The book which best expresses how I aspire to improve my teaching has nothing to do with teaching. It’s Better, by Atul Gawande – a surgeon writing about how he and his profession can improve their performance. In my brief blogging career, I have eschewed comparisons between medicine and education; too many seem hackneyed, simplistic or rhetorical. This book is so good, its message so apposite for teachers, that I shall now break this rule.
Gawande’s meditations on medical practice span time and space and range from the general to the personal in their search for insight. In examining hand washing, for example, he begins with Semmelweiss’s pioneering attempts to convince his peers that this simple measure worked, then proceeds to consider the travails of his colleagues today, whose job is to ensure medical staff implement Semmelweiss’s nineteenth-century findings. He explains the occasions when he and his peers breach these protocols and concludes by considering his own culpability for the spread of infection. In other chapters, he considers the counter-intuitive demands of battlefield medicine, the ethics of participation in execution as a doctor and the unanswerable dilemma of when to stop fighting for a patient’s survival.
The topics on which Gawande focuses are intriguing, his writing is clear and well-researched, adding to his power; I’m not sure any of this is the key to his importance however. His underlying philosophy is what makes the book so compelling. Gawande breaks great performance down into three elements: diligence, doing right and performance; I’d like to highlight three related themes which are woven through the chapters and which I believe offer a model of practice as appropriate for teachers as much as they do for doctors.
Gawande shows an impressive willingness to examine his own conduct, success and failure. Most of his chapter on hand-washing could be described as conventional, albeit beautifully written: he examines the history of hand washing, the barriers which make ideal practice more difficult than it may sound and the partially successful interventions which have increased compliance but yielded only temporary results. Gawande spends time with the infection control team in his own hospital; as he does so, he takes on their perspective, writing of doctors, supposed healers, as vectors for the transmission of disease. In concluding he returns to this prism, concentrating on his own practice:
Yokoe pointed out that three of the eight rooms had bright yellow precaution signs because of patients inside with MRSA or VRE. Only then did I realize we were on the floor of one of my own patients. One of those signs hung on his door….
“Until that moment, when I stood there looking at the sign on his door, it had not occurred to me that I might have given him that infection. But the truth is I may have. One of us certainly did.”
This ability to inspect what he does through the eyes of others acts, I believe, as a model which any teacher can adopt. Only ruthless introspection like this can reveal the limitations of our own practice, values and beliefs, and the effects they have on our work.
Actions based upon ethics
It may be easy (and reassuring) to view doctors as professionals trained to a given standard and to see medicine as a scientific and technical profession; Gawande unveils the importance of each doctor’s judgement and conscience in their work. In considering whether to introduce a chaperone to the room when examining a female patient, how much doctors should be paid or whether they should attend or even carry out executions, Gawande looks at questions for which no straightforward answer exists, which rely, instead, on doctors’ own conclusions as to what is right. When should doctors stop fighting? They may give up on a patient who could survive; they may continue treating a patient who has no hope of true recovery. The distinction is one which doctors must judge with protocols which quickly become too blurred to offer clear answers:
In the end, no guidelines can tell us what we have power over and what we don’t. In the face of uncertainty, wisdom is to err on the side of pushing, to not give up. But you have to be ready to recognize when the pushing can turn to harm.
“In a way, our task is to “Always Fight.” But our fight is not always to do more. It is to do right by our patients, even though what is right is not always clear.”
Gawande’s open, honest reflections demonstrate the importance he places on carefully weighing up questions of his actions and revisiting his mistakes in the hope of doing what is best. To me, our actions each day in school embody individual answers to a host of ethical questions, although we rarely take time to review our responses. Who we are helping (and thus, who we are ignoring) at any time is an ethical question we do not always answer well. Laura McInerney’s post on the ‘Redorgreenpen problem’ remains my favourite example of a reflection on this issue, in part because of its rarity. When we balance the time we spend in order to act as Ofsted would (we believe) wish, as parents may demand, as we might wish for ourselves and our students, we are implicitly expressing judgements as to how we believe the world should be shaped. Gawande models the consideration of his own actions and their implications in a way which I believe we would do well to emulate.
Gawande’s desire to better his own work shines through every page of the book; he writes equally insightfully as to how his whole profession can do the same. He focuses on better applying existing knowledge and best practice more thoroughly and universally as the primary means to do so. In the care for Cystic Fibrosis, for example, the American care centre with the best survival rates approaches the problem differently to most others: it finds every possible means to maintain patients’ lung function at a level which equals or even betters that of a healthy person. Pursuing this led the centre to invent a new stethoscope and a mechanised chest-thumping vest, but Gawande shows that achieving it also requires a doctor to talk through barriers to taking medication with a teenage girl for whom other priorities are getting in the way of regular treatment. This dedication to both a high absolute standard (lung function) and constant improvement in their own work has led the best centres to show dramatic progress in the survival and health of their patients. As a result, while the most successful hospitals’ methods are adopted around the country, those leading hospitals are already taking the next step beyond their existing work: a bell curve exists and remains as to performance, as those “In the top quartile are improving fastest… They are at risk of breaking away.” Another impressive example of the power of surgeons’ ingenious self-improvement comes from Gawande’s trip to India:
Among the many distressing things I saw in Nanded was the incredible numbers of patients with perforated ulcers… [The treatment] is a big and traumatic operation, and often these patients were in no condition to survive it. So Motewar did a remarkable thing. He invented a new operation: a laparoscopic repair of the ulcerous perforation, using quarter-inch incisions and taking an average of forty-five minutes….
“Motewar… had mulled over the ulcer problem off and on for years and became convinced he could devise a better treatment… And over time, Motewar carefully worked out his technique. I saw him do the operation and it was elegant and swift. He even did a randomized trial, which he presented at a conference and which revealed the operation to have fewer complications and a far more rapid recovery than the standard procedure. In that remote, dust-covered town in Maharashtra, Motewar and his colleagues had become among the most proficient ulcer surgeons in the world.”
I have long believed that most teachers are in possession of almost all they need to know about how their classroom should work. Progress, Gawande argues, comes not from awaiting research or mandates for change, but from pursuing our own principles by dedicating ourselves to relentless self-improvement and the refinement of our practice.
How can I get better?
Gawande’s afterword offers a list of actions he advocates which support us to become ‘positive deviants’ and which, I believe, apply equally to teachers:
- Ask an unscripted question
- Don’t complain
- Count something
- Write something
I can think of few better recipes for bettering myself as a teacher. I commend the book to you!