Thanks to Steve Freeman for a great pair of book recommendations - Atul Gawande’s Complications (A Surgeon’s Notes on an Imperfect Science) and Better (A Surgeon’s Notes on Performance).

Keen observation, great writing, and a mine of great stories about individuals and groups working in a field of particular “risk and consequence”, as Gawande memorably puts it.

The second book, Better, has some important lessons for anyone involved in an activity in which individual and group performance is critical. Gawande identifies three critical areas - Diligence, Doing Right and Ingenuity, going on to illustrate all three with anecdotes, stories, and experiences across a range of medical practice - immunising 4.2 million children against Polio in three days in rural India, treating battlefield casualties in Iraq and Afghanistan, the ethics of medical examinations, malpractice suits, and medical staff assisting in executions, reasons for the significant differences in outcome between the average and the best (even when all are following “standard” practice).

This last point bears some thinking about. The treatment of Cystic Fibrosis (CF) has improved immensely since a set of practices pioneered in the 1950s and 60s have become commonplace - the average life expectancy of sufferers rising from three years in 1957 to 33 in 2003. Yet the best one or two treatment centres - following what appeared to be the same practices - consistently exceeded this average - by up to 50%. We want the bell-curve for such patterns to be skewed to the high end, but it remains obstinately un-skewed: the negative deviants are - thankfully - rare, but the positive deviants are correspondingly thin on the ground.

Why should this be? As Gawande says

Patients with CF at Fairview got the same things that patients everywhere got… Yet somehow, everything [Warren] Warwick [director of the Fairview clinic] did was different.

The conversation between Warwick and a young patient whose lung function stats had dipped is a model of humane concern and effective intervention: it’s a long extract, excerpted here, along with audio of Gawande reading from other parts of Better.

Gawande finishes with his own five recommendations on becoming a Positive Deviant (Gawande’s points, my glosses):

Ask an unscripted question
Goes beyond standard procedure - this provides context, and opens channels for delivery and reception of weak signals.

Don’t Complain
Moaning about things - either to yourself or with others - serves no useful purpose. It saps energy and makes everyone feel worse. Don’t do it!

Measure something
Finding something you care about enough to want to track. Formalise your curiosity (if you don’t, you won’t have any context for action)

Write something
Documenting your observations - in however simple a form - is a way of making a contribution. You’ll need to reflect and develop a level of thoughtfulness that you wouldn’t otherwise have done.

Change
Be passionate about using what you have learned to change what you do and how you do it.

Risk and consequence, though dramatically highlighted in medicine, are characteristic of any worthwhile venture. Diligence, ingenuity, doing right - these are touchstones of mindful practice in any discipline.