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TED2012

Atul Gawande: How do we heal medicine?

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Our medical systems are broken. Doctors are capable of extraordinary (and expensive) treatments, but they are losing their core focus: actually treating people. Doctor and writer Atul Gawande suggests we take a step back and look at new ways to do medicine -- with fewer cowboys and more pit crews.

- Surgeon and journalist
Surgeon by day and public health journalist by night, Atul Gawande explores how doctors can dramatically improve their practice using something as simple as a checklist. Full bio

I got my start
00:15
in writing and research
00:18
as a surgical trainee,
00:20
as someone who was a long ways away
00:23
from becoming any kind of an expert at anything.
00:25
So the natural question you ask then at that point
00:28
is, how do I get good at what I'm trying to do?
00:31
And it became a question of,
00:33
how do we all get good
00:35
at what we're trying to do?
00:37
It's hard enough to learn to get the skills,
00:40
try to learn all the material you have to absorb
00:44
at any task you're taking on.
00:47
I had to think about how I sew and how I cut,
00:49
but then also how I pick the right person
00:52
to come to an operating room.
00:54
And then in the midst of all this
00:56
came this new context
00:58
for thinking about what it meant to be good.
01:00
In the last few years
01:02
we realized we were in the deepest crisis
01:04
of medicine's existence
01:07
due to something you don't normally think about
01:09
when you're a doctor
01:11
concerned with how you do good for people,
01:13
which is the cost
01:16
of health care.
01:18
There's not a country in the world
01:20
that now is not asking
01:23
whether we can afford what doctors do.
01:25
The political fight that we've developed
01:28
has become one around
01:31
whether it's the government that's the problem
01:33
or is it insurance companies that are the problem.
01:36
And the answer is yes and no;
01:41
it's deeper than all of that.
01:45
The cause of our troubles
01:47
is actually the complexity that science has given us.
01:49
And in order to understand this,
01:52
I'm going to take you back a couple of generations.
01:54
I want to take you back
01:58
to a time when Lewis Thomas was writing in his book, "The Youngest Science."
02:00
Lewis Thomas was a physician-writer,
02:03
one of my favorite writers.
02:05
And he wrote this book to explain, among other things,
02:07
what it was like to be a medical intern
02:10
at the Boston City Hospital
02:13
in the pre-penicillin year
02:15
of 1937.
02:17
It was a time when medicine was cheap
02:20
and very ineffective.
02:24
If you were in a hospital, he said,
02:28
it was going to do you good
02:31
only because it offered you
02:34
some warmth, some food, shelter,
02:36
and maybe the caring attention
02:40
of a nurse.
02:42
Doctors and medicine
02:44
made no difference at all.
02:48
That didn't seem to prevent the doctors
02:50
from being frantically busy in their days,
02:52
as he explained.
02:54
What they were trying to do
02:56
was figure out whether you might have one of the diagnoses
02:58
for which they could do something.
03:01
And there were a few.
03:04
You might have a lobar pneumonia, for example,
03:06
and they could give you an antiserum,
03:09
an injection of rabid antibodies
03:11
to the bacterium streptococcus,
03:15
if the intern sub-typed it correctly.
03:18
If you had an acute congestive heart failure,
03:22
they could bleed a pint of blood from you
03:25
by opening up an arm vein,
03:28
giving you a crude leaf preparation of digitalis
03:31
and then giving you oxygen by tent.
03:34
If you had early signs of paralysis
03:39
and you were really good at asking personal questions,
03:41
you might figure out
03:44
that this paralysis someone has is from syphilis,
03:46
in which case you could give this nice concoction
03:49
of mercury and arsenic --
03:52
as long as you didn't overdose them and kill them.
03:56
Beyond these sorts of things,
04:01
a medical doctor didn't have a lot that they could do.
04:03
This was when the core structure of medicine
04:08
was created --
04:10
what it meant to be good at what we did
04:12
and how we wanted to build medicine to be.
04:15
It was at a time
04:17
when what was known you could know,
04:19
you could hold it all in your head, and you could do it all.
04:21
If you had a prescription pad,
04:24
if you had a nurse,
04:26
if you had a hospital
04:28
that would give you a place to convalesce, maybe some basic tools,
04:30
you really could do it all.
04:33
You set the fracture, you drew the blood,
04:35
you spun the blood,
04:38
looked at it under the microscope,
04:40
you plated the culture, you injected the antiserum.
04:42
This was a life as a craftsman.
04:45
As a result, we built it around
04:50
a culture and set of values
04:53
that said what you were good at
04:55
was being daring,
04:58
at being courageous,
05:00
at being independent and self-sufficient.
05:02
Autonomy was our highest value.
05:06
Go a couple generations forward
05:12
to where we are, though,
05:14
and it looks like a completely different world.
05:16
We have now found treatments
05:18
for nearly all of the tens of thousands of conditions
05:21
that a human being can have.
05:25
We can't cure it all.
05:27
We can't guarantee that everybody will live a long and healthy life.
05:29
But we can make it possible
05:32
for most.
05:34
But what does it take?
05:37
Well, we've now discovered
05:39
4,000 medical and surgical procedures.
05:41
We've discovered 6,000 drugs
05:45
that I'm now licensed to prescribe.
05:48
And we're trying to deploy this capability,
05:51
town by town,
05:53
to every person alive --
05:55
in our own country,
05:59
let alone around the world.
06:01
And we've reached the point where we've realized,
06:03
as doctors,
06:06
we can't know it all.
06:08
We can't do it all
06:10
by ourselves.
06:13
There was a study where they looked
06:15
at how many clinicians it took to take care of you
06:17
if you came into a hospital,
06:19
as it changed over time.
06:21
And in the year 1970,
06:23
it took just over two full-time equivalents of clinicians.
06:25
That is to say,
06:28
it took basically the nursing time
06:30
and then just a little bit of time for a doctor
06:33
who more or less checked in on you
06:35
once a day.
06:37
By the end of the 20th century,
06:39
it had become more than 15 clinicians
06:42
for the same typical hospital patient --
06:45
specialists, physical therapists,
06:48
the nurses.
06:51
We're all specialists now,
06:54
even the primary care physicians.
06:56
Everyone just has
06:58
a piece of the care.
07:00
But holding onto that structure we built
07:03
around the daring, independence,
07:05
self-sufficiency
07:07
of each of those people
07:09
has become a disaster.
07:12
We have trained, hired and rewarded people
07:14
to be cowboys.
07:18
But it's pit crews that we need,
07:21
pit crews for patients.
07:24
There's evidence all around us:
07:26
40 percent of our coronary artery disease patients
07:28
in our communities
07:31
receive incomplete or inappropriate care.
07:33
60 percent
07:37
of our asthma, stroke patients
07:39
receive incomplete or inappropriate care.
07:42
Two million people come into hospitals
07:46
and pick up an infection
07:49
they didn't have
07:51
because someone failed to follow
07:53
the basic practices of hygiene.
07:56
Our experience
07:59
as people who get sick,
08:01
need help from other people,
08:03
is that we have amazing clinicians
08:05
that we can turn to --
08:08
hardworking, incredibly well-trained and very smart --
08:10
that we have access to incredible technologies
08:13
that give us great hope,
08:16
but little sense
08:18
that it consistently all comes together for you
08:20
from start to finish
08:24
in a successful way.
08:27
There's another sign
08:30
that we need pit crews,
08:32
and that's the unmanageable cost
08:34
of our care.
08:37
Now we in medicine, I think,
08:40
are baffled by this question of cost.
08:42
We want to say, "This is just the way it is.
08:44
This is just what medicine requires."
08:48
When you go from a world
08:50
where you treated arthritis with aspirin,
08:52
that mostly didn't do the job,
08:55
to one where, if it gets bad enough,
08:58
we can do a hip replacement, a knee replacement
09:00
that gives you years, maybe decades,
09:02
without disability,
09:05
a dramatic change,
09:07
well is it any surprise
09:09
that that $40,000 hip replacement
09:11
replacing the 10-cent aspirin
09:14
is more expensive?
09:16
It's just the way it is.
09:18
But I think we're ignoring certain facts
09:21
that tell us something about what we can do.
09:23
As we've looked at the data
09:28
about the results that have come
09:30
as the complexity has increased,
09:33
we found
09:35
that the most expensive care
09:37
is not necessarily the best care.
09:39
And vice versa,
09:42
the best care
09:44
often turns out to be the least expensive --
09:46
has fewer complications,
09:49
the people get more efficient at what they do.
09:52
And what that means
09:55
is there's hope.
09:57
Because [if] to have the best results,
10:00
you really needed the most expensive care
10:03
in the country, or in the world,
10:06
well then we really would be talking about rationing
10:08
who we're going to cut off from Medicare.
10:11
That would be really our only choice.
10:15
But when we look at the positive deviants --
10:19
the ones who are getting the best results
10:21
at the lowest costs --
10:24
we find the ones that look the most like systems
10:26
are the most successful.
10:29
That is to say, they found ways
10:31
to get all of the different pieces,
10:34
all of the different components,
10:36
to come together into a whole.
10:38
Having great components is not enough,
10:41
and yet we've been obsessed in medicine with components.
10:44
We want the best drugs, the best technologies,
10:48
the best specialists,
10:51
but we don't think too much
10:54
about how it all comes together.
10:56
It's a terrible design strategy actually.
10:59
There's a famous thought experiment
11:03
that touches exactly on this
11:06
that said, what if you built a car
11:08
from the very best car parts?
11:10
Well it would lead you to put in Porsche brakes,
11:13
a Ferrari engine,
11:16
a Volvo body, a BMW chassis.
11:18
And you put it all together and what do you get?
11:21
A very expensive pile of junk that does not go anywhere.
11:24
And that is what medicine can feel like sometimes.
11:28
It's not a system.
11:33
Now a system, however,
11:36
when things start to come together,
11:38
you realize it has certain skills
11:41
for acting and looking that way.
11:44
Skill number one
11:47
is the ability to recognize success
11:49
and the ability to recognize failure.
11:51
When you are a specialist,
11:54
you can't see the end result very well.
11:56
You have to become really interested in data,
11:59
unsexy as that sounds.
12:02
One of my colleagues is a surgeon in Cedar Rapids, Iowa,
12:04
and he got interested in the question of,
12:07
well how many CT scans did they do
12:11
for their community in Cedar Rapids?
12:13
He got interested in this
12:15
because there had been government reports,
12:17
newspaper reports, journal articles
12:19
saying that there had been too many CT scans done.
12:21
He didn't see it in his own patients.
12:24
And so he asked the question, "How many did we do?"
12:28
and he wanted to get the data.
12:30
It took him three months.
12:32
No one had asked this question in his community before.
12:34
And what he found was that,
12:37
for the 300,000 people in their community,
12:39
in the previous year
12:41
they had done 52,000 CT scans.
12:43
They had found a problem.
12:48
Which brings us to skill number two a system has.
12:51
Skill one, find where your failures are.
12:56
Skill two is devise solutions.
12:59
I got interested in this
13:03
when the World Health Organization came to my team
13:05
asking if we could help with a project
13:07
to reduce deaths in surgery.
13:09
The volume of surgery had spread
13:11
around the world,
13:13
but the safety of surgery
13:15
had not.
13:17
Now our usual tactics for tackling problems like these
13:19
are to do more training,
13:22
give people more specialization
13:24
or bring in more technology.
13:27
Well in surgery, you couldn't have people who are more specialized
13:30
and you couldn't have people who are better trained.
13:33
And yet we see unconscionable levels
13:36
of death, disability
13:39
that could be avoided.
13:43
And so we looked at what other high-risk industries do.
13:45
We looked at skyscraper construction,
13:47
we looked at the aviation world,
13:49
and we found
13:52
that they have technology, they have training,
13:54
and then they have one other thing:
13:56
They have checklists.
13:59
I did not expect
14:02
to be spending a significant part
14:04
of my time as a Harvard surgeon
14:06
worrying about checklists.
14:08
And yet, what we found
14:11
were that these were tools
14:13
to help make experts better.
14:16
We got the lead safety engineer for Boeing to help us.
14:19
Could we design a checklist for surgery?
14:23
Not for the lowest people on the totem pole,
14:26
but for the folks
14:28
who were all the way around the chain,
14:30
the entire team including the surgeons.
14:32
And what they taught us
14:34
was that designing a checklist
14:36
to help people handle complexity
14:38
actually involves more difficulty than I had understood.
14:40
You have to think about things
14:43
like pause points.
14:45
You need to identify the moments in a process
14:47
when you can actually catch a problem before it's a danger
14:50
and do something about it.
14:52
You have to identify
14:54
that this is a before-takeoff checklist.
14:56
And then you need to focus on the killer items.
14:59
An aviation checklist,
15:02
like this one for a single-engine plane,
15:04
isn't a recipe for how to fly a plane,
15:06
it's a reminder of the key things
15:08
that get forgotten or missed
15:10
if they're not checked.
15:13
So we did this.
15:15
We created a 19-item two-minute checklist
15:17
for surgical teams.
15:20
We had the pause points
15:22
immediately before anesthesia is given,
15:24
immediately before the knife hits the skin,
15:27
immediately before the patient leaves the room.
15:30
And we had a mix of dumb stuff on there --
15:33
making sure an antibiotic is given in the right time frame
15:36
because that cuts the infection rate by half --
15:39
and then interesting stuff,
15:41
because you can't make a recipe for something as complicated as surgery.
15:43
Instead, you can make a recipe
15:46
for how to have a team that's prepared for the unexpected.
15:48
And we had items like making sure everyone in the room
15:51
had introduced themselves by name at the start of the day,
15:54
because you get half a dozen people or more
15:57
who are sometimes coming together as a team
15:59
for the very first time that day that you're coming in.
16:02
We implemented this checklist
16:05
in eight hospitals around the world,
16:07
deliberately in places from rural Tanzania
16:10
to the University of Washington in Seattle.
16:12
We found that after they adopted it
16:15
the complication rates fell
16:18
35 percent.
16:20
It fell in every hospital it went into.
16:22
The death rates fell
16:25
47 percent.
16:27
This was bigger than a drug.
16:30
(Applause)
16:32
And that brings us
16:38
to skill number three,
16:40
the ability to implement this,
16:43
to get colleagues across the entire chain
16:45
to actually do these things.
16:48
And it's been slow to spread.
16:51
This is not yet our norm in surgery --
16:53
let alone making checklists
16:57
to go onto childbirth and other areas.
16:59
There's a deep resistance
17:02
because using these tools
17:04
forces us to confront
17:06
that we're not a system,
17:08
forces us to behave with a different set of values.
17:10
Just using a checklist
17:13
requires you to embrace different values from the ones we've had,
17:15
like humility,
17:18
discipline,
17:22
teamwork.
17:25
This is the opposite of what we were built on:
17:27
independence, self-sufficiency,
17:30
autonomy.
17:32
I met an actual cowboy, by the way.
17:35
I asked him, what was it like
17:38
to actually herd a thousand cattle
17:41
across hundreds of miles?
17:43
How did you do that?
17:45
And he said, "We have the cowboys stationed at distinct places all around."
17:47
They communicate electronically constantly,
17:50
and they have protocols and checklists
17:53
for how they handle everything --
17:55
(Laughter)
17:57
-- from bad weather
17:59
to emergencies or inoculations for the cattle.
18:01
Even the cowboys are pit crews now.
18:04
And it seemed like time
18:08
that we become that way ourselves.
18:10
Making systems work
18:12
is the great task of my generation
18:14
of physicians and scientists.
18:17
But I would go further and say
18:19
that making systems work,
18:21
whether in health care, education,
18:23
climate change,
18:25
making a pathway out of poverty,
18:27
is the great task of our generation as a whole.
18:29
In every field, knowledge has exploded,
18:33
but it has brought complexity,
18:36
it has brought specialization.
18:38
And we've come to a place where we have no choice
18:41
but to recognize,
18:43
as individualistic as we want to be,
18:45
complexity requires
18:48
group success.
18:51
We all need to be pit crews now.
18:53
Thank you.
18:57
(Applause)
18:59

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About the Speaker:

Atul Gawande - Surgeon and journalist
Surgeon by day and public health journalist by night, Atul Gawande explores how doctors can dramatically improve their practice using something as simple as a checklist.

Why you should listen

Atul Gawande is author of three best-selling books: Complications, a memoir of surgery; Better: A Surgeon's Notes on Performance; and The Checklist Manifesto. His new book is Being Mortal: Medicine and What Matters in the End.

He is also a surgeon at Brigham and Women’s Hospital in Boston, a staff writer for The New Yorker, and a professor at Harvard Medical School and the Harvard School of Public Health. He has won the Lewis Thomas Prize for Writing about Science, a MacArthur Fellowship, and two National Magazine Awards. In his work in public health, he is Executive Director of Ariadne Labs, a joint center for health systems innovation, and chairman of Lifebox, a nonprofit organization making surgery safer globally.

Photo: Aubrey Calo

More profile about the speaker
Atul Gawande | Speaker | TED.com