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Practice made perfect

A doctor explores the ingenuity and discipline involved in improving medical care

Better: A Surgeon's Notes on Performance
By Atul Gawande
Metropolitan , 273 pp., $24

From our first encounter, we -- the ailing public -- expect physicians to be poised between empathic concern and dispassionate acuity: to care enough to go the extra mile, and to see well enough to grasp its terrain. Whether these expectations come from our pop-culture mythologizing of the profession or the vulnerability that attends ill health, the fact is that we, and they, have set the standard of engagement inhumanly high. Wanting our doctors to be warrior-gods generally discourages the archetype from dropping a scalpel, misreading an X-ray, or having a lousy day. When such fallibility presents itself, the audience's outrage can only correspond to its prior glorification.

Atul Gawande, a surgeon whose essays about medicine and humanity have graced The New Yorker for the past several years, consistently manages to dodge this dichotomy with his candor and humility. His first book, "Complications: A Surgeon's Notes on an Imperfect Science," explored the paradigm of medical training as an elaborate choreography among art, science, chance, and human error. A general and endocrine surgeon at Brigham and Women's Hospital in Boston, he writes medical sociology from the front lines, looking beyond the specifics of his trade to consider global and systemic dilemmas. What does it mean that soldiers are dying less often but suffering in greater numbers? How can attention to cultural norms help effect the largest polio mop-up in history? Mostly, and repeatedly, the question Gawande poses at the heart of each of his essays is deceptively straightforward and can-do : How do we get it right, or barring that, just an iota better?

Because one iota, when it comes to the bean counters of mortality, is a whole lot of living. And Gawande is not afraid to eschew showboat subjects (thrill-a-minute stories from the O R , second-chance surgical saves) for the blander territory of seminal change: Wash your hands. Leaflet the world to get annual mammograms. Give soldiers equipment they're likely to wear. Some of the most dramatic stories in medical history have such mundane instruction at their core -- the rise of the public health movement in response to cholera and yellow fever in the industrial world, the 1918 influenza pandemic and its effect on the First World War. After some of the heart-stopping stories of "Complications," Gawande has done the braver thing here by tackling quieter themes. And inside these seemingly workaday solutions are tales with heroic protagonists and stunning consequences.

None was more surprising to me than the exploration of what happens when you pay attention to what's going well and what isn't, and then quantify the results . In obstetrics, this workaday attitude belonged to a doctor named Virginia Apgar , a tall tomboy who was one of Columbia's first female surgical residents in the 1930s. Apgar went on to become an anesthesiologist, noticing time and again that struggling newborns -- the ones who weren't thriving -- were given up on too soon. So she devised a scorecard: points for crying, for heart rate, for pinking up or moving all four limbs. The Apgar score was conceived in 1953, and its existence -- a way to tally the first crucial moments after delivery -- altered the face of modern childbirth, anticipating the rise of neonatal intensive care units as well as changes in prenatal care and the delivery room. An unstoppable woman who routinely carried a scalpel and a piece of tubing in her purse, Apgar had the optimism and good sense to organize and standardize the data of hope. Her contribution, unlike her results, was incalculable.

Throughout "Better," Gawande addresses the ethical and philosophical questions of medicine's role toward the common good. "The Doctors of the Death Chamber" concerns the physicians and nurses who agree, with whatever personal qualms, to attend to the prisoners receiving lethal injection. Their stance on the death penalty is less relevant, Gawande convinces us, than society's obligation to uphold the moral center of medicine -- to separate the hand of healing from the hand of punishment . His description of the valiant on-the-fly medicine practiced in rural India is no less daunting and provocative. Gawande tells one story of an 80-year-old man who, though he could barely walk, traveled 20 miles to the hospital; he was then sent out in search of sterile gloves from a street vendor. And each of these stories doubtless speaks for 10,000 more .

It is easy, in the high-gloss, sometimes thrilling world of modern medicine, to pay attention to the cowboys and the quarterbacks. Gawande is unassuming in every way, and yet his prose is infused with steadfast determination and hope. If society is the patient here, I can't think of a better guy to have our back.

Gail Caldwell is chief book critic of the Globe. She can be reached at caldwell@globe.com.

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