Atul Gawande Writing Style

Atul Gawande writes medical nonfiction in the first person, and the doctor telling the story is often the one who got it wrong. His first book, Complications, collects essays about surgery, and two of its best-known passages are about him: a central line he cannot get into a vein, and an emergency tracheotomy that goes badly and nearly kills the patient on the table. He was a surgical resident at the time. He published it under his own name.

The admission buys the authority he spends later. A reader who has watched a writer be the incompetent one in his own scene extends that writer a credit an unbroken record cannot earn, because an unbroken record has no way of showing what its author does with a bad outcome. Gawande draws on that credit deliberately. By the time The Checklist Manifesto asks operating rooms to change how they behave, the reader has already seen the author fail at the thing he is now legislating.

Being Mortal argues that medicine handles the end of a life badly, offering procedures where it should be asking a person what the remaining time is for. Partway through the writing, Gawande's father, himself a doctor, falls ill. The book does not step outside itself at that point. The son who has been telling other families how the conversation should go has to have it about his own father, and the thesis acquires a defendant who happens to be the author.

Take the sequence from him and leave the calm alone. Find the place in your own work where you were wrong, write it at the length it actually took, and put it in front of the paragraph where you tell somebody else what to do.

The case that came out all right

He tends to choose failures where the patient survived. The tracheotomy in Complications comes close to killing the patient on the table and does not, and that outcome is what makes the passage usable, because a reader who is not being asked to grieve is free to examine the error. Grief closes an argument down. A death in the second paragraph makes any analysis that follows look cold. It also hands the writer a solemnity the reader cannot argue with. The near miss keeps the sequence available for study while still costing something real. Sort your own record for the ones that almost went wrong.

The confession placed before the claim it pays for

Look at where the admissions sit relative to the recommendations, because the distance is deliberate. Complications establishes his fallibility early and draws on it through everything that follows. Inside a single essay the order holds too: the thing that went wrong is reported early, the argument about what should change arrives after it, and the reader has therefore settled the question of the writer's honesty before being asked to agree with him. Reverse the order and the piece becomes a lecture with an apology stapled to the end, which reads as insurance. Sequence carries this, not quantity. One case in the right place outperforms a running tone of humility.

Fault kept in two places

He holds two findings that most writing about error picks between. He did it, and the room made it likely. In the airway case his hands are the ones that failed, and the essay also asks how the hospital came to have him doing that procedure at that hour. Neither claim is allowed to cancel the other. Holding both is harder than it looks. The two want to fight. Once a systems explanation is admitted, the personal admission starts to look like modesty about something that was arguably not his fault. He keeps them apart in time. The personal share is taken while the scene is still running, and the institutional share once it has stopped.

The book that puts its author in the dock

Being Mortal states a position about how the last stretch of a life should be handled, then applies the position to the author's own family while the book is being written. His father falls ill. What follows is not a case he selected. He had no control over the outcome, or over whether his own advice would hold up in practice. Few writers of nonfiction take this bet, and the reason to notice it here is mechanical rather than admiring, since a thesis that has survived contact with the author's worst year is a different object from a thesis illustrated with other people's worst years. If you try it, understand that you are committing in advance to publish the result.

The recommendation aimed first at himself

The Checklist Manifesto argues that experts under load forget steps they know perfectly well, and the first expert it establishes this about is Gawande. He is a surgeon writing a book that asks surgeons to submit to a list, a request his profession resents, and he defuses the resentment by conceding his own memory before he raises anybody else's. The checklist he ends up advocating is a device for protecting patients from him. Any argument for a constraint can be built on that footing. Name the failure the constraint is meant to catch, put yourself inside it, and the constraint stops sounding like something handed down by people who do not do the work.

The conference borrowed as a form

Surgery runs a weekly meeting called morbidity and mortality, at which a surgeon presents a case that went badly to a room of colleagues and answers their questions about it. Gawande wrote an essay about that room, and he also imported its agenda. Case, then sequence, then the question, then an argument about what would have to change: that is how the meeting proceeds and it is the shape of a great deal of his prose. Most jobs run some version of it, a post-mortem, a debrief, an incident review. If yours does, you already own a form for writing about error. The useful part is that it was designed by people who needed it to work.

The answerable first person

Watch the grammar at the point of fault. The subject is I. The verb is short and active. The object is the person or the part of the body involved. He does not write that the airway was lost or that complications developed, which is the construction his profession reaches for and the one Charles Baxter took apart in his essay Mistakes Were Made, where a sentence sheds its subject and the event ends up belonging to nobody. A single clause carries the whole admission. Everything around it can then be as measured as he likes, since the reader has already watched the writer decline an exit that was standing open.

The withheld verdict

He reports his own error without ruling on it. No sentence assigns him a grade. No paragraph considers what kind of doctor this made him. What the reader gets is the sequence, and a free hand with the verdict. Chekhov put this as a rule for fiction, that the artist has to be an impartial witness to his characters and not their judge, and Gawande applies it to a character he happens to be. The gain is that a reader who has not been told what to think tends to think it harder. The cost is a reader who decides you are cold, and that is a price he evidently accepts.

The reader placed in the same chair

Before the analysis begins, he establishes that the mistake was available to anybody standing where he stood. The information was ambiguous, the clock was running, and the other option carried its own risk. That move turns a confession into an argument, because a reader who can picture herself making the same call stops being a spectator at somebody else's failure and becomes a person with a problem. Placement decides whether it works. Put it before the failure and it reads as a plea entered in advance, so in his essays the failure comes first and at full length, and the reader is implicated afterwards.

The subtitle that lowers the claim

Two of his four books call themselves notes on the cover. Complications is A Surgeon's Notes on an Imperfect Science and Better is A Surgeon's Notes on Performance, and the word does work before a reader has opened either. Notes are provisional, taken by somebody still inside the job. The subtitle of Complications goes further and concedes the whole field, an imperfect science, printed under the title of a book by one of its practitioners. The claim on the cover is smaller than the book. Titles usually run the other way.

Confessing to something that cost you nothing

The first imitation error is a mistake chosen for how well it survives being told. It is embarrassing and not damaging. It happened long ago, the writer has visibly recovered, and the paragraph works as a credential. Gawande's cases have a person on the other side of them. The paragraph that follows carries weight. Test your candidate by writing the sentence that names who paid. If that sentence has no object in it, keep looking.

Delivering the remorse along with the facts

Writers get the incident right and then bury it under feeling. The account arrives with adjectives attached, the word terrible does work the sequence was supposed to do, and the reader spends the passage watching the writer suffer instead of watching the event. Gawande keeps the register flat where the material is worst. The reason is practical. Remorse on the page is a claim about the writer's character, and no reader can verify it from outside. A sequence of actions checks against itself. Report the minute and let the reader supply what it deserves.

Reaching for the system before you have been answerable

Institutional explanation is the most available exit in this kind of writing and the most damaging one to take early. Handoffs, understaffing, hierarchy, the length of the shift: true, relevant, and entirely capable of dissolving the writer out of his own story. What remains is a piece in which something unfortunate occurred and the prose has stopped naming who did it. Gawande earns the systems argument by being the answerable party first, which is why it does not read as a plea. Orwell does the same thing in Shooting an Elephant, where the machinery of empire is the subject and he shoots the elephant anyway, on the page, because a crowd is watching and he does not want to look a fool.

Arranging the room so the fault lands next door

A confession can be built so that the error is technically admitted and functionally somebody else's. The nurse who said nothing, the attending who was unreachable, the colleague who handed over badly: name one of them in the same breath as your own mistake and the reader will do the arithmetic you were hoping for. His rooms contain no incompetents. The people around him are tired, junior, senior, busy, reasonable. The error stays where he put it. Joan Didion opens The White Album by reproducing her own psychiatric evaluation, and the effect depends on the same discipline, since the document is about her and she spends no line on who else was having a bad decade.