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.
Atul Gawande - Surgeon, writer, public health innovator
Surgeon and public health professor by day, writer by night, Atul Gawande explores how doctors can dramatically improve their practice using approaches as simple as a checklist – or coaching. Full bio
Surgeon and public health professor by day, writer by night, Atul Gawande explores how doctors can dramatically improve their practice using approaches as simple as a checklist – or coaching. Full bio
Double-click the English transcript below to play the video.
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I got my start
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in writing and research
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as a surgical trainee,
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as someone who was a long ways away
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from becoming any kind of an expert at anything.
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So the natural question you ask then at that point
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is, how do I get good at what I'm trying to do?
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And it became a question of,
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how do we all get good
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at what we're trying to do?
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It's hard enough to learn to get the skills,
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try to learn all the material you have to absorb
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at any task you're taking on.
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I had to think about how I sew and how I cut,
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but then also how I pick the right person
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to come to an operating room.
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And then in the midst of all this
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came this new context
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for thinking about what it meant to be good.
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In the last few years
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we realized we were in the deepest crisis
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of medicine's existence
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due to something you don't normally think about
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when you're a doctor
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concerned with how you do good for people,
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which is the cost
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of health care.
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There's not a country in the world
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that now is not asking
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whether we can afford what doctors do.
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The political fight that we've developed
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has become one around
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whether it's the government that's the problem
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or is it insurance companies that are the problem.
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And the answer is yes and no;
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it's deeper than all of that.
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The cause of our troubles
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is actually the complexity that science has given us.
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And in order to understand this,
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I'm going to take you back a couple of generations.
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I want to take you back
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to a time when Lewis Thomas was writing in his book, "The Youngest Science."
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Lewis Thomas was a physician-writer,
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one of my favorite writers.
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And he wrote this book to explain, among other things,
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what it was like to be a medical intern
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at the Boston City Hospital
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in the pre-penicillin year
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of 1937.
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It was a time when medicine was cheap
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and very ineffective.
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If you were in a hospital, he said,
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it was going to do you good
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only because it offered you
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some warmth, some food, shelter,
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and maybe the caring attention
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of a nurse.
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Doctors and medicine
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made no difference at all.
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That didn't seem to prevent the doctors
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from being frantically busy in their days,
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as he explained.
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What they were trying to do
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was figure out whether you might have one of the diagnoses
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for which they could do something.
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And there were a few.
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You might have a lobar pneumonia, for example,
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and they could give you an antiserum,
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an injection of rabid antibodies
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to the bacterium streptococcus,
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if the intern sub-typed it correctly.
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If you had an acute congestive heart failure,
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they could bleed a pint of blood from you
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by opening up an arm vein,
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giving you a crude leaf preparation of digitalis
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and then giving you oxygen by tent.
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If you had early signs of paralysis
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and you were really good at asking personal questions,
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you might figure out
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that this paralysis someone has is from syphilis,
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in which case you could give this nice concoction
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of mercury and arsenic --
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as long as you didn't overdose them and kill them.
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Beyond these sorts of things,
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a medical doctor didn't have a lot that they could do.
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This was when the core structure of medicine
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was created --
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what it meant to be good at what we did
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and how we wanted to build medicine to be.
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It was at a time
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when what was known you could know,
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you could hold it all in your head, and you could do it all.
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If you had a prescription pad,
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if you had a nurse,
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if you had a hospital
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that would give you a place to convalesce, maybe some basic tools,
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you really could do it all.
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You set the fracture, you drew the blood,
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you spun the blood,
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looked at it under the microscope,
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you plated the culture, you injected the antiserum.
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This was a life as a craftsman.
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As a result, we built it around
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a culture and set of values
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that said what you were good at
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was being daring,
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at being courageous,
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at being independent and self-sufficient.
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Autonomy was our highest value.
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Go a couple generations forward
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to where we are, though,
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and it looks like a completely different world.
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We have now found treatments
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for nearly all of the tens of thousands of conditions
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that a human being can have.
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We can't cure it all.
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We can't guarantee that everybody will live a long and healthy life.
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But we can make it possible
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for most.
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But what does it take?
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Well, we've now discovered
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4,000 medical and surgical procedures.
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We've discovered 6,000 drugs
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that I'm now licensed to prescribe.
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And we're trying to deploy this capability,
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town by town,
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to every person alive --
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in our own country,
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let alone around the world.
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And we've reached the point where we've realized,
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as doctors,
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we can't know it all.
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We can't do it all
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by ourselves.
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There was a study where they looked
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at how many clinicians it took to take care of you
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if you came into a hospital,
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as it changed over time.
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And in the year 1970,
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it took just over two full-time equivalents of clinicians.
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That is to say,
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it took basically the nursing time
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and then just a little bit of time for a doctor
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who more or less checked in on you
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once a day.
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By the end of the 20th century,
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it had become more than 15 clinicians
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for the same typical hospital patient --
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specialists, physical therapists,
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the nurses.
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We're all specialists now,
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even the primary care physicians.
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Everyone just has
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a piece of the care.
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But holding onto that structure we built
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around the daring, independence,
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self-sufficiency
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of each of those people
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has become a disaster.
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We have trained, hired and rewarded people
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to be cowboys.
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But it's pit crews that we need,
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pit crews for patients.
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There's evidence all around us:
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40 percent of our coronary artery disease patients
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in our communities
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receive incomplete or inappropriate care.
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60 percent
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of our asthma, stroke patients
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receive incomplete or inappropriate care.
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Two million people come into hospitals
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and pick up an infection
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they didn't have
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because someone failed to follow
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the basic practices of hygiene.
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Our experience
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as people who get sick,
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need help from other people,
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is that we have amazing clinicians
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that we can turn to --
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hardworking, incredibly well-trained and very smart --
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that we have access to incredible technologies
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that give us great hope,
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but little sense
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that it consistently all comes together for you
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from start to finish
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in a successful way.
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There's another sign
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that we need pit crews,
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and that's the unmanageable cost
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of our care.
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Now we in medicine, I think,
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are baffled by this question of cost.
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We want to say, "This is just the way it is.
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This is just what medicine requires."
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When you go from a world
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where you treated arthritis with aspirin,
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that mostly didn't do the job,
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to one where, if it gets bad enough,
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we can do a hip replacement, a knee replacement
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that gives you years, maybe decades,
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without disability,
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a dramatic change,
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well is it any surprise
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that that $40,000 hip replacement
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replacing the 10-cent aspirin
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is more expensive?
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It's just the way it is.
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But I think we're ignoring certain facts
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that tell us something about what we can do.
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As we've looked at the data
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about the results that have come
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as the complexity has increased,
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we found
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that the most expensive care
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is not necessarily the best care.
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And vice versa,
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the best care
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often turns out to be the least expensive --
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has fewer complications,
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the people get more efficient at what they do.
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And what that means
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is there's hope.
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Because [if] to have the best results,
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you really needed the most expensive care
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in the country, or in the world,
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well then we really would be talking about rationing
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who we're going to cut off from Medicare.
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That would be really our only choice.
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But when we look at the positive deviants --
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the ones who are getting the best results
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at the lowest costs --
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we find the ones that look the most like systems
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are the most successful.
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That is to say, they found ways
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to get all of the different pieces,
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all of the different components,
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to come together into a whole.
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Having great components is not enough,
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and yet we've been obsessed in medicine with components.
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We want the best drugs, the best technologies,
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the best specialists,
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but we don't think too much
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about how it all comes together.
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It's a terrible design strategy actually.
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There's a famous thought experiment
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that touches exactly on this
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that said, what if you built a car
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from the very best car parts?
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Well it would lead you to put in Porsche brakes,
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a Ferrari engine,
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a Volvo body, a BMW chassis.
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And you put it all together and what do you get?
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A very expensive pile of junk that does not go anywhere.
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And that is what medicine can feel like sometimes.
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It's not a system.
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Now a system, however,
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when things start to come together,
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you realize it has certain skills
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for acting and looking that way.
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Skill number one
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is the ability to recognize success
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and the ability to recognize failure.
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When you are a specialist,
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you can't see the end result very well.
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You have to become really interested in data,
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unsexy as that sounds.
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One of my colleagues is a surgeon in Cedar Rapids, Iowa,
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and he got interested in the question of,
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well how many CT scans did they do
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for their community in Cedar Rapids?
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He got interested in this
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because there had been government reports,
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newspaper reports, journal articles
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saying that there had been too many CT scans done.
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He didn't see it in his own patients.
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And so he asked the question, "How many did we do?"
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and he wanted to get the data.
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It took him three months.
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No one had asked this question in his community before.
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And what he found was that,
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for the 300,000 people in their community,
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in the previous year
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they had done 52,000 CT scans.
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They had found a problem.
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Which brings us to skill number two a system has.
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Skill one, find where your failures are.
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Skill two is devise solutions.
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I got interested in this
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when the World Health Organization came to my team
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asking if we could help with a project
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to reduce deaths in surgery.
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The volume of surgery had spread
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around the world,
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but the safety of surgery
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had not.
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Now our usual tactics for tackling problems like these
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are to do more training,
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give people more specialization
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or bring in more technology.
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Well in surgery, you couldn't have people who are more specialized
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and you couldn't have people who are better trained.
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And yet we see unconscionable levels
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of death, disability
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that could be avoided.
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And so we looked at what other high-risk industries do.
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We looked at skyscraper construction,
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we looked at the aviation world,
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and we found
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that they have technology, they have training,
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and then they have one other thing:
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They have checklists.
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I did not expect
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to be spending a significant part
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of my time as a Harvard surgeon
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worrying about checklists.
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And yet, what we found
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were that these were tools
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to help make experts better.
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We got the lead safety engineer for Boeing to help us.
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Could we design a checklist for surgery?
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Not for the lowest people on the totem pole,
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but for the folks
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who were all the way around the chain,
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the entire team including the surgeons.
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And what they taught us
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was that designing a checklist
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to help people handle complexity
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actually involves more difficulty than I had understood.
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You have to think about things
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like pause points.
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You need to identify the moments in a process
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when you can actually catch a problem before it's a danger
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and do something about it.
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You have to identify
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that this is a before-takeoff checklist.
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And then you need to focus on the killer items.
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An aviation checklist,
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like this one for a single-engine plane,
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isn't a recipe for how to fly a plane,
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it's a reminder of the key things
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that get forgotten or missed
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if they're not checked.
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So we did this.
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We created a 19-item two-minute checklist
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for surgical teams.
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We had the pause points
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immediately before anesthesia is given,
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immediately before the knife hits the skin,
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immediately before the patient leaves the room.
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And we had a mix of dumb stuff on there --
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making sure an antibiotic is given in the right time frame
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because that cuts the infection rate by half --
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and then interesting stuff,
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because you can't make a recipe for something as complicated as surgery.
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Instead, you can make a recipe
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for how to have a team that's prepared for the unexpected.
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And we had items like making sure everyone in the room
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had introduced themselves by name at the start of the day,
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because you get half a dozen people or more
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who are sometimes coming together as a team
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for the very first time that day that you're coming in.
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We implemented this checklist
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in eight hospitals around the world,
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deliberately in places from rural Tanzania
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to the University of Washington in Seattle.
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We found that after they adopted it
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the complication rates fell
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35 percent.
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It fell in every hospital it went into.
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The death rates fell
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47 percent.
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This was bigger than a drug.
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(Applause)
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And that brings us
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to skill number three,
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the ability to implement this,
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to get colleagues across the entire chain
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to actually do these things.
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And it's been slow to spread.
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This is not yet our norm in surgery --
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let alone making checklists
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to go onto childbirth and other areas.
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There's a deep resistance
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because using these tools
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forces us to confront
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that we're not a system,
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forces us to behave with a different set of values.
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Just using a checklist
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requires you to embrace different values from the ones we've had,
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like humility,
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discipline,
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teamwork.
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This is the opposite of what we were built on:
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independence, self-sufficiency,
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autonomy.
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I met an actual cowboy, by the way.
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I asked him, what was it like
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to actually herd a thousand cattle
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across hundreds of miles?
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How did you do that?
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And he said, "We have the cowboys stationed at distinct places all around."
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They communicate electronically constantly,
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and they have protocols and checklists
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for how they handle everything --
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(Laughter)
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-- from bad weather
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to emergencies or inoculations for the cattle.
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Even the cowboys are pit crews now.
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And it seemed like time
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that we become that way ourselves.
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Making systems work
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is the great task of my generation
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of physicians and scientists.
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But I would go further and say
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that making systems work,
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whether in health care, education,
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climate change,
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making a pathway out of poverty,
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is the great task of our generation as a whole.
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In every field, knowledge has exploded,
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but it has brought complexity,
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it has brought specialization.
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And we've come to a place where we have no choice
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but to recognize,
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as individualistic as we want to be,
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complexity requires
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group success.
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We all need to be pit crews now.
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Thank you.
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(Applause)
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ABOUT THE SPEAKER
Atul Gawande - Surgeon, writer, public health innovatorSurgeon and public health professor by day, writer by night, Atul Gawande explores how doctors can dramatically improve their practice using approaches as simple as a checklist – or coaching.
Why you should listen
Atul Gawande is author of several best-selling books, including Complications: A Surgeon's Notes on an Imperfect Science, Better: A Surgeon's Notes on Performance, Being Mortal: Medicine and What Matters in the End and The Checklist Manifesto.
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 chair of Lifebox, a nonprofit organization making surgery safer globally.
In June 2018, Gawande was chosen to lead the new healthcare company set up by Amazon, JPMorgan and Berkshire Hathaway.
Photo: Aubrey Calo
Atul Gawande | Speaker | TED.com