How do we heal medicine Atul Gawande

i got my start

in writing and research as a surgical

trainee

as someone who was a long ways away from

becoming any kind of an expert at

anything so the natural question you ask

then at that point

is how do i get good at what i’m trying

to do and it became a question of

how do we all get good at what we’re

trying to do

it’s hard enough to learn to get the

skills

try to learn all the material you have

to absorb at

any task you’re taking on i had to think

about how i

sew and how i cut but then also how i

pick the right person to come to an

operating room

and then in the midst of all this came

this new context for thinking about

what it meant to be good in the last few

years we realized we’re in the deepest

crisis

of medicine’s existence due to something

you don’t normally think about

when you’re a doctor concerned with how

you do good for people

which is the cost of health care

there’s not a country in the world that

now is not asking

whether we can afford what doctors do

the political fight that we’ve developed

has become one around

whether it’s the government that’s the

problem or is it

insurance companies that are the problem

and the answer is yes

and no it’s deeper than all of that the

cause of our troubles is actually

the complexity that science has given us

in order to understand

this i’m going to take you back a couple

of generations

i want to take you back to a time when

louis thomas was writing in his book

the youngest science lewis thomas was a

physician writer one of my one of my

favorite writers

and he wrote this book to explain among

other things what it was like

to be a medical intern at the boston

city hospital

in the pre-penicillin year of 1937.

it was a time when medicine was cheap

and very ineffective

if you were in a hospital he said it was

going to do you good only because it

offered you

some warmth some food

shelter and maybe the caring attention

of a nurse doctors and medicine

made no difference at all that didn’t

seem to prevent the doctors from being

frantically

busy in their days as he explained what

they were trying to do

was figure out whether you might have

one of the diagnoses for which they

could do something

and there were a few you might have a

low bar pneumonia for example

and they could give you an anti-serum an

injection

of rabid antibodies to the bacterium

streptococcus

if the intern subtyped it correctly

if you had an acute congestive heart

failure

they could bleed a pint of blood from

you by opening up an arm vein

giving you a crude leaf preparation of

digitalis

and then giving you oxygen by tent

if you had early signs of paralysis and

you were really good at asking personal

questions you might figure out that

this paralysis someone has is from

syphilis

in which case you could give this nice

concoction of

mercury and arsenic

as long as you didn’t overdose them and

kill them

beyond these sorts of things a medical

doctor didn’t have a lot that they could

do

this was when the core structure of

medicine was created what

what it meant to be good at what we did

and and how we wanted to build medicine

to be it was

at a time when what was known you could

know

you could hold it all in your head and

you could do it all if you had a

prescription pad

if you had a nurse if you had a hospital

that would give you a place to

convalesce maybe some basic tools you

really could do it all

you set the fracture you drew the blood

you spun the blood and looked at it

under the microscope you plated the

culture you

injected the anti-serum this was

a life as a craftsman

as a result we built it around

a culture and set of values that said

what you were good at

was being daring at being

courageous at being independent

and self-sufficient autonomy

was our highest value

go a couple generations forward to where

we are though

and it looks like a completely different

world we have now

found treatments for nearly all of the

tens of thousands of conditions

that a human being can have we can’t

cure it all

we can’t guarantee that everybody will

live a long and healthy life

but we can make it possible for most

but what does it take well we’ve now

discovered 4 000 medical and surgical

procedures

we’ve discovered 6 000 drugs that i’m

now licensed to prescribe

and we’re trying to deploy this

capability town by town

to every person alive

in our own country let alone around the

world

and we’ve reached the point where we’ve

realized as doctors

we can’t know it all we can’t

do it all by ourselves

there was a study where they looked at

how many clinicians it took to take

care of you if you came into a hospital

as it changed over time

and in the year 1970 it took just over

two full-time equivalents

of clinicians that is to say it took

basically

the nursing time and then just a little

bit of time for a doctor who more or

less checked in on you

once a day by the end of the 20th

century

it had become more than 15 clinicians

for the same typical hospital patient

specialists physical therapists

the nurses we’re all specialists now

even the primary care physicians

everyone just has a piece

of the care but holding on to that

structure we built around the

daring independence self-sufficiency

of each of those people has become a

disaster

we have trained hired and rewarded

people

to be cowboys but it’s

pit crews that we need pit crews

for patients there’s evidence all around

us

forty percent of our coronary artery

disease patients in our communities

receive incomplete or inappropriate care

sixty percent of our asthma

stroke patients receive incomplete or

inappropriate care

two million people come into hospitals

and pick

up an infection they didn’t have

because someone failed to follow the

basic practices of hygiene

our experience as people who

get sick need help from other people is

that we have

amazing clinicians that we can turn to

hard working

incredibly well trained very smart that

we have access to

incredible technologies that give us

great hope

the little sense that it consistently

all comes together for you from start

to finish in a successful way

there’s another sign that we need pit

crews

and that’s the unmanageable cost

of our care now we in medicine i think

are baffled by this question of cost we

want to say

this is just the way it is this is just

what

medicine requires when you go from a

world where you treated arthritis

with aspirin that mostly didn’t

do the job to one where if it gets bad

enough we can do a hip replacement a

knee replacement

that gives you years maybe decades

without disability a dramatic change

well

is it any surprise that that forty

thousand dollar hip replacement

replacing that the ten cent aspirin is

is more expensive it’s just the way it

is but i think we’re ignoring certain

facts that tell us something

about what we can do

as we’ve looked at the data about the

results

that have come as the complexity of

increased we found

that the most expensive care

is not necessarily the best care and

vice versa

the best care often turns out to be the

least

expensive it has fewer complications

the people get more efficient at what

they do

and what that means is there’s hope

because to have the best results you

really needed

the most expensive care in the country

or in the world

well then we really would be talking

about rationing

who we’re going to cut off a medicare

that would be really our only choice

but when we look at the positive

deviants the ones who are

getting the best results at the lowest

costs

we find the ones that look most like

systems are the most

successful that is to say they found

ways to get

all of the different pieces all of the

different components

to come together into a hole

having great components is not enough

and yet we’ve been

been obsessed in medicine with

components we want the best drugs

the best technologies the best

specialists

but we don’t think too much about how

it all comes together it’s a terrible

design strategy actually

if you well there’s a famous thought

experiment that touches exactly on this

they said what if you built a car from

the very best

car parts well it would lead you to put

in porsche brakes a ferrari engine a

volvo body

a bmw chassis and you put it all

together and what do you get

a very expensive pile of junk that does

not go anywhere

and that is what medicine can feel like

sometimes it’s not a system

now a system however when things start

to come together

you realize it has certain skills for

acting and looking that way

skill number one is the ability to

recognize success and the ability to

recognize

failure when you are a specialist you

can’t see

the end result very well you have to

become really interested

in data unsexy as that sounds

one of my colleagues is a surgeon in

cedar rapids iowa and he got interested

in

the question of well how many ct scans

did they do for their community

in cedar rapids he got interested in

this because there had been

government reports newspaper reports a

journal article saying that there had

been

too many ct scans done we didn’t see it

in his own patients and so he asked the

question how many did we do and he

wanted to get the data it took him three

months no one had asked this question

in his community before and what he

found was that for the

300 000 people in their community in the

previous year they had done

52 000 ct scans

they had found a problem

which brings us to skill number two

a system has skill one find

whether where your failures are skill

two is devise

solutions i get interested in this when

the world

health organization came to my team

asking if we could help with a project

to reduce

deaths in surgery the volume of surgery

had spread around the world

but the safety of surgery had not

now our usual tactics for tackling

problems like these are

to do more training give people more

specialization

or bring in more technology well in

surgery you couldn’t have people who are

more specialized and you couldn’t have

people who are better trained

and yet we see unconscionable levels

of death disability

that could be avoided and so we looked

at what other high-risk industries

do we looked at skyscraper construction

we looked at the aviation

world and we found that they have

technology they have training and then

they have one other thing

they have checklists

i did not expect to be spending a

significant part of my

time as a harvard surgeon worrying about

checklists

and yet what we found were that

these were tools to help make

experts better we got the lead

safety engineer for boeing to help us

could we design a checklist

for surgery not for the lowest people on

the total bull but for

the folks who were all the way around

the chain the entire team

including the surgeons and what they

taught us was that

designing a checklist to help people

handle complexity actually

involves more difficulty than i’d

understood you have to think about

things like

pause points you need to identify the

moments in a process

when you can actually catch a problem

before it’s a danger

and do something about it you have to

identify that this is a before

takeoff checklist and then you need to

focus on the killer items an aviation

checklist like this

one for a single engine plane isn’t a

recipe for how to fly a plane

it’s a reminder of the key things that

get forgotten

or missed if they’re not checked

so we did this we created a 19 item two

minute

checklist for surgical teams we had the

pause points

immediately before anesthesia is given

immediately before

the knife hits the skin immediately

before the patient leaves the room

and we had a mix of dumb stuff on there

making sure an antibiotic

is given in the right time frame because

that cuts the infection rate by half

and then interesting stuff because you

can’t make a recipe for something as

complicated as surgery

instead you can make a recipe for how to

have a team that’s prepared for the

unexpected

and we had items like making sure

everyone in the room had introduced

themselves by name at the start of the

day

because you have half a dozen people or

more who are sometimes coming together

as a team

for the very first time that day that

you’re coming in

we implemented this checklist in eight

hospitals around the world

deliberately in places from rural

tanzania to the university of washington

in seattle we found that after they

adopted it

the the complication rates fell 35

percent

it fell in every hospital it went into

the death rates fell 47 percent

this was bigger than a drug

and that brings us to skill number three

the ability to implement this to get

colleagues across the entire chain

to actually do these things

and it’s been slow to spread this is not

yet

our norm in surgery let alone making

checklists to go on to

childbirth and other areas there’s a

deep resistance

because using these tools forces

us to confront that we’re not a system

forces

us to behave with a different set of

values just

using a checklist requires you to

embrace different values from ones we’ve

had like

humility

discipline teamwork

this is the opposite of what we were

built on independence

self-sufficiency autonomy

i met an actual cowboy by the way

i asked him what was it like to actually

you know

herd a thousand cattle across hundreds

of miles how did you do that

and he said we have the cowboys

stationed at

distinct places all around they

communicate electronically constantly

and they have protocols and checklists

for

how they handle everything from

bad weather to emergencies or

inoculations for the cattle

even the cowboys are pit crews now

and it seemed like time that we become

that way ourselves

making systems work is the great task

of my generation of physicians and

scientists

but i would go further and say that

making systems work whether in health

care

education climate change

making a pathway out of poverty is the

great task of our generation as a whole

in every field knowledge has exploded

but it has brought complexity it has

brought specialization

and we’ve come to a place where we have

no choice but to recognize

as individualistic as we want to be

complexity requires group success

we all need to be pit crews now

thank you

you