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