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TED2017

Atul Gawande: Want to get great at something? Get a coach

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How do we improve in the face of complexity? Atul Gawande has studied this question with a surgeon's precision. He shares what he's found to be the key: having a good coach to provide a more accurate picture of our reality, to instill positive habits of thinking, and to break our actions down and then help us build them back up again. "It's not how good you are now; it's how good you're going to be that really matters," Gawande says.

- 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 don't come to you today as an expert.
00:12
I come to you as someone
who has been really interested
00:14
in how I get better at what I do
00:17
and how we all do.
00:20
I think it's not just
how good you are now,
00:23
I think it's how good you're going to be
that really matters.
00:25
I was visiting this birth center
in the north of India.
00:29
I was watching the birth attendants,
00:32
and I realized I was witnessing in them
an extreme form of this very struggle,
00:34
which is how people improve
in the face of complexity --
00:39
or don't.
00:43
The women here are delivering in a region
00:46
where the typical birth center
has a one-in-20 death rate for the babies,
00:48
and the moms are dying at a rate
ten times higher than they do elsewhere.
00:54
Now, we've known the critical practices
00:59
that stop the big killers
in birth for decades,
01:02
and the thing about it is
that even in this place --
01:05
in this place especially,
01:09
the simplest things are not simple.
01:11
We know for example you should wash hands
and put on clean gloves,
01:13
but here,
01:18
the tap is in another room,
01:19
and they don't have clean gloves.
01:22
To reuse their gloves,
01:25
they wash them in this basin
of dilute bleach,
01:26
but you can see there's still blood
on the gloves from the last delivery.
01:30
Ten percent of babies are born
with difficulty breathing everywhere.
01:39
We know what to do.
01:43
You dry the baby with a clean cloth
to stimulate them to breathe.
01:44
If they don't start to breathe,
01:48
you suction out their airways.
01:50
And if that doesn't work,
you give them breaths with the baby mask.
01:52
But these are skills that they've learned
mostly from textbooks,
01:57
and that baby mask is broken.
02:01
In this one disturbing image for me
02:09
is a picture that brings home
just how dire the situation is.
02:12
This is a baby 10 minutes after birth,
02:17
and he's alive,
02:19
but only just.
02:22
No clean cloth,
02:24
has not been dried,
02:25
not warming skin to skin,
02:27
an unsterile clamp across the cord.
02:31
He's an infection waiting to happen,
02:34
and he's losing
his temperature by the minute.
02:35
Successful child delivery
requires a successful team of people.
02:41
A whole team has to be
skilled and coordinated;
02:45
the nurses who do the deliveries
in a place like this,
02:47
the doctor who backs them up,
02:50
the supply clerk who's responsible
for 22 critical drugs and supplies
02:52
being in stock and at the bedside,
02:56
the medical officer in charge,
02:59
responsible for the quality
of the whole facility.
03:00
The thing is they are all
experienced professionals.
03:05
I didn't meet anybody who hadn't been
part of thousands of deliveries.
03:09
But against the complexities
that they face,
03:15
they seem to be at their limits.
03:18
They were not getting better anymore.
03:21
It's how good you're going to be
that really matters.
03:25
It presses on a fundamental question.
03:32
How do professionals
get better at what they do?
03:35
How do they get great?
03:39
And there are two views about this.
03:41
One is the traditional pedagogical view.
03:42
That is that you go to school,
03:45
you study, you practice,
you learn, you graduate,
03:47
and then you go out into the world
03:50
and you make your way on your own.
03:52
A professional is someone who is capable
of managing their own improvement.
03:54
That is the approach that virtually
all professionals have learned by.
03:59
That's how doctors learn,
04:04
that's how lawyers do,
04:05
scientists ...
04:07
musicians.
04:09
And the thing is, it works.
04:12
Consider for example legendary
Juilliard violin instructor Dorothy DeLay.
04:15
She trained an amazing roster
of violin virtuosos:
04:20
Midori, Sarah Chang, Itzhak Perlman.
04:24
Each of them came to her as young talents,
04:26
and they worked with her over years.
04:30
What she worked on most, she said,
04:32
was inculcating in them
habits of thinking and of learning
04:34
so that they could make their way
in the world without her
04:38
when they were done.
04:41
Now, the contrasting view
comes out of sports.
04:45
And they say "You are never done,
04:50
everybody needs a coach."
04:52
Everyone.
04:54
The greatest in the world needs a coach.
04:56
So I tried to think
about this as a surgeon.
05:01
Pay someone to come
into my operating room,
05:05
observe me and critique me.
05:10
That seems absurd.
05:14
Expertise means not needing to be coached.
05:16
So then which view is right?
05:20
I learned that coaching came into sports
as a very American idea.
05:25
In 1875,
05:30
Harvard and Yale played one of the very
first American-rules football games.
05:32
Yale hired a head coach;
05:36
Harvard did not.
05:39
The results?
05:41
Over the next three decades,
05:42
Harvard won just four times.
05:44
Harvard hired a coach.
05:47
(Laughter)
05:50
And it became the way that sports works.
05:52
But is it necessary then?
05:56
Does it transfer into other fields?
05:57
I decided to ask, of all people,
06:01
Itzhak Perlman.
06:03
He had trained the Dorothy DeLay way
06:05
and became arguably the greatest
violinist of his generation.
06:08
One of the beautiful things about
getting to write for "The New Yorker"
06:12
is I call people up,
and they return my phone calls.
06:16
(Laughter)
06:19
And Perlman returned my phone call.
06:20
So we ended up having
an almost two-hour conversation
06:23
about how he got
to where he got in his career.
06:25
And I asked him, I said,
"Why don't violinists have coaches?"
06:30
And he said, "I don't know,
06:34
but I always had a coach."
06:37
"You always had a coach?"
06:39
"Oh yeah, my wife, Toby."
06:41
They had graduated
together from Juilliard,
06:45
and she had given up her job
as a concert violinist
06:48
to be his coach,
06:52
sitting in the audience,
06:53
observing him and giving him feedback.
06:55
"Itzhak, in that middle section,
06:57
you know you sounded
a little bit mechanical.
07:00
What can you differently next time?"
07:03
It was crucial to everything
he became, he said.
07:06
Turns out there are numerous problems
in making it on your own.
07:10
You don't recognize the issues
that are standing in your way
07:15
or if you do,
07:18
you don't necessarily
know how to fix them.
07:19
And the result is
that somewhere along the way,
07:21
you stop improving.
07:24
And I thought about that,
07:28
and I realized that was exactly
what had happened to me as a surgeon.
07:30
I'd entered practice in 2003,
07:34
and for the first several years,
07:37
it was just this steady, upward
improvement in my learning curve.
07:38
I watched my complication rates drop
from one year to the next.
07:43
And after about five years,
07:47
they leveled out.
07:48
And a few more years after that,
07:51
I realized I wasn't getting
any better anymore.
07:52
And I thought: "Is this
as good as I'm going to get?"
07:56
So I thought a little more and I said ...
08:00
"OK,
08:03
I'll try a coach."
08:05
So I asked a former professor
of mine who had retired,
08:07
his name is Bob Osteen,
08:11
and he agreed to come to my operating room
08:13
and observe me.
08:16
The case --
08:19
I remember that first case.
08:20
It went beautifully.
08:21
I didn't think there would be
anything much he'd have to say
08:23
when we were done.
08:26
Instead, he had a whole page
dense with notes.
08:27
(Laughter)
08:31
"Just small things," he said.
08:33
(Laughter)
08:34
But it's the small things that matter.
08:35
"Did you notice that the light
had swung out of the wound
08:39
during the case?
08:42
You spent about half an hour
08:43
just operating off the light
from reflected surfaces."
08:45
"Another thing I noticed," he said,
08:49
"Your elbow goes up in the air
every once in a while.
08:51
That means you're not in full control.
08:54
A surgeon's elbows should be down
at their sides resting comfortably.
08:57
So that means if you feel
your elbow going in the air,
09:01
you should get a different instrument,
or just move your feet."
09:04
It was a whole other level of awareness.
09:09
And I had to think,
09:14
you know, there was something
fundamentally profound about this.
09:17
He was describing what great coaches do,
09:21
and what they do is they are
your external eyes and ears,
09:24
providing a more accurate
picture of your reality.
09:27
They're recognizing the fundamentals.
09:31
They're breaking your actions down
09:33
and then helping you
build them back up again.
09:36
After two months of coaching,
09:38
I felt myself getting better again.
09:40
And after a year,
09:43
I saw my complications
drop down even further.
09:44
It was painful.
09:49
I didn't like being observed,
09:51
and at times I didn't want
to have to work on things.
09:54
I also felt there were periods where
I would get worse before I got better.
09:57
But it made me realize
10:01
that the coaches were onto something
profoundly important.
10:02
In my other work,
10:09
I lead a health systems innovation center
called Ariadne Labs,
10:10
where we work on problems
in the delivery of health care,
10:14
including global childbirth.
10:18
As part of it,
10:20
we had worked with
the World Health Organization
10:21
to devise a safe childbirth checklist.
10:24
It lays out the fundamentals.
10:26
It breaks down the fundamentals --
10:28
the critical actions
a team needs to go through
10:30
when a woman comes in in labor,
10:33
when she's ready to push,
10:35
when the baby is out,
10:37
and then when the mom and baby
are ready to go home.
10:39
And we knew
10:42
that just handing out a checklist
wasn't going to change very much,
10:43
and even just teaching it in the classroom
wasn't necessarily going to be enough
10:46
to get people to make the changes
that you needed to bring it alive.
10:51
And I thought on my experience and said,
10:55
"What if we tried coaching?
10:57
What if we tried coaching
at a massive scale?"
11:00
We found some incredible partners,
11:04
including the government of India,
11:07
and we ran a trial there
in 120 birth centers.
11:10
In Uttar Pradesh,
in India's largest state.
11:13
Half of the centers
basically we just observed,
11:17
but the other half
got visits from coaches.
11:23
We trained an army
of doctors and nurses like this one
11:25
who learned to observe the care
and also the managers
11:29
and then help them
build on their strengths
11:34
and address their weaknesses.
11:36
One of the skills for example
they had to work on with people --
11:38
turned out to be
fundamentally important --
11:41
was communication.
11:44
Getting the nurses to practice speaking up
when the baby mask is broken
11:45
or the gloves are not in stock
11:49
or someone's not washing their hands.
11:51
And then getting others,
including the managers,
11:53
to practice listening.
11:55
This small army of coaches
ended up coaching 400 nurses
11:57
and other birth attendants,
12:02
and 100 physicians and managers.
12:04
We tracked the results
across 160,000 births.
12:07
The results ...
12:13
in the control group you had --
12:15
and these are the ones
who did not get coaching --
12:17
they delivered on only one-third
of 18 basic practices
12:19
that we were measuring.
12:23
And most important was
over the course of the years of study,
12:25
we saw no improvement over time.
12:28
The other folks
got four months of coaching
12:30
and then it tapered off over eight months,
12:33
and we saw them increase
12:35
to greater than two-thirds
of the practices being delivered.
12:37
It works.
12:42
We could see the improvement in quality,
12:43
and you could see it happen
across a whole range of centers
12:47
that suggested that coaching
could be a whole line of way
12:50
that we bring value to what we do.
12:53
You can imagine the whole job category
that could reach out in the world
12:56
and that millions of people could fulfill.
13:00
We were clearly
at the beginning of it, though,
13:04
because there was still a distance to go.
13:06
You have to put
all of the checklist together
13:08
to achieve the substantial
reductions in mortality.
13:10
But we began seeing the first places
that were getting there,
13:14
and this center was one of them
13:17
because coaching helped them
learn to execute on the fundamentals.
13:19
And you could see it here.
13:24
This is a 23-year-old woman
13:27
who had come in by ambulance,
13:30
in labor with her third child.
13:32
She broke her water in the triage area,
13:35
so they brought her directly
to the labor and delivery room,
13:41
and then they ran through their checks.
13:44
I put the time stamp on here
13:46
so you could see
how quickly all of this happens
13:48
and how much more complicated
that makes things.
13:51
Within four minutes,
13:54
they had taken the blood pressure,
measured her pulse
13:55
and also measured
the heart rate of the baby.
13:59
That meant that the blood pressure cuff
and the fetal Doppler monitor,
14:02
they were all there,
and the nurse knew how to use them.
14:05
The team was skilled and coordinated.
14:08
The mom was doing great,
14:11
the baby's heart rate was 143,
which is normal.
14:12
Eight minutes later, the intensity
of the contractions picked up,
14:16
so the nurse washed her hands,
14:20
put on clean gloves,
14:22
examined her and found
that her cervix was fully dilated.
14:23
The baby was ready to come.
14:27
She then went straight over
to do her next set of checks.
14:29
All of the equipment,
she worked her way through
14:33
and made sure she had everything
she needed at the bedside.
14:35
The baby mask was there,
the sterile towel,
14:38
the sterile equipment that you needed.
14:40
And then three minutes later,
one push and that baby was out.
14:42
(Applause)
14:48
I was watching this delivery,
14:52
and suddenly I realized that the mood
in that room had changed.
14:54
The nurse was looking
at the community health worker
15:00
who had come in with the woman
15:02
because that baby
did not seem to be alive.
15:04
She was blue and floppy and not breathing.
15:08
She would be one of that one-in-20.
15:12
But the nurse kept going
with her checkpoints.
15:16
She dried that baby with a clean towel.
15:19
And after a minute,
when that didn't stimulate that baby,
15:22
she ran to get the baby mask
15:25
and the other one went to get the suction.
15:28
She didn't have a mechanical suction
because you could count on electricity,
15:31
so she used a mouth suction,
15:35
and within 20 seconds,
15:36
she was clearing out
that little girl's airways.
15:37
And she got back a green, thick liquid,
15:40
and within a minute
of being able to do that
15:42
and suctioning out over and over,
15:44
that baby started to breathe.
15:46
(Applause)
15:47
Another minute and that baby was crying.
15:53
And five minutes after that,
15:57
she was pink and warming
on her mother's chest,
15:59
and that mother reached out
to grab that nurse's hand,
16:02
and they could all breathe.
16:05
I saw a team transformed
because of coaching.
16:09
And I saw at least one life
saved because of it.
16:13
We followed up with that mother
a few months later.
16:17
Mom and baby were doing great.
16:20
The baby's name is Anshika.
16:23
It means "beautiful."
16:27
And she is what's possible
16:30
when we really understand
16:31
how people get better at what they do.
16:33
Thank you.
16:36
(Applause)
16:37

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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