoking read, accessible and relatable to a broad audience. Despite being published in 2007, Gawande’s message remains relevant to our approach to healthcare in the post-pandemic world. If anything, the last three years have only further highlighted Gawande’s core thesis on the importance of building positive deviants and bettering our performance in the face of obstacles, limited resources, and in a culture of complacency. The distinct patient anecdotes Gawande recounts are expertly threaded into a congruent story of how to become ‘better’ at igniting change and inspiring others to do so too. Admirably, he does not restrain from giving a clear stance on controversial topics, eliciting a sense of trust in the reader. It makes the journey through his book personally reflective and leaves us convinced to better ourselves in our own lives.

As a first-year Master’s student, I have experienced the challenges of being a novice in my research field, while also trying to become a positive deviant in my own right. As such, some of Gawande’s final words resonated deeply with me: “Arriving at meaningful solutions is an inevitably slow and difficult process. Nonetheless […], 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.”

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