How do we fix medicine? Atul Gawande at TED2012

Posted by: Ben Lillie

Photo: James Duncan Davidson

How do we get good at anything? Doctor Atul Gawande opens his talk at TED2012 by asking that question. He writes as well as practices medicine, and constantly has to confront that question about everything in his life. But there’s a new crisis, the incredible cost of healthcare. The fight is framed as: Is government the problem, or are the insurance companies? “The answer is yes. And no.” It’s more subtle than that.

He quotes Lewis Thomas, the great physician and writer of science, on the days before penicillin, when a hospital was mostly a place to rest. The doctors were custodians more than healers, and any benefit was from having shelter, food and attention.

Of course, the doctors were still frenetically busy. Was there a diagnosis they might have missed? Something they could have done to make one person better? There were a few conditions they could cure, a few options that might work, but not a lot, and they weren’t great.

Now, Gawande says, only a few generations later the changes are unfathomable, “The volume of knowledge and discovery have eclipsed the imagination.”

Our institutions were developed to handle a situation where a doctor could be an autonomous individual, could know about all diseases, write prescriptions, plate the culture, and set the fracture, spun the blood — could do everything themselves. None of that is true anymore. There are MRIs to run, physical therapy to do, and highly intricate surgeries to perform.

We have treatments for tens of thousands of conditions. There are 4000 medical and surgical procedures, 6000 drugs he is legally allowed to prescribe — and that’s the new problem. We’re starting, Gawande argues, to realize, as doctors, “that we can’t do it all.”

Here’s some data. In 1970, the number of doctors a patient at a hospital saw, on average, was 2. By the end of the 20th century, it was 15. Each doctor is a specialist now, even primary physicians. Gawande says that has been a disaster, “We’ve trained, hired and rewarded people to be cowboys, but it’s pitcrews we need.” There’s data: 40% of coronary heart disease patients receive incomplete care, and 60% of pneumonia patients. Two million people walk into hospital and get infection they didn’t have because someone forgot to wash their hands.

We have amazing clinicians, and access to incredible technologies, but our experience is that it rarely comes together successfully. The unmanageable cost is one of the signs we need pit crews rather than cowboys. Doctors tend to think that that’s just the way it is. More complicated care costs more.

But that’s not true. There is a wide gap between the best results and the worst results, and the outcomes don’t match the cost. The highest price doesn’t necessarily produce the best health outcome. And that, oddly, is a point of hope. “If to have the best results required you to get the most expensive care, we really would be talking about rationing.” But if you look at successful cases, it’s not quality components, but getting everything to come together in the right way. Here’s a thought experiment: “What if you built a car from the very best car parts… What would you have? A very expensive pile of junk that doesn’t go anywhere.” Medicine feels like that. It’s not a system.

A huge part of the problem is that we don’t have some very important skills for making systems.

1) To really evaluate succes and failure. “When you’re a specialist you can’t see the whole story. You have to be incredibly interested in data. That’s not sexy.”

2) Finding solutions to the failings. Gawande got interested when the World Health Organization asked his team for a way to reduce deaths in surgery around the developing world. The normal response would be to do more training, but everyone was well trained. But they looked at other industries. It turns out that a very basic tool of aviation, skyscraper construction, and high risk industries was… a checklist.

It’s surprising, but a checklist is a way make a recipe for how to have a team that’s prepared for the unexpected. So they designed a checklist for surgery and, “We implemented the checklist in 8 hospitals around the world from rural Tanzania to Seattle. After they adopted it the complication rates fell 35% in every hospital it went into. Death rates fell 47%.”

It’s hard to get physicians to do this. It’s not part of their jobs, they don’t want to think about every little problem. But the lists are powerful. They force us to admit to certain things, to admit humility, to value teamwork. The opposite of the cowboy model.

Gawande once met an actual cowboy. He asked him he he did all the corralling of herds of cattle. The answer: Electronic communications, managed by checklists.” “Even cowboys are like pitcrews now”

“Making systems work in medicine is the great task of my generation of physicians and sciences.” In fact, it’s the great task of our generation in all fields. Knowledge has become too complex to handle as individuals which means that, “As individualistic as we want to be, complexity requires group success. We all need to be pit crews now.”

The talk ends, and moves back to the dinner table, to take questions.

Ryan Phelan: You’re one of my heroes. Have you thought about how checklists could be used in the communication between doctors and terminally ill patients.

AG: We’re working on it. With the whole death-panel scare, the government is afraid of it. But we have private funding, and we’re making a list of questions, not about what they want, but about what their biggest fears are, what their goals are. When we understand that we can make recommendations.

Stewart Brand: It strikes me that robotized medicine can replace the checklist.

AG: Yes, we can automate more. But the question is, when should that automated thing to pop the cataract out of your eye. Maybe we could automate that. But we should not cut the human out, we need structure to make us better as teams.

Ken Robinson: I gave a talk to a set of pathologists, at the end I was offered a free autopsy. People give what they can. What they were afraid of was the increasing beaurocratization of the field. Is there something peculiar in the culture of medicine that attracts this? Perhaps I’m naive, but you’d expect if you went into surgery they’d check what they’re doing.

AG: It’s less than norm in most fields. In medicine we’ve become specialized atomized units have not been able to find out how to herd the cats, and how to be interested in building organizations that are highly successful. That’s not necessarily something we think we do.

Chris Anderson: Are you trying to create a science of simplicity?

AG: Yes. There are simple solutions to address increasingly high complexity. But, if we believe it’s only technology that handles complexity, we’ll go adrift. Even the tech needs to fit to the people we’re trying to help.

Ryan Phalan: What you’re doing is truly disruptive. It’s not just about new tools, but about changing the arrogance of healthcare.

Comments (36)

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  • Sandra Bruggeman commented on Mar 1 2012

    Some hospitals have been using systems charting for 30 years (sort of like a checklist by system). I’ve spent considerable time filling out those forms and the doctors didn’t even look at it. That happened more than once. I quit filling them out. There are better databases in the world than what they use for electronic medical records. Seems like most can’t find anything. They just ask you. And even if you wrote things like allergies on your chart, wristband, and told twelve people on the way into surgery, they miss it and you get the thing you were allergic to anyway (hamburger, hamburger, hamburger…no matter what you order, they bring you the same thing). They have process issues. There’s a huge discrepancy between people that know and people that read about it. Most obvious when physicians want to believe population studies, but that’s not you (from the patient perspective). Hospitals/doctors aren’t that impressive at the moment. Having a bunch of physicians from every discipline that don’t talk to each other or keep sending you back to your primary for everything is annoying also. And not being able to ask more than one question without turning it into twenty office visits is a pain too. They make the patient revolve around them. And when you’re sick, people don’t have patience for that. I’m scared to walk in the door. I’m afraid they’ll kill me.

  • Aleta Badowski commented on Feb 29 2012

    I am currently sitting in a hospital room with my daughter who has had spine surgery and she has a team of people taking care of her. Surgeon, endocrinologist (she has type 1 diabetes), pain management, infectious disease specialists (she had an infection inher rods in her spine), home care reps, and a whole slew of nurses. What a team! This is her fifth spine surgery over ten years and I can see how technology has benefitted the healthcare system. Everyone is able to view everyone else’s decisions and see current information. However, the humans still have to make the decisions, and having the full information in front of them allows them to make better ones. I want the surgeon to be focused on his job and the endocrinologist focused on her diabetes and the pain management to be focused on her comfort, but they all have to consider everything about the patient, and the consequences of their decisions. Technology allows them to do this. From where I sit now, I think the technology is fantastic and the knowledge and expertise these people have is able to be used to the best of its ability because of the technology. However, nothing will replace the care and attention of the nurses and the face to face consults with the doctors. It’s reassuring to see the numbers on the screen and wonderful that the alarms go off on the machines telling you there’s a problem. But nothing is more reassuring than the nod of the head of the experts and the words of comfort of the nurses. No amount of technology will replace that – in fact it will enhance the humanistic side of medicine, by taking care of the statistics and giving us the facts and therefore allowing the medical profession to concentrate on the patient care. Yes, a checklist is a wonderful thing but every checklist is different for every patient, and the checklist would need to be constantly updated and augmented, otherwise having a standard checklist would seriously narrow the scope of what might be wrong or what might need to be checked. Unlike a plane, or a bridge, whose changes are spread over a long period of time,patients are constantly changing, the checklist may be changed so frequently it no longer becomes a useful tool. As you say, knowledge has become too complex for an individual, and it may be too complex for a checklist too. As I see it today, it is a collaboration between technology and the expert knowledge we have available – we have to continue to grow in both and find out how both can work together efficiently. This will take time, and it will be trial and error and it will be forever evolving. We have to make sure the system is fluid enough and is able to roll and pitch with the constant changes that are taking place in medicine.

    • Stephen Mulkey commented on Jun 6 2012

      In the checklist program that Gawande talks about, each of the different hospitals were encouraged to adjust the checklist to their own personal situation. The checklist was designed to be an ever evolving entity, just like the checklists for pilots. The Aviation industry has whole organizations devoted to developing and maintaining their checklists. Medicine will eventually need the same thing if checklists are to become more widespread.

  • Amardeep Karodkar commented on Feb 29 2012

    You are genius Dr.Atul Gawande,

    • Amardeep Karodkar commented on Mar 6 2012

      The checklist is an peace of idea to reduce the amount of complexity in medicine, Dr. Atul Gawande given us fantastic and new way to look at this complex world ( medicine),and to solve the complex issues profoundly and diligently. Medicine has had trouble to make peoples life better, one man or women cant not hold the entire knowledge of medicine in their head. But using checklist like idea can better and save others life. and can improve team work. So I thank you for the all efforts that Dr. Gawande put to save life’s around the world. I wish him all the very best for future endeavors.

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