Better: A Surgeon’s Notes on Performance by Atul Gawande

Short summary: I loved this book. I’ve read it end-to-end twice, and dipped back into specific sections a few times since. While the book is written by a surgeon, and naturally focuses on medical situations, he does so in a style that is totally readable by everyone, and on topics that I think are important to everyone, not just other surgeons. To give you an flavor of the book, here’s two quick points that really resonated with me personally.

The opening chapter gives a great description of all his non-medical preparations for a specific surgery case of a patient of his; describing all his dealing with hospital administrators, the patient, nurses, other doctors in the hours required to plan the surgery, and the unforeseen circumstances which change those plans without warning. All this is before he finally gets to do what he trained to do – pick up a knife to start cutting.

This hit a chord with me, because I find it interesting how much it also applied to other fields. Software development is often portrayed as people sitting at desks typing source code, and thats it. Much like surgery is portrayed as a solitary surgeon with a knife. Or a live concert by U2 is portrayed as the four band members who get on stage. The amount of behind-the-scenes work in each of these fields is colossal, and coordinating all those people is a seriously complex task in itself. Throughout the book he outlines work that people are doing to improving existing complex large-group processes. People who were, literally, “making things better”. I found it all very inspirational.

Later in the book, he described a logistical situation in Karnataka, India, reacting to a confirmed case of Polio. To stop this one case becoming a Polio epidemic, the World Health Organization did a vaccination program in the area. Sounds boring and routine. Aid agencies have been doing vaccination programs for years, it should routine, right?The numbers quoted from Brian Wheeler, Chief Operations Officer for WHO’s polio program, just blew my mind.

They had to vaccinate every child under 5 years of age in an area of 50,000 square miles centered around that single Polio case. Anything less then 90% coverage of the target population – the percentage needed to shut down transmission enough to stop the spread – would be a failure. To do this, they needed to hiring and train 37,000 vaccinators, 4000 health care supervisors, rent 2000 vehicles, supply 18,000+ insulated vaccine carriers, get everyone to the actual location in rural India and have the workers go door to door to vaccinate 4.2 million children.

In three days.

And they didn’t have much advance notice either – from the first confirmed report of Polio to people on the ground, starting the Polio vaccination program was only 32 days.

How do you make all that more efficient for future outbreaks? Everything from rapid escalation processes, so WHO gets involved sooner,  to dealing with cultural/social/educations issues. And they’re still figuring it out.

Try to read a few pages; I suspect you just wont be able to put it down. Thats what happened to me with both of his books so far. His previous book “Complications” was great, and this new book was as good, or maybe even… better?

The Baby Owners Manual

Bought this book again recently, and thought it was finally time to post a review of it.

I first found this in a bookshop years ago, just when some engineer friends of mine had their first baby, so I bought it as an impulse joke gift for them. It was easy to read, informative, and entertaining. I’m an engineer, with no prior baby experience, as were my two newly-parented friends; obviously the author’s target audience.

The book itself was written by father-and-son combination (a doctor and a parent) in the style of a computer manual – you know… the manual you never read… the manual which comes with your new PC… full of simplified diagrams, with bubbles and arrows, showing you how to plug in the printer? and troubleshooting techniques if the mouse doesnt work?… well, this book is exactly that, except its all about how to pickup a baby, burp a baby, change a baby’s diaper (different instructions for boy and girl!), wrap a baby, simple medical issues, while sending you to your nearest Baby Service Provider for more complex problems.

They smiled politely when I gave them the book, but you could tell they thought I was a little nuts.

Weeks later, they each pulled me aside and confided that they learnt lots from the book, loved it and were busy recommending it to other parents. It had become their first book to reach for, exactly because of its quick-troubleshooting design, and they learnt lots of practical tips just browsing through. Wow, funny and really useful. That settled it. Over the years, its become a kinda tradition now for me to buy it for any engineer friends who are having their first baby. So, Monday night, I delivered a copy of this book, along with some other gifts to a proud new parent at Mozilla. At this point, I’ve bought maybe a dozen copies, mostly through amazon, so who knows what that is doing to my own Amazon.com account profile! 🙂

The publishers must think its successful, because they have recently started a series of books in a similar vein: The Dog Owner’s Manual, The Cat Owner’s Manual, The Toddler Owner’s Manual, The Home Owner’s Manual, etc…

The Tipping Point by Malcolm Gladwell

It felt to me like he was covering a bunch of different topics, or short essays, all in the same book. Some resonated with me much more then others. In particular, these two:

Chapter1: Epidemics:
To me, I always thought of epidemics in the medical sense, flu outbreaks, avian flu, etc. However, I was fascinated by how the same study of epidemics could be applied to other completely unrelated fields. Human fashion. Graffiti. Litter. Teenage smoking. One example he detailed was a gonorrhea outbreak in Colorado Springs, Colorado (population 100,000+), which tipped over from statistically insignificant background noise, to epidemic, because of the activity of 168 people in 6 local bars in 4 small neighborhoods of the town. A statically insignificant small group of people. Another epidemic example he detailed was how “The Broken Window Theory” was applied to the New York City subway, dealing with graffiti, and fare-evaders. I particularly like the two cultural insights behind how they dealt with fare-evaders.

The first culture changes was with the cops. Seem the cops preferred to chase bigger fish, instead of wasting the afternoon doing paperwork on one trivial misdemeanor fare-evader arrest. However, a few simple ideas changed things dramatically. Instead of doing onesy-twosy arrests, they had 10+ plain clothes cops handcuff fare evaders to each other on the platform like a large daisy chain, and then only come up from the subway station with a “full” daisy chain. Instead of driving each suspect through traffic to the police station, they converted a bus into a mobile police station so that paperwork, fingerprints, background checks could done on site without a slow trip to the police station. Instead of just fining someone for fare-evading, and letting them go, they always ran a full background criminal check on each fare evader – and found something interesting: 1 out of 7 fare-evaders had outstanding arrest warrants; 1 out of 20 had illegal weapons. Suddenly, the cops on the street felt it was not “just a fare-evader”… now a daisy-chain of 20 fare-evaders was a really interesting surprise bonanza box, and the easiest way in the world to catch “real” bad guys.

The second cultural change was with the subway riders. Seems that the general public attitude had deteriorated to “why should I pay, if everyone else is evading”. Even people who would not normally break the rules, who would never consider themselves as criminals, were avoiding paying fares “because everyone else did it too”. However, the daisy-chain of handcuffed fare-evaders was a clearly visible deterrent, a reminder of what the rules were, and how society expected people to behave. Quickly, the number of people trying to fare-evade dropped. Which meant more people paid. It also created the perception of the subway being safer, so more people felt safe to choose to travel on subway. So even more people paid. All this meant they had more money to fix other problems, like old rolling stock, tracks, ticketing systems, etc.
Of course, the NYC subway is not perfect, then and now. However, a handful of small, carefully chosen physical changes, triggered a couple of critical cultural changes, which turned around a problem that had previously been almost given up for lost. I realized its really easy to trick yourself into thinking that a big reward requires a big effort project, and then with those mental blinkers on, only allow yourself to consider big ticket items. “How little things can make a big difference” is a really good subtitle for this book.

Chapter 5: Human group size:
Gladwell contends that human groups, and intra-group human loyalties, only scale up to about 150 people. His suggests its a function of the limits of the human brain to handle all the combinations of relationships between everyone in the group. For groups under 150 people, the inter-personal relationships, friendships, peer pressure, of everyone knowing each other tends to keep people focused and working together towards a common group goal. However, groups that grow over 150 quickly lose internal cohesion, internal focus, because they are just too big for everyone to really know everyone else. Once that cohesion breaks down, people instead start forming smaller subgroups, trusting their own subgroup, questioning motives of those other subgroups, and focusing on their own personal agendas. In a Western-business culture setting, it would be called internal-company-rivalry.

I once worked in a company as it grew from 42people to 180people, and experienced that change of internal cohesion myself. At the time, I just knew “things had changed”, but only later, looking back, I figured out it was to do with how many people were in the company, and not feeling like we were all working together anymore. Personally, I’d always thought the change from “we tight knit small band of brothers in a small company” to “I’m just a nameless cog in a faceless bureaucracy” started to happen somewhere around 100 people, but that was just a gut guess. However, Gladwell shows examples of hunter gatherer tribes, ranging from Australia to Greenland, all averaging just under 150 people per village. The Hutterites (a religion similar roots to the Amish) have a strict policy that once a community approaches 150 people, its splits into two equal separate communities. In business, the same principle is followed by Gore Associates (the manufacturer of GoreTex)… and they believe that contributes to why they have employee turnover 1/3 of the industry average, are profitable for 35 years in a row (and counting), and are constantly successfully innovating new products and markets… all without formal management structures. In groups under 150, he suggests that “personal loyalties and direct man-to-man contacts” keep everyone focused on doing the right thing for the organisation.

There’s quite a lot of the book given to describing Mavens, Connectors and Salesmen. I’m still thinking that part over, not convinced yet.

Would I recommend this book? Yes, especially these two chapters.