Atul Gawande

In the end, people don't view their life as merely the average of all its moments__hich, after all, is mostly nothing much plus some sleep. For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by the significant moments, the ones where something happens. Measurements of people's minute-by-minute levels of pleasure and pain miss this fundamental aspect of human existence. A seemingly happy life maybe empty. A seemingly difficult life may be devoted to a great cause. We have purposes larger than ourselves.

People seemed to have two different selves__n experiencing self who endures every moment equally and a remembering self who gives almost all the weight of judgment afterward to two single points in time, the worst moment and the last one. The remembering self seems to stick to the Peak-End rule even when the ending is an anomaly. Just a few minutes without pain at the end of their medical procedure dramatically reduced patients_ overall pain ratings even after they__ experienced more than half an hour of high level of pain. __hat wasn__ so terrible,_ they__ reported afterward. A bad ending skewed the pain scores upward just as dramatically.

Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is. And if we recognised the opportunity, the two-minute WHO checklist is just a start.

No matter what measures are taken, doctors will sometimes falter, and it isn't reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.

Most people are squeamish about saying how much they earn, but in medicine the situation seems especially fraught. Doctors aren't supposed to be in it for the money, and the more concerned a doctor seems to be about making money the more suspicious people become about the care being provided.

Cost is the spectre haunting health reform. For many decades, the great flaw in the American health-care system was its unconscionable gaps in coverage.

Oliver Sacks remains my hero to this day. He was one of the first medical writers I read. The other was Lewis Thomas, who is no longer alive but is just heroic to me.

No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it. You must consider what is covered for a patient and what is not.

Every country in the world is battling the rising cost of health care. No community anywhere has demonstrably lowered its health-care costs (not just slowed their rate of increase) by improving medical services. They've lowered costs only by cutting or rationing them.

People say that the most expensive piece of medical equipment is the doctor's pen. It's not that we make all the money. It's that we order all the money.

The history of American agriculture suggests that you can have transformation without a master plan, without knowing all the answers up front.

Our health-care morass is like the problems of global warming and the national debt - the kind of vast policy failure that is far easier to get into than to get out of. Americans say that they want leaders who will take on these problems.

Health care confronts us with a difficult test. We have never corrected failure in something so deeply embedded in people's lives and in the economy without the pressure of an outright crisis.

There is a saying about surgeons, meant as a reproof: "Sometimes wrong; never in doubt." But this seemed to me their strength. Each day surgeons are faced with uncertainties. Information is inadequate; the science is ambiguous; one's knowledge and abilities are never perfect. Even with the simplest operation, it cannot be taken for granted that a patient will come through better off - or even alive. Standing at the table my first time, I wondered how the surgeon knew that he would do this patient good, that all the steps would go as planned, that the bleeding would be controlled and infection would not take hold and organs would not be injured. He didn't, of course. But still he cut.

Are doctors who make mistakes villains? No, because then we all are.

The core predicament of medicine - the thing that makes being a patient so wrenching, being a doctor so difficult, and being a part of society that pays the bills they run up so vexing - is uncertainty. With all that we know nowadays about people and diseases and how to diagnose and treat them, it can be hard to see this, hard to grasp how deeply uncertainty runs. As a doctor, you come to find, however, that the struggle in caring for people is more often with what you do not know than what you do. Medicine's ground state is uncertainty. And wisdom - for both the patients and doctors - is defined by how one copes with it.

If there is a credo in practical medicine, it is that the important thing is to be sensible.

We want progress in medicine to be clear and unequivocal, but of course it rarely is. Every new treatment has gaping unknowns - for both patients and society - and it can be hard to decide what do do about them.