When we all have a piece of care, or a piece of a problem, very often none of us can actually see what the outcome is and the owner can't see the function of the system.
And so then you start finding things like data really matter.
Hello and welcome. I'm Shane Parrish, and this is another episode of the Knowledge Project, a podcast exploring the ideas, methods, and mental models that help you learn from the best of what other people have already figured out.
To learn more about the show, go to fs .blog slash podcast.
My guest today is Atul Gawande.
Atul is a globally renowned surgeon, writer, and public health innovator.
He's written four New York Times bestsellers, Complications, Better, The Checklist Manifesto, and Being Mortal.
In his spare time, he's also a staff writer for the New Yorker.
Atul has dedicated his career to not only building, but scaling better healthcare delivery.
Shortly after this interview is recorded, he was named the CEO of the healthcare initiative between JP Morgan Chase, Berkshire Hathaway, and Amazon .com.
Commenting on the initiative, Amazon .com CEO, Jeff Bezos said, the degree of difficulty is high and success is going to require an expert's knowledge, a beginner's mind, and a long -term orientation.
Atul embodies all three.
This interview almost never happened as my flight to Boston was canceled because of weather more times than I can count.
I think you'll see how persistence was rewarded when you listen to this wide -ranging conversation.
Let's get started. I'm going to ask you a question.
I was debating on the flight over here today, how I wanted to start this interview, and I think we're going to go back to like med school, which is why did you want to become a doctor?
Well, I didn't want to become a doctor.
So, you know, I grew up in southeastern Ohio, the kid of two Indian immigrant doctors, and of course, what do they expect?
But, you know, it's when will you go to medical school?
And so I spent college, I majored in biology, but I also majored in political science, kind of looking for there must be more to the world than just medicine.
And I found it. I found it in lots and lots of different places.
Some in science. I worked in a lab.
Some, you know, I tried everything in college.
I was in a band. I learned to play guitar.
I wrote music reviews for the student newspaper.
I joined Amnesty International.
I worked on Gary Hart's very short -lived campaign for president as a volunteer.
And then when I got out of Stanford, I went on to do a master's degree in politics and philosophy economics at Oxford out of hope that I could maybe do a graduate degree in political theory or something like that.
And I just found I wasn't very good at those questions.
And a lot of the things that I tried, I just wasn't really made for or cut out for.
And I kept coming back to medicine as a place where I was familiar.
I was comfortable. It wasn't for the best reasons, right?
It was a place that I knew and I could thrive.
What I also liked about it was you didn't actually have to decide what you wanted to be when you grew up.
So it deferred all kinds of decisions while I figured out everything else along the way.
So when I got out of graduate school and decided just stop with a master's degree in philosophy and then I worked actually in politics for a couple of years on the Hill and found I didn't want to just work in politics.
I kept finding myself gravitating back to medicine where you could have skill.
The values were at the core of it for me that it was about grappling with how science meets humanity in a place where and policy and the world and all the complexities of life.
In a place where you could really think about the individual in front of you but also the system as a whole.
And I wanted to somehow connect on both levels.
It's interesting to hear you say that you felt like you weren't good at something because from the outside looking in, you're a surgeon, a prolific writer on multiple subjects at the New Yorker, multiple books.
And so it looks like and a researcher on top of all of that, right?
Not to mention a husband and a father.
So it looks like failure is not really in your vocabulary.
Well but A, it doesn't mean I do all of those things well.
And B, you know I like having a lot of irons in the fire.
I like being a jack of all trades and finding the edges between things is often where I have something to add.
If you look at what I contribute in these spaces, it's not genius ideas, a checklist for surgery.
It's just taking an idea from one domain and saying let's bring it over to the other and see if it can work.
Or you know understanding what people's goals are when they face mortality in the end of life.
A lot of them just come from digging in deep enough to understand the gap between what we're aspiring for and the reality of what we're doing and then trying to figure out where the bridge is to narrow that wide gap.
And so most of my value just comes from saying and pointing out, wow we don't live up to what we say we're going to do.
It's not for, usually not for evil reasons, it's usually for really complicated reasons and then unknotting the complexity and just taking time to do that.
I find in each line of work, whether it's surgery, our public health research center where we're sitting today, Ariadne Labs, or my writing, I'm just doing the same thing over and over again actually.
Was it conscious to apply ideas from other domains or was there an aha moment that this makes sense or how did that come about?
I think it's more personality.
I mean I think I grew up kind of interested in how the world worked and I had a very limited advantage point in my town in Ohio growing up and every opportunity to see more, you know, my handle hold was through science.
My parents were doctors and that gave me a way of seeing and thinking about the world.
But then my parents were also people who are deeply involved in the community in trying to deal with the challenges in a community that had a college but was also the poorest county in Ohio.
My brain worked in such a way that I loved understanding the ideas at a ideas level and then trying to figure out how you grounded.
I was always looking for ways to understand the world and that meant needing to bridge and look more widely.
And so each move, college and then going beyond, kept widening that and I've just loved that.
I've loved adding another space that I could explore and it was only by happenstance.
It was very late that I found I had anything to contribute and that really wasn't until my 30s when I finally found I could connect the dots between different things I've been learning about.
In your book Complications, one of the things that you explore is what makes a good doctor.
Can you expand on that for us?
Well, in some ways I think I've been interested in that from the very beginning.
So Complications was written out of my early New Yorker articles where I was a trainee in surgery and I was very interested in what does it mean to be good at what we do as a doctor when I'm still learning, I'm practicing on human beings.
My very first article was about a computer that could diagnose heart attacks better than the most experienced doctor could and a hernia factory in Toronto where none of them were actually trained as surgeons.
One was like a family physician but they did more hernia operations at lower cost with far better results than any I would ever achieve.
Because that's all they did all day.
All day they were a factory.
They did a dozen hernias a day.
There are all kinds of interesting questions about that to me.
Here I am at the beginning of my training and what was evident was there are things happening with technology and computer science and what's that going to mean about what it means for me to be good at what I do in the future.
But second is that I'm learning and I'm crap.
How do I have permission to be crap and to learn along the way and how do we even ask permission for such a thing and have a learning curve.
Admit that there's a learning curve.
Those kinds of things and then add to it that you have folks who it's not all about being at Harvard and going to the very best program and being the most pedigreed and the most credentialed.
You had these folks who were getting remarkable results and it was not about just their performance.
It was the team and the organization they built around them.
So suddenly this question of what does it mean to be good at what we do I've been I've been mining that and searching for answers to that all the way along the way and that has come to include what does it mean to be good when it comes to our costs.
What does it mean to be good with care at the end of life.
What does it mean to be good at what we do when the science is exploding faster than we can understand it.
What does it mean to be good when you know there's a new piece of data that comes out that says this is the latest greatest breakthrough drug but now I've been around long enough to have seen where some of them don't turn out to work in the long run.
So is it good to be conservative.
Is it good to be you know take the first thing out of the box.
There's so many interesting questions in this space and I feel like they're very general questions.
Medicine is just a place where you're applying these very basic questions.
In a space that you have lives on the line and you have a lot of money and you have a lot of complexity and so it makes it a really interesting kind of and meaningful domain to people even though I think a lot of the things I'm asking about apply widely.
What's changed in your mind about what it meant to be a good doctor since you were a resident writing that and today.
I think it's evolved you know in the beginning it was a lot around how do you cope with the reality of error.
Complications was partly about the nature of you know how errors occur.
Some of it's because of ignorance and we just don't have the science.
Some of it's because of errors and actually failure to do what we ought to know how to do and learning curves and and systems and things like that and some of it is the reality of complexity meaning that you're always fallible and that you will never be error free.
As I then finished my training and went into practice I became comfortable with the fact that I was doing what I could to keep the reality of the system around me being as important in the outcomes of my patients as me.
In fact in some ways more important.
The how well the place I work in delivers makes a huge difference in whether people do well or not and so that became the next area of obsession.
How do I understand the bell curve.
Why there's a wide gap between the performance of different people and different places depending on where you go to as a patient and then by the by you know the next stage I'd found that I could try solutions and borrow them from different places and checklist manifesto was you know it's like it's
like you're I'm getting to take people along as I'm growing up going through this process and then you know no surprise mortality then becomes what you start thinking about.
Of course it was you know not coincidentally turning 50 not coincidentally having a dad who was diagnosed with a brain tumor not coincidentally having more than a decade of having to talk to people about these kinds of situations and not feeling like I was doing very well and again it was recognizing
boy there's a gap here between what we think should be happening in the ways we deal with mortality and how we understand it and the reality of what we do day to day and digging in there was where I've gone and so it's just this progressive process and I feel like now for the last five six years it's
actually gotten harder to write about in some ways.
I'm really trying to wrap my mind around how you change systems so checklist manifesto was here's a solution that boy if you did x y and z use this checklist in surgery and it'll cut the death rate 50 percent.
That's a straightforward thing to do.
Now how do I make a system where people are actually doing it when people don't want to do it or doing it automatically?
Right they're doing it automatically.
They they feel it's part of what they're doing.
Since we published our initial results it's 2009.
We had demonstrated in eight cities a 50 % reduction in mortality.
I think we're past in that time 100 million of the world 300 million operations are done with the solution and we've demonstrated in places like South Carolina, Scotland and Moldova markedly improved outcomes at large population level and yet entire parts of big patches of our own country we're just
not doing it. It's the standard of care but we don't do it so how do you change behavior and the system and it's not as simple as we should pass a law and of course that's the challenge writ large.
We're all puzzling over how do we make the complexity of our systems whether it's health care economics schools work at scale.
What have you learned about what we know about changing systems not only in maybe the medical field but other systems or other large organizations that would have maybe not sort of the same consequences as medicine but similar complexity?
Well I think that the first level is what we have to unlearn which is we we see what should happen.
The doctors should be washing their hands the operation should be done in in this following way that's better than the other way we've gathered the evidence we've shown it to be true and the and then we think well let's just train it let's just teach it and and then you've taught everybody in fact that's
our dominant way in health care that we make things happen we just discover we still suck and so then we get mad and then we say well now you must do x wash your hands do the operations in the following way get organized and we have mandates and requirements and regulations and litigation and and and so on and it
does make for some better outcomes things get slightly better but it's an expensive way of making things work and then the third level is realizing we have to systematize what we do and part of it is creating a process solution a better process that makes it easier to do the right thing than to not do
the right thing and so that's a can be a checklist or it can be all kinds of things but then the challenge is implement implementing that and we've learned a lot about the components of implementing it there's a pathway of implementation like doing a big bang as we call it you know saying everybody
in our hospital is all going to use this checklist tomorrow and we're going to do that in a big bang just it's never worked we've never seen it work at all with thousands of places are rolled out never seen it work instead you have to do a process of gather a team a team of champions they have to look
at this thing that you want to do and ask questions would will this work as designed in our place and how do we have to change it and you virtually always have to make changes then and so you need you need people who own making it happen in that alone is a big thing how do you if you have an owner to
turn to so in surgery you have owners to turn to there are managers there are people who run operating rooms and are chiefs of surgery and so on we've been running these trials in childbirth though and that's a completely different story in large parts of the world you go and say who owns responsibility
for reducing the death rate of the of moms and babies in your primary birth center and it's just a lot of like I don't know who's responsible for that like I'm just a doctor not me like you know who's responsible making sure the supplies arrive well there's a supply clerk yeah who's responsible for you
know the nurses knowing what to do well the nurses are responsible for that but who's responsible making sure the system that all of things come together there is no owner so creating an owner is one of the key things that you have to have in a system and suddenly you're into things like governance
and responsibility and that's politics and you know but it's really interesting pulling pulling those very human things apart realizing nobody owns responsibility for seeing the system as a system for its function and then for plugging solutions in that that can make it work and winning people over
to it and adapting it and making it happen i think the second thing there's so many things this is the problem with figuring out even how to write about it because there's so many dimensions to all of this that you start losing the sense of capability like oh man there's so many things I got to do around
this but I do think that there are ways that you start to figure out how to pull it together so the second thing that I was about to say is that when we all have a piece of care or a piece of a problem very often none of us can actually see what the outcome is and the owner can't see the function of the system
and so then you start finding things like data really matter so you know suddenly you're into all these really unsexy things you got owners and managers and you have data like but but lives are unlike like like you don't you can't find a single new england publication you can find every week you'll
find here is a drug that makes a difference here is a specialist technique that can make a difference but you don't have a single article demonstrating that the leader who makes sure all those things come together is worth multiple percentage points of mortality reduction and and that that's really
interesting to me that we haven't made that into a tractable tangible and then what are they doing better that could be possibly copied or yeah and so we've started to unravel that we started to pull those things apart and and it and it often is really mundane things one example we published some data on hospitals
and and the variation between hospitals with a colleague that we partnered with named rafaela sadun who's at harvard business school and we measured across hospitals in the implementing safe surgery programs and so on and you know for many of your listeners it's like oh this is totally just like business
101 do you hire for talent and their ability to achieve the your your main goals and objectives do you number two do you have measures of whether you are achieving those goals and objectives number three do you have goals and objectives do you have targets for what you aim to do that you're measuring
against and hiring for and then fourth do you standardize operations around do you do you make a kind of a checklist for the key things that you are your key targets and what you're trying to accomplish and we now have see that there is direct correlation between the more of patients are substantially
better off patients are and better off in terms of quality and we also see there isn't a single hospital we have measured yet that is doing it at the highest levels that would get a you know five on a five point scale in all of those domains the average hospital has got poor performance in at least
one of them and we have lots of hospitals that are just ones and twos on all of them because they don't die you know businesses go out of business you know one of the interesting things is that joining up with her she said you know manufacturers and retailers the ones just go out of business in healthcare they
keep on going and the only thing we have going for us is the schools are even worse on our measurement scores i want to go back to something you said about the new england journal and how every week there's something coming out that's new and novel and yet we're attracted to that and we're not attracted
to the boring more fundamental things that make a lot of quantifiably make a larger difference why do you think that is well so i mean i've called it that we we've been fantastic at breakthrough innovation and we've had no no real understanding of follow through innovation and i think it's partly that the follow
through innovation can seem like it's only about about nuts and bolts and not about ideas and that it's just about herculean effort instead of about recognizing that there are ways that you can actually influence and have control some degree of control with regard to the world around you so in many
ways how did the breakthrough happen the breakthrough drug was found because you really began under to understand the interconnected complex systems at a cellular level that govern a cancer well all we're doing need to be doing and we've been doing this work as part of my public health work is unraveling
making it almost scientific what's the nature of the human systems their interconnections where the dependencies are where the bottlenecks are and how to make that work and apply ideas to it what you've called in your blog mental models you know that you know there is path dependence there are emergent
properties and as soon as you start getting that vocabulary and a sense of expertise and understanding of the complexity and how much smarter some people are about being able to be good at that work versus others now it's no longer about just slogging it out and dotting i's and crossing t's it's that if you
are if you're intelligent and structured about the way you do things you can get phenomenally better results doing this kind of work and so as we make that happen you know a lot of my writing to some extent is trying to say hey figuring out how to get people to wash hands a it's actually a really interesting
problem yeah and and and b you know we have two million people a year who pick up infections mostly because someone didn't wash their hands it's a hundred thousand lives lost a year like you can save lives and uh and there are areas where you can have leverage and you can also totally screw it up like
screaming at people to start washing hands yeah just stop it doesn't work we have lots of evidence it doesn't work let's let's let's move on i think we you and i should create the journal of boring things that work and we'll put clickbaity headlines in there so people actually read it right you won't
believe what what this blog uncovers about how we save lives except wash your hands one of the things that really attracted me to your writing and your work at the very start was not only how good of a writer you were but i remember reading about a study you referenced which was samuel gorevitz and alister
mack entire about human fallibility or necessary fallibility um and they kind of said we fail for two reasons one is that we're ignorant the other is that we're inept and at the time i was working for an intelligence agency and i started to see all of these parallels between our failures and failures
in medicine and also all of these parallels in organizations and trying to systematize getting better and basic improvements and how far they can go but also in terms of this necessary fallibility you're never going to be a hundred percent correct you're never going to have all the answers and at any
point in time retrospectively you'll always be able to look back and say you should have done something different even though in the moment that decision might have been the right decision you'll have this hindsight that allows you to take a different path i'm wondering why is it applying knowledge
that we have so brutally hard to these problems which is speaking to the failure of ineptitude well so first of all i want to just call out again gorevitz and mack entire um that paper was a 1976 paper for me has been the most influential thing in my career just because it gave me a handlehold for thinking
about problems and um you know and they and you mentioned it as a study but in fact it was just two philosophers who were thinking about why do we fail at anything we do and you know the the big deal to me about that paper was it pointed out it helped me think about where we were also in history as
well for most of human history for for like 99 .99 percent of it our world was governed largely by ignorance we did not know the diseases that that um could afflict the human body or understand them let alone what to do about them we didn't understand how you know societies rose and fell we didn't understand how
how economics worked even in the most basic components um and you know now we're in a place in the 21st century we haven't answered all the questions but we have equally now a problem of ignorance and of what they called ineptitude i prefer to call failure to deliver a little less judgmental which is um
that your uh that you know now we've discovered for example in health care we've discovered that there are more than 70 000 ways the human body can fail 70 000 different diagnoses for our 13 organ systems we've developed 6 000 drugs 4 000 medical and surgical procedures and now we're trying to deploy
that capability town by town to everybody alive and then when you start dissecting what's the nature of that fallibility that failure to deliver well first of all that list i just told you that's incredible there's nothing like it i would argue this is humankind's most ambitious endeavor is to deploy
all of these discoveries in the right way in the right time the right place without also bankrupting society how do we make this happen and um and there are two aspects of it as you point out a substantial amount of it can be solved by being able to understand and address the complexity of the of of making
all of these things happen understanding the variation in how human beings um can have these things occur and what they what we know about how how we can manage it um but then there's the additional reality of um necessary fallibility as they called it which is um we will never have complete knowledge
of all of the conditions and states of the world and we will continue to find we still don't have an understanding of all of the laws that apply to it um so even if we were to come to a complete understanding of all the laws of the universe we it we won't be able to understand all of the interconnections
and all of the particularities and how they all interconnect and so we're always making our best prediction and effort to be able to drive that um and so grappling something about that is deeply human so we have a long way to go being i think one of the really the first generation where we need an equal
amount or sometimes even greater amount of discovery and follow through how we manage this complexity the volume of knowledge the our capabilities the and then also how we grapple with and manage the reality of necessary fallibility it's interesting to me that they actually termed it ineptitude the failure
the failure to deliver because um that word has a judgment applied to it right like you know if an individual or a group of individuals fail to apply the knowledge that exists correctly they're just inept right but but there's all kinds of issues of justice and things that go into it too because that failure
to deliver when you do the wrong thing and somebody dies we want to hold responsive people responsible and we should and um and at the same time we have also to grapple with the reality of fallibility the reality of not everything being in an individual's control but being a property of a system as
well and that subverts all the ways that our brains generally work yeah definitely we have a high tolerance for forgiving mistakes when we don't know what the right outcome is but as you pointed out i mean it's a lot more difficult when we do know that there's an established method for solving this particular
problem how do you end up with open and honest reporting in the medical system for doctors i think you mentioned and m &m and morbid morbidity immortality morbidity immortality conference i was wondering if you can give us some insight into that yeah um we just had ours uh um uh today um is it today
no it was yesterday um so this is a conference we have every week seven o 'clock for an hour and it's a um and in that meeting we bring the complications which is to say the cases that had things go wrong where um uh where uh the patient had a bad outcome and we're specifically bringing up the cases
where um we're addressing errors and you know what could we have done differently and how can we learn from it and make things better and then every death is also reviewed there and uh and some of them can be prevented and some can't and part of what's interesting to me is the culture of that there
is a space that it's actually a legally protected space for us to be open every week about what went wrong and what happened to people including you know terrible things um people left permanently disabled because of something that we've done and it's a kind of ritual where the person presenting stands
at the front of the room and says i was responsible for this and my responsibility is not perfection my responsibility is however that we always have to be aiming for it even even when we know we're going to fall short and then the second part is not only owning it but also the fact that next week we're
going to have another meeting and there's going to be more cases that we will have that we've never come to conference and said guess what we have nothing to talk about yeah we always have more in fact to talk about then we can possibly fit into that meeting and and that process however has gotten us
to a place where we have you know lower and lower and lower death rates faster and faster recovery of people um people doing better and better uh and higher and higher expectations of ourselves um about what we can pull off it's i'm just trying to imagine myself being there and this tension between kind
of like denying that i had made a mistake and then like this self -doubt that would creep in about oh like what am i going to do next time and that this kind of continuum between the two how in fact it's like there's there's some shame to not being able to admit that you have something that you you know
so the irony is surgeons are very confident people you can't go into an operating room and do an operation without you know a kind of slightly absurd sense of confidence in yourself um you know sometimes wrong never in doubt it would be our mantra um but um in that room there's a kind of humility expected
that is uh you know it is it's not cool in that room to like you know uh flagellate yourself over the whole thing it's a um it's in a way a kind of emotionless presentation here's where you know where where x person did something wrong and you know here's what i think i should have done differently
it's it's a kind of you you have to take some ownership and and there's always a temptation to want to blame someone not in the room the nurses fall yeah the anesthesiologists fall whatever but we you know but but then the problem is that you didn't bring them in the room like they should be here as
well if they're they should have been there they that we should that we should you know we bring the people who are part of the team to be part of the discussion so that everybody's everybody's on it now creating that space is a is a combination of um culture it's been surgery couldn't get off the ground
in the early part of the century without creating that place where you could engineer you could work on engineering why are so many people dying how do we cut down the infection rate what do we do about you know making this very complicated thing work um and so we develop that culture uh the um making
that be not punitive so the minute it starts to become something where and you're out you know i'm going to use this again that where the information you use becomes weaponized that's the problem so the high reliability organization is a place where people are kind of obsessed with failure are actually
energized by like i want to ferret out and find the next thing we can fix and the uh and the opposite is the toxic organization where um admitting failure just opens you up to attack and um and removal um so it's you know there are structures that can make it that are important to that like not making
it so that um you're sued for your ability you know for talking about these things yeah um but it is so much more about the culture that you build um and in the country at large we don't live in that space we still are in a space where you know presidents acknowledging mistakes is seen still as a kind
of weakness um and it's something that holds us back i was remarking over the weekend with a friend of mine that i can't remember the last time i saw a leader in a presidential debate or even any political debate say i don't know i know it's like it's remarkable to me how these people have so much intelligence
there's so many different domains but uh those simple words can kind of bring us back have you studied other industries that have sort of catastrophic consequences and what their disclosure policies are to get at some sort of learning i think you mentioned pilots in your book about reporting to nasa is there
anything else that comes to mind yeah i mean the the the pilots example is one where nasa also has a protected space where if you submit a report on an error or on a what they call a near miss it didn't crash the plane but it could have you get a jet get out of jail free card so by reporting on it you
you are not um subject to investigation now i i think that there's we're coming to understand what people call a just culture which is that there are clear norms and values which are there is no get out of jail free card you lie about uh what's the what's happened or falsify information um you hide
information you um uh or you are actively um subverting the system more malicious in certain ways and those are those kind of behavioral norms are ones that should get you fired and are appropriately removed but then when you're talking about um fallibility uh human weakness the um you know problems
that occur because people are in conflict or they're tired or or all of those things or you just you don't you weren't thinking um those are part of uh human beings trying to work together on really hard things and so in other industries that i've seen that have been able to create that space you know
engineers on successful teams are able to create and you can see on teams within the same organization and the same research lab for example you can see good and bad culture within the teams but when when the leader has made it so people can actually speak up a woman named amy edmundson has done a lot
of research on how you create psychological safety and it's creating a place where the you know it when because um everybody is speaking with an equal voice people from the highest level to the lowest level they have all been able to um and when that exchange is the way that it that it occurs then you
know you're there we're seeing it in our operating rooms we introduced our safe surgery checklist and one of the key items on the checklist i think one of the most powerful is um that that people in the room all discuss the case the anesthesiologist the nurse and the and the clinician and the surgeon uh
to discuss what are the medical issues the patient what's our plan for the day what are our worries about you know what are the non -routine things that can go wrong is the is the um is the equipment and and everything else in place uh at the start we ask people to introduce themselves by name and role
yeah and it's like coming into a meeting room and everybody goes around introduce themselves and what we found is that that activates the likelihood that everybody will speak up and if it's run well uh then everybody has spoken and we can see that the that the places where that ability from the medical
student to the um most experienced clinician of the room it's not it's not you know you can see places where it's the surgeon doing all the talking and you can see places where that's nurse doing all the talking and yeah and and you know the power differential has gotten out of whack why do you think
that is like just the the mere math or mere matter of kind of introducing yourself with your role is it because we with our roles like what is it behind that that gives you the confidence to be like oh no i think so um now not well studying the operating room but the reasonable evidence from psychologists
looking at this question that when people have gotten to speak in in a room just by introducing yourself saying here's my name here's where i'm from in a in a meeting where people are new to the meeting the people who haven't been able to introduce themselves are much less likely to say anything in the course
of the meeting but if you've actually been able to hear yourself in the room and say i'm here this is who i am uh there that that removes your barrier of wondering whether i'm even allowed to speak in this room right uh so it's that cycle it's that psychological someone like giving you permission to
to speak in by introducing yourself you've in all practical terms been given permission to speak aside from the m &m what specific sort of performance techniques do you use um to get better at surgery i know you wrote in new york article about hiring a coach yeah can you expand on that yeah so you know
what what's what's interesting about um the work as it's gone along is the first step is trying to make sure you don't do the stupid things that um people already know about that demonstrably get to better results that's that you know do your checklist don't don't make the dumb mistakes um but then
if you're trying to get to excellence at the other end of the scale it's interesting to me that we have such different theories across different professions about how you make that happen um the pedagogical theory is you go to juliard you get your 10 000 hours of practice with the violin and you then
head out into the world and you're responsible for the rest of your self -improvement along the way that model is the primary one in professional life most musicians in medicine in teaching in business um the other model is mostly out of sports and that's the coaching model and that says i don't care if you're
roger federer you you will have blind spots when it comes to your own improvement and you need a coach yeah and uh and over time i think what we've been learning is the coaching model beats the teaching model has significant advantages um it's certainly true in sports that when you've had teams you
know you go back to the uh the first football games um american football games uh that happened in the 19th century harvard and yale played the first you know kind of official football game and yale early on decided that they would have a coach and harvard said that's very very de classe very uncool
like you know gentlemen don't need to be we just know right and uh yale won something like over the next uh couple of decades won all but a couple of the uh of the games and then harvard got a coach and so uh applying that idea we have you know i was writing that new yorker uncle i was just trying it
out for myself i had one of my former professors who i'd admired and he'd retired come to the operating room observe me and give feedback after about 10 years of being in practice when my complication rates had sort of flattened out i wasn't getting any better so you had plateaued i'd plateaued um and then
getting his coaching first of all you know watching one case and he had all kinds of things he had for me to work on uh including where i was standing and how i used the light in the field and you know these things that i had uh that that i couldn't see for myself and it's an important part of what a coach
does is they provide an external uh check on your understanding of your reality it's different from a mentor mentors a lot of coaches i hear about that people call their coach are just kind of life mentors or mentors they don't have any data they're working from they're just having what you say is going
on in your life and what you need is someone who's observing you collecting or talking to lots of people around you getting getting some way to get an external fix on your reality well we've actually now at area any labs we've launched a project funded by our malpractice insurer to uh pilot bringing
coaches to um uh to surgeons in all of our affiliated hospitals and trying it out which means we have to learn how to teach people to be coaches and create a way to make it scalable to do those things like in sports you know we've scaled coaching all the way down to uh pewee league baseball yeah we
we have not remotely figured out how to do that as a routine part of being inside complex uh uh organizations are doing really complex things and we're we're now trying to learn how to make that part of what we do and and push the upper end of the excellent scale is it fair to say that the largest value
of a coach is actually being outside of that ecosystem and then showing you different perspectives on it because you're in that ecosystem and i'm trying to relate this back to like first year physics right where you're you're the guy standing on the train with the ball in your hand and it's like how
fast is the ball moving and you're like well relative to me which is what you see it's not moving at all but if you're outside of the train it's moving at the speed of the train and then the coach is the person outside of that train going like hey there's more to this system than you're seeing because you're
so involved in what you're doing well i would describe coaching slightly differently so um i distinguish between the coach and the mentor and there's a distinction between the coach and the teacher as well and oh yeah let's let's go into this yeah so the teaching technique would you know what you described
would be a teaching technique okay a coach has a few things they offer you an external version of your reality they also work with you to set a goal so here is where what what i see are the gaps in your performance or or what's going on what do you want to work on what what are your goals and it's a little
different so for example a tennis player hires the coach so you know my goal is i want to be get to number one well in order to get to number one here are the 10 things that are wrong in your game as i view it from the outside and you know you have to be able to feel that you trust the coach to have added
to your own perception and you're integrating their perception with yours and you may disagree in some places not but for for the most part you got to be willing to work with them and um but then the second thing is then you you are picking that goal a little more complicated if you're the coach on the basketball
team because they can bench you right you know they're not working for you yeah um but you're joining that team because you have a set of goals you have a coach to work with around your particular gaps and what you want to aim for but you have to buy into what the whatever the goals are you've got to
buy into them and then you're the agent of making closing that gap right now the coach may bring some teaching let me model for you how to really make this shot or let me suggest to you where you should move your feet and that kind of thing um or in the operating room let me suggest you you know think
about what other instruments to use but um uh at its ideal level you know for example now what am i working on with my coach in the operating room it's teaching how do i so i'm a real micro manager i i'm such a perfectionist i have a hard time giving a trainee any rope which i'm sure makes patients
happy i want to come down i want to talk about that in a second yeah um but uh you know there are ways to safely delegate and let people struggle and so my coach is working with me on like so if you want to be better at teaching people and get some better ratings on my teaching um i have to give people
a little more opportunity to struggle um and so my goal is 30 seconds i'm going to give them 30 seconds of struggling before i take over so like if there's if they can't find you know there's a part of in an operation where you might have to find a blood vessel or a nerve and they can't find it and i
get you know like let's move this case along here it is instead i'm like literally trying to get in the habit of counting in my head one two yeah it's so hard i can never get to 30 yeah but what's this in ways a parent right you watch your kids struggle and you're like you want to cut it off and give
them the answer it's much like much like parenting uh where so so that's the difference like a parent isn't teaching sometimes is the teacher but it's much more what do you want to do uh as you know you're asking your child what do you want to do what um what what's important to you and will you be
willing to have me give you feedback and some outside perspective on this sometimes not and i'm still going to give it to you and then and then they have to connect the dots that's that's ultimately the hard part is that they have to learn it so related to that i want i want to talk about the duty of care to
the patient and um as i understand it it's to give the patient the best possible care which uh would preclude a resident from doing it if there's somebody with more experience who's done it before and yet we have this kind of situation where we have to train doctors i'm curious to explore the tension between the duty
to provide the best care possible and the need to learn yeah and it's really hard because the um and then so it's a it's a short -term long -term question we will be unable to provide the best possible care to a given patient over time if we are are not also training people right and giving people opportunity
to learn so i want the most experienced person well the most experienced person is going to age out pretty soon and so we have to have that way to make that happen and so um it's like a lot of things in medicine my primary duty is to the benefit of this patient now regardless of whether i use the entire
world's resources in the process whether i fail to uh train anybody in that process whether nobody learns anything out of it um and the societal reality that we all benefit as patients if we have some understanding of i didn't use all the resources on this person and um and we have people who are learning
as we go along so since it's a problem of the commons how do we all benefit from it while not losing it all the the way i look at it is what really pisses people off about um training is if you're going to learn on me but not somebody else yeah if there's a privilege somebody who doesn't get it and so that when we
say well we'll learn on the homeless people or you know so the underlying social strata you see during training is there are some people who will be the people who you know the the medical student does their first suturing you know of their of their uh the cut on their you know on their face and then
there are the people who the chairman of surgery comes in and um he or she is you know no one's going to touch them except for you know x y z person and um part of getting to a better place is that we now a it's simply not permissible in american health care to have trainees uh taking care of most people
like you know the veterans administration used to be a place where it was a lot of people were being taken care of by trainees it's not possible you've taken care of with by a trainee who has not got supervision and so that's you know changing remarkably now though you have to create the safe space
that that the people can actually learn and that means um are acknowledging that uh that teams take care of people that um there are appropriate you know basically we we have this term um oh i'm because it's not a totally memorable term but it's basically that you have uh arrived at a place where you
have a kind of certified ability to do this part of things and maybe it's to you know you've reached the stage where um i've observed you you've done some practicing before you've done it on people now we've practiced on people and anybody might be the realm of who they practice on and now the medical
student has learned to do this and they are the one who can put in the nasogastric tube um and then at this level they can open and close the incision and at this level they can do most of the operation and that we really start to realize we have teams of people and this has also got to be the way we
improve outcomes in health care and lower the costs as we start pushing down the components of things that really don't need somebody with 50 years of experience that that you you have uh the team members who are uh uh who have learned to handle the different parts of the care and then knit it together
and more and more the role of the most experienced person is to make sure that all the parts come together that's that's the the irony is the most experienced people are doing some of the most mundane crap in the system and meanwhile there seems to be you know if your experience as a patient is that it's
as if nobody's in charge who is making sure all this stuff comes together oh i don't want to bother my doctor with you know calling up the other specialist who disagrees with them and sorting out what's going on because they're so busy that's crazy talk like yeah we need we need the most experienced
people on how are all of these components working together or not working together and then and then making it making that happen you you mentioned sort of medical costs i want to grab onto that and kind of run with it a bit and maybe from the outside looking in and from doctors that i've talked to
you from the inside looking at there's something wrong with medicine but what's wrong with medicine well there's there's a couple things to separate here though fact of rising health care costs is not the problem what is uh the problem is how much of the costs are rising that have that are not actually
connected in any way to value so an example would be that we have a substantial amount of health care that we provide that provides no benefit or makes you worse estimates are that about 30 of health care is waste it's going to things that are either much higher administrative costs that add no value
or are actual treatments and tests and procedures and drugs that are of no benefit or actively harmful you know i've written about for example there was a study of 26 different um tests and procedures ranging from uh eeg for headaches eegs are good for detecting seizures they're of no benefit for evaluating
people with headaches to cardiac catheterization for people with stable heart disease where medication management is actually the better way it is of no value or act of harm to do these things and it turned out that between 25 and 42 percent of medicare patients um of all medicare patients 25 to 42
percent will have one of those 26 things done to them in any given year and that's just 26 of the thousands of things that we do so you know that estimate of 30 percent uh is waste sounds incredible but in fact my experiences as well as lots of data is that that's the case um and so our ability to uh
begin and and the biggest problem there is again the lack of a system around this care that when you step back and actually begin to measure uh what are what are we doing to people and is it actually providing benefit and as we add more and more information we're getting more out of it i'll give one
example um in uh back surgery we have a bunch of studies showing that when you do back surgery for pain spinal spinal surgery for pain um as opposed for as opposed to for neurological symptoms where you have actual nerve damage but when it's for pain the average people have no um no benefit for disability
or pain at about uh nine months or so okay that the average person has not benefited and uh and so that has not filtered through and been adopted in any significant way but now we're beginning to deploy systems which actually track for your health system how do your patients actually do right lo and behold
they're showing the same thing yeah but seeing now in our system our surgeons are getting no benefit for this operation in reducing people's disability or pain um at nine months after this procedure so now we have information that suggests our system is just not working right so we need to we need to
and we can manage against that endpoint and we can you know goes back to those management metrics we talked about now i have a measure now i have a target let's not make that let's make it so the average person has significant benefit when we operate and uh and then we you know change the process and the ways
we do things and simplify it and get unnecessary wasted costs out of it and also take out the harm and we're still a long way away from uh managing in a systematic way that way what percentage of total medical expenditures approximately occur in the last like two months two years of life well so the last
year of life we know that 25 of medicare spending is in the last year of life and most of that's in the last few months so that's not 25 of all spending medicare is just after 65 that's about half of spending occurs after age 60 half of all your healthcare spending on average will be after your age
65 so that's a huge chunk um but it's not like you know i've seen people claiming that you know all of it is because of end of life care and that's not true either it's a substantial amount so maybe a philosophical question how how do you think about that how do you think we should think about that as
a society is it i come from canada so we have more socialized sort of health care system where the costs are rising obviously and these questions come up occasionally which is like what is that sort of duty of care to the patient if we're going to spend a hundred thousand dollars to extend somebody's
life for a week um how do you think about that can you expand on that yeah there's a couple things one is we think the u .s is a big outlier in this way but in fact it's not um when you look at um studies outside the u .s it's also fairly typical that it'd be around 23 to 25 of spending after age 65 the last
year of life and when you understand that um that what happens is that we are in a situation where when you come to the end of life you don't know when that last year of life is oh there's tremendous uncertainty and how we manage that uncertainty is the is the great difficulty and we manage it really
badly um and so this is the second part of it is that we assume that hey if i'm going to spend 100 000 that the problem is that we're um we're just not you know we have to make a brutal decision and say look it gives people an extra month of life and sorry you just don't get it it's not worth it um
there's a there's we should be a you mentioned brutal it'll also be almost unpalatable yes well and and that's why discussing end of life care and talking about what we do in when people have serious life limiting illnesses um was branded as a death panel and when i started writing about this it was to
try to understand it doesn't feel that way i'm a cancer surgeon yeah and what i what it feels like instead is it just feels like bad decision making yeah and and uh there um and this is what we found basically there's some key lessons uh and i'm a little embarrassed that it took me interviewing 200
patients and scores of practitioners to figure this out but um because it's going to seem so duh but this is what came out of my trying to write my last book it's going to be an article in the journal of boring right exactly this is all part of the journal so the the key lesson is that people have priorities
in their life besides just living longer they have goals for their quality of life as well as just and and not just surviving uh those goals and priorities differ from person to person and change over time for people and so you you have to ask people what their goals and priorities are we rarely ask
we just finished a survey in massachusetts and it's our third year of doing the survey and it hasn't but we're at 25 of people who have a serious life limiting illness in the last year and have been hospitalized only 25 have had that conversation about their goals and priorities for their quality of life
um uh with their clinician when we don't have that conversation the result is that the care is often out of alignment with people's priorities and goals and the result of that is suffering it also is the result is cost yeah we're often doing things that people don't want that are on the assumption that they
would sacrifice any amount of quality of life for the sake of studies that have been shown including a randomized trial at the mass general hospital with state for lung cancer patients who all died in the course of care and when they had conversations with a palliative care expert about their goals
for their quality of life the result was that they stopped their chemotherapy um two months earlier uh 50 lower likelihood that they would still be on chemotherapy two months before the end of their life they um spent about a third less money and time in the hospital and time in the icu and had more
time at home um and the kicker was they lived 25 longer which meant that making that last ditch operation the last ditch right line of chemotherapy when the four others didn't work is mostly adding toxicity and harm out of an inability to come to a good decision about what your goals and priorities
are and to honor them and to actually listen and so what what we're finding is when you that the flip side is when you actually have conversations with people and make it a normal part of what we do about your goals and priorities for your quality of life as well as for survival we make better decisions
about care they get they get better outcomes including they just feel better that you measure lower rates of anxiety and depression and getting pain under control better and avoiding nausea and all these things that actually matter to people they are more functional they're able to be at home and do
the things they want to do more and they live equally long if not longer in in the average situation it's probably a bit of a false duality in all situations but in some situations it does exist and how do you think about the tension personally in between um quantity of life and quality of life there
are certainly situations so a classic case and point is a patient who's in the icu on a ventilator uh suffering and they are not getting better they're just getting worse and we'll have a family discussion and when we don't have that discussion about what would this person be willing to go through for the sake
of another week where we can't make them better and what would they not be willing to go through and the family will say another week on a ventilator is not life to them that they would not consider them by the way it's not life to me so uh when we decide to then turn off the ventilator and remove the breathing
tube going down their throat and let them be comfortable where we may be shortening life they may lose that week too but it's it's a week of suffering and uh and many people would choose not to have that week not everybody and what's important is that we ask because there are some people yeah for whom they
would uh they would say i still want that week and and that's okay but it is not the vast majority it's over 85 percent who say that um that there are limits to what they are willing to endure for the sake of uh longer life two questions left one easy and one more philosophical uh and self -reflective
we'll start with the easy one which is uh what do you wish all patients knew what i wish all patients knew is what the role of the clinician ought to be and what their role is and that you can demand it and the the role of the clinician is not just to tell you the facts of what your situation is here's
your disease here are the options a b and c here the pros the cons the risks the benefits but the role of a clinician is also be a counselor and that means that the clinician should be someone who helps you understand and identify your goals given the cards in your hand right now which may not be a great hand but what matters
to you now and um they should then be able to help you understand here are the options here's the you know what what they understand about them but then help me match what my goal is with which one might give me my best shot at achieving that without sacrificing things that are important to me and your
role is that you need to help the clinician understand your goals and um and to be as clear as you can about that you know my father when he had his brain tumor um his first goal was he was a surgeon do not give me a treatment that's going to cost me my ability to keep doing surgery we already knew
was an incurable cancer so everything we were doing was to prolong life and to him life one of its key values was getting to continue to take care of patients and so you know having even with all of the experience in the room that my mother my father and i had as doctors we were all doctors we counted
120 years of experience in the room as we're talking to the oncologist and they go over eight different chemotherapies that he can have and we have no idea what like they're eight different combinations as much as they try to explain cannot understand yeah what all the choices are and so wanted the guidance
from the oncologist well which ones which option would allow him to do surgery not lose his ability to do surgery or when he did lose his ability to do surgery then his goal was well what i still love is being with people and so i want to be able to sit at the family dinner table and be around with family
or friends and actually still have enough energy to converse and enough mental capacity to do that which ones would have such severe side effects i'd be too wiped out or have to be in an institution or would be struggling to get to that dinner table those became the guideposts and i think the critical
thing for people to understand this isn't just about the end of life life is the accumulation of illnesses most of which you'll survive and now have have to manage as time goes on and you'll have medicines you'll need to be on and they'll have side effects and there'll be things that they help you do
and things that they might hurt you from doing you have to help us understand what your priorities and goals are for what matters in your life and then you have a right to ask and demand that we help you pick the choices that will best achieve those within the realm of what's actually possible it's
matching care to kind of your your goals and desires it's a matching problem yeah and and it's more complex than a simple algorithm or just knowing what the studies show you know understanding a person and what what matters to them can include things like i need to get to a wedding next week or i really
you know can't stand how much i've had to be in the hospital i just need a break right now and understanding what are the costs what are you know there's not an algorithm that gives the answers to these so that's the this is the area where you get into some necessary fallibility but but is some of the most
gratifying work you do as a clinician is is this kind of judgment and work with the patient i want to end with what is the greatest misperception that other people have about you and who you are i was going to start with that one but i figured it'd be too heavy um i think uh what are the greatest misperceptions
one one might be that um i'm smarter than i am i you know um a lot of what i do is really just try to figure out the simple stuff and um and and understand how you make that go and i think i sometimes get credit for um and i get a lot more credit for discovering things or making insights than i deserve
it's it's um i'm mostly connecting ideas that none of which i've created and just try to make them a little more salient at a given moment because it was turned out to be meaningful for me i think another thing is that i don't sleep i get i get plenty of sleep and um uh and then i think uh maybe another
one is that um is that uh i think i can seem pretty relaxed but i'm actually kind of a um uh ocd control freak so um uh anybody who has to work with me uh one of my colleagues here um knows uh that it's not easy actually working around me but you know it's it's uh i get to do really cool stuff and i
feel really lucky that i'm in a phase in my life where i spend all my time working on things i want to be working on and um but um uh it's all hard work and it's all you know putting in the hours and and uh and then deciding that um you know the reason i get my sleep is because i just i'm ruthless about prioritization yeah
i i just only just try to do no more than a couple of things at a time i may do something different in a couple months so it can make it seem like i'm doing a million things at once but i'm not actually i'm only doing one thing at a time this has been a phenomenal conversation i want to thank you so much
thank you shane it's a great pleasure to meet you and get get to get to talk to you in person thanks hey guys this is shane again just a few more things before we wrap up you can find show notes at fernomstreetblog .com .com.
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