How do we heal medicine? | Atul Gawande

Summary

The speaker reflects on the evolution of medicine from a time of limited capabilities to the current era of vast knowledge and complexity. He emphasizes the shift from individual autonomy to the necessity of teamwork in healthcare, akin to pit crews, to address the rising costs and inefficiencies. By adopting systems thinking and utilizing tools like checklists, the medical field can improve patient outcomes and reduce complications, highlighting the need for a cultural change towards interdependence and collective success.

Takeaways

• 📚 The speaker started in writing and research as a surgical trainee, far from being an expert, and questioned how to become good at what they do.
• 🤔 The question of how to excel in one's field is universal, and it's not just about learning skills but also about the right selection of people for tasks like surgeries.
• 🏥 The healthcare crisis is not just about politics or insurance; it's deeply rooted in the complexity of medical science and its increasing cost.
• 📚 Lewis Thomas's book 'The Youngest Science' provides a historical perspective on the simplicity and ineffectiveness of medicine before modern advancements.
• 🛠️ Medicine was once a field where a doctor could know everything and perform all tasks, but now it's a complex system with thousands of procedures and drugs.
• 👥 The modern healthcare system requires a team approach, not individual cowboys, to provide comprehensive care to patients.
• 📉 Despite the increase in medical knowledge and capabilities, studies show that the most expensive care is not necessarily the best, and sometimes the best care is the least expensive.
• 📈 The success in healthcare is more about creating a system where all components work together effectively, rather than focusing on individual components like drugs or specialists.
• 📋 The implementation of checklists in high-risk industries, including aviation and surgery, has proven to reduce errors and improve outcomes.
• 🌟 The success of a surgical checklist in reducing complications and death rates by significant percentages highlights the power of systematic approaches in medicine.
• 🔧 Embracing values like humility, discipline, and teamwork is necessary for the effective implementation of systems in healthcare and other fields.

Q & A

What was the initial context of the speaker's journey in writing and research?

The speaker started as a surgical trainee, far from being an expert, and was trying to figure out how to excel in their field.

What is the main challenge the speaker identifies in learning a new skill or task?

The main challenge is the difficulty of acquiring the necessary skills and the overwhelming amount of material one must absorb to master any task.

How has the medical field evolved in terms of complexity and the number of available treatments?

The medical field has become vastly complex with the discovery of 4,000 medical and surgical procedures and 6,000 prescription drugs, aiming to treat nearly all human conditions.

What was the state of medicine like during Lewis Thomas's time as described in 'The Youngest Science'?

During Lewis Thomas's time, medicine was cheap and largely ineffective, with treatments available for only a few conditions like lobar pneumonia, acute congestive heart failure, and syphilis.

What was the core structure of medicine like when it was first created?

The core structure of medicine was built around the idea of being a craftsman, where doctors could know and do everything with basic tools and a small team.

Why has the traditional value of autonomy in medicine become problematic in the modern context?

The value of autonomy has become problematic because modern medicine requires a team approach to handle the complexity and specialization, similar to a pit crew rather than individual cowboys.

What is the current crisis in medicine according to the speaker?

The current crisis in medicine is the unaffordability of healthcare due to its increasing cost, which is a concern worldwide.

What is the relationship between the cost of healthcare and the quality of care provided?

Contrary to common belief, the most expensive care is not necessarily the best; in fact, the best care often turns out to be the least expensive with fewer complications.

What is the significance of the checklist in improving surgical outcomes as mentioned in the script?

The checklist is a tool to help manage complexity and ensure that no critical steps are missed, leading to a significant reduction in complications and death rates in surgery.

What values does the speaker suggest are necessary for effective teamwork in medicine?

The necessary values for effective teamwork in medicine include humility, discipline, and a focus on teamwork, as opposed to the traditional values of independence and autonomy.

What is the speaker's call to action for the future of medicine and other fields?

The speaker calls for the recognition of the need for systems thinking and group success in all fields, including healthcare, education, climate change, and poverty alleviation, due to the increasing complexity and specialization.

Outlines

00:00

🔍 The Quest for Mastery Amidst Medical Complexity

The speaker starts as a novice in the medical field, pondering how to excel in their craft. They reflect on the challenges of learning and mastering skills, as well as the selection of the right team for surgery. The narrative then shifts to the broader crisis in healthcare due to its escalating costs, a concern that transcends political blame games and is rooted in the complexity introduced by scientific advancements. The speaker takes us back in time to the era of Lewis Thomas, highlighting the simplicity and limited effectiveness of medicine in 1937, which paradoxically made it more affordable. The talk emphasizes the evolution of medical practice from a craftsman's approach to a complex system requiring a deep understanding of the entire field.

05:00

🚀 Transition from Cowboy to Pit Crew in Medicine

This paragraph discusses the transformation of medicine from an era of limited but manageable knowledge to the current state where thousands of treatments and drugs exist. The speaker points out that the autonomy and independence valued in the past have become problematic in today's specialized and complex medical landscape. Historical data reveals a significant increase in the number of clinicians required per patient over time. The speaker argues for a shift from individualistic 'cowboy' approaches to collaborative 'pit crew' models, emphasizing the need for systems that ensure comprehensive and appropriate care. They also highlight the correlation between cost and quality of care, suggesting that the most expensive care isn't always the best, and that efficiency can lead to better outcomes.

10:03

🛠️ Embracing Systematic Solutions in Healthcare

The speaker delves into the need for systems thinking in healthcare, using the analogy of assembling a car from the best parts, which without a systematic approach, results in failure. They advocate for recognizing success and failure, devising solutions, and the importance of data in this process. A personal account of a surgeon's initiative to understand CT scan overuse in his community exemplifies the power of data in identifying systemic issues. The speaker then discusses their involvement with the World Health Organization to improve surgery safety globally, drawing inspiration from other high-risk industries that use checklists to manage complexity and ensure consistency in critical tasks.

15:04

🌟 Implementing Checklists for Surgical Success

The speaker shares the development and implementation of a surgical checklist designed to enhance team preparedness and reduce complications. With input from experts like the lead safety engineer for Boeing, the checklist includes crucial pause points and focuses on essential items that are often overlooked. The results from its use in eight diverse hospitals are remarkable, with a significant reduction in complications and death rates. However, the speaker notes resistance to this new approach due to its challenge to traditional values of independence and autonomy in medicine. They conclude by emphasizing the necessity of systems thinking and teamwork in various fields beyond healthcare, calling for a collective embrace of humility, discipline, and collaboration.

Keywords

💡Expertise

Expertise refers to a high level of skill or knowledge in a specific area. In the video, the speaker reflects on the journey of becoming proficient in their field, which is a central theme as they discuss how to improve in medicine and the challenges of mastering the vast knowledge required.

💡Complexity

Complexity in this context denotes the intricate and multifaceted nature of modern medicine, which has grown exponentially with new treatments and procedures. The speaker uses the term to highlight the difficulty in managing the vast amount of medical knowledge and the need for a systematic approach to healthcare.

💡Healthcare Costs

Healthcare costs are the expenses associated with the provision of medical services. The speaker mentions the crisis in the medical field due to the escalating costs of healthcare, which has become a global concern and a central issue in political and economic discussions.

💡Specialization

Specialization is the process of focusing on a specific area within a broader field. The video discusses the evolution of medicine where general practitioners have become specialists, each handling a part of patient care, reflecting the increased complexity and division of labor in the medical field.

💡Autonomy

Autonomy is the concept of self-governance and independence. Historically, medicine valued autonomy highly, with doctors making decisions independently. However, the speaker argues that this value is now a hindrance to the collaborative, systemic approach needed in modern healthcare.

💡Pit Crews

The term 'pit crews' is borrowed from racing and refers to teams that work together to achieve a common goal quickly and efficiently. The speaker uses this metaphor to illustrate the need for a coordinated team effort in healthcare, as opposed to the individualistic 'cowboy' approach.

💡Checklists

Checklists are tools used to ensure that no steps are missed in a process. In the video, the speaker discusses the implementation of surgical checklists to improve patient safety and reduce errors, emphasizing the importance of systematic approaches over reliance on individual memory and skill.

💡Systemic Approach

A systemic approach involves considering the entire system rather than its individual components. The speaker argues for a systemic approach in healthcare to address the complexity and interdependence of modern medical practices, as opposed to focusing solely on the components like drugs or technologies.

💡Positive Deviants

Positive deviants are individuals or groups that perform better than their peers despite similar circumstances. The video mentions positive deviants in healthcare as examples of institutions that achieve better patient outcomes at lower costs, often by employing a more systematic approach.

💡Teamwork

Teamwork is the collaborative effort of a group to achieve a common goal. The speaker emphasizes the importance of teamwork in healthcare, suggesting that it is essential for managing the complexity of modern medicine and for providing comprehensive and effective patient care.

💡Humility

Humility is the quality of being modest and not overly proud. In the context of the video, humility is highlighted as a necessary value for healthcare professionals to adopt, especially when using tools like checklists, which require acknowledging that no one person can remember everything and that collaboration is key.

Highlights

The speaker began as a surgical trainee, far from being an expert, and questioned how to excel in his field.

The speaker explores the broader question of how anyone can become proficient in their chosen endeavor.

The importance of learning skills and absorbing necessary material for any task is emphasized.

The speaker discusses the selection of the right person for the operating room as a critical aspect of surgical success.

A new context for defining excellence in medicine emerged due to the crisis in healthcare costs.

The political debate around healthcare costs is highlighted, with the speaker suggesting that the issue is deeper than government or insurance companies.

The root cause of healthcare issues is identified as the complexity introduced by scientific advancements.

Lewis Thomas's book 'The Youngest Science' is referenced to illustrate the state of medicine in 1937, which was cheap but largely ineffective.

The speaker contrasts the limited medical interventions available in 1937 with the vast array of treatments available today.

The evolution from a craftsman-like approach to medicine to a complex system of medical and surgical procedures is described.

The current healthcare system is criticized for its focus on individual autonomy rather than collective efficiency.

The speaker presents data showing that the most expensive care is not always the best, and the best care can often be the least expensive.

The concept of 'positive deviants' in healthcare is introduced, referring to those achieving the best results at the lowest costs.

The speaker advocates for a system approach in healthcare, rather than a focus on individual components.

A thought experiment about building a car with the best parts is used to illustrate the importance of system integration over individual components.

The development and success of a surgical checklist is detailed, demonstrating a simple tool's impact on reducing complications and deaths.

The speaker calls for a shift in values from independence to humility, discipline, and teamwork in healthcare.

The need for systems thinking is extended beyond healthcare to other fields such as education, climate change, and poverty alleviation.

The speaker concludes by emphasizing that the ability to make systems work is the defining challenge of the current generation.

Transcripts

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 were 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.

And 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 Lewis Thomas was writing in his book, "The Youngest Science."

Lewis Thomas was a physician-writer,

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 lobar pneumonia, for example,

and they could give you an antiserum,

an injection of rabid antibodies

to the bacterium streptococcus,

if the intern sub-typed 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 it meant to be good at what we did

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,

looked at it under the microscope,

you plated the culture, you injected the antiserum.

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 onto 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:

40 percent of our coronary artery disease patients

in our communities

receive incomplete or inappropriate care.

60 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 --

hardworking, incredibly well-trained and very smart --

that we have access to incredible technologies

that give us great hope,

but 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 $40,000 hip replacement

replacing the 10-cent aspirin

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 has 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 --

has fewer complications,

the people get more efficient at what they do.

And what that means

is there's hope.

Because [if] 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 from 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 the 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 whole.

Having great components is not enough,

and yet we've 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.

There's a famous thought experiment

that touches exactly on this

that 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, journal articles

saying that there had been too many CT scans done.

He 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 where your failures are.

Skill two is devise solutions.

I got 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 totem pole,

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 had 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 get 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 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.

(Applause)

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 onto 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 the 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 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 --

(Laughter)

-- 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.

(Applause)