English-Video.net comment policy

The comment field is common to all languages

Let's write in your language and use "Google Translate" together

Please refer to informative community guidelines on TED.com

TED2012

Atul Gawande: How do we heal medicine?

Filmed
Views 1,680,556

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

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

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

▲Back to top

About the speaker:

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

Why you should listen

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

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

Photo: Aubrey Calo

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