#42 Atul Gawande: The Path to Perpetual Progress
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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.com.

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 was recorded, he was named the CEO of the healthcare initiative between JPMorgan 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. A tool embodies all three.

This interview almost never happened, as my flight to Boston was cancelled 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. ♪

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I'm gonna 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 gonna 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 that? 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, you know,

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 University.

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 with

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 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. You know, I'm not, if you look at what I contribute in these spaces, it's not genius ideas. It's,

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 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 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 and like was there an aha moment that this makes sense? Or like 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 vantage 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 were 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. And so, you know,

My brain worked in such a way that I loved understanding the ideas at an ideas level and then trying to figure out how you ground it. So 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'd 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. One of my

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 the surgeons were, 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. And they...

And so 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. And 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 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 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 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

um, in a space that, uh, 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, uh, kind of, um, and, and meaningful domain to people, even though it, 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, um,

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 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 on climbing the learning curve, but now mystified and struggling with 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.

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 next stage, I'd found

that I could try solutions and borrow them from different places and Checklist Manifesto was, you know, so 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 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.

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 & Z use this checklist and surgery will cut the death rate 50%. 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 feel it's part of what they're doing. You know, we are, since we published our initial results, it's 2009, we had demonstrated in eight cities a 50% reduction in mortality.

you know i think we're past in that time 100 million of the world's 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 the world 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 healthcare, 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 see what should happen. The doctors should be washing their hands. The operation should be done in this following way. That's better than the other way. We've gathered the evidence. We've shown it to be true. And then we think, well, let's just train it. Let's just teach it.

And then you've taught everybody. In fact, that's our dominant way in healthcare that we make things happen. We just train people longer. And then you 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 so on. And it does make for some better outcomes. Things get slightly better, but it's a very 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 can be a checklist or it can be all kinds of things. But then the challenge is implementing that. And we've learned a lot about the components of implementing it. There's a pathway of implementation like code

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 gonna 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 and

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. Will this work as designed in our place and how do we have to change it? And you virtually always have to make changes. And so you need people who own things.

making it happen. 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 for 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 for making sure the system, that all of those 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. But it's really interesting 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 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 lives are unlikely. Like you can't find a single New England Journal 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 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 it often is really mundane things. One example.

We published some data on hospitals 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 country 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 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 make a kind of

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 that you do the better off 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. Yeah. 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

Um, 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, um, no, no real understanding of follow through innovation. And, um,

I think it's partly that the follow-through innovation can seem like it's only 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 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. And B, you know, we have 2 million people a year who pick up infections, mostly because someone didn't wash their hands. It's 100,000 lives lost a year. Like, you can save lives. 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 move on. I think you and I should create the Journal of Boring Things That Work, and we'll put click-baity headlines in there so people actually read it. Right. You won't believe what this blog uncovers about how we save lives. Wash your hands. Yeah.

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 Gorvitz and Alistair MacIntyre about human fallibility or necessary fallibility.

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.

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 valuability 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

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 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, Gorvitz and McIntyre. 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 all,

for like 99.99% of it, our world was governed largely by ignorance. We did not know the diseases that 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 economics worked, even in the most basic components. And

you know, now we're in a place in the 21st century where we haven't answered all the questions, but we have equally now a problem of ignorance and of what they call ineptitude. I prefer to call failure to deliver, a little less judgmental.

which is that you're-- that, you know, now we've discovered, for example, in healthcare, 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, in the right place without also bankrupting society. How do we make this happen? 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 making all of these things happen, understanding the variation in how human beings can have these things occur and what we know about how we can manage it. But then there's

the additional reality of necessary fallibility, as they called it, which is 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.

So even if we were to come to a complete understanding of all the laws of the universe, 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 in order to be able to drive that. 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, our capabilities, 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 to deliver because that word has a judgment applied to it. 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 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 people responsible and we should. 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 an M&M program.

Morbidity and Mortality Conference. Morbidity and Mortality Conference. I was wondering if you can give us some insight into that. Yeah. We just had ours today. Is it today? No, it was yesterday. So this is a conference we have every week, 7 o'clock for an hour. And in that meeting, we bring the...

complications which is to say the cases that had things go wrong where where the patient had a bad outcome and we're specifically bringing up the cases where 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 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, 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. 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 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. 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 than we can possibly fit into that meeting. And that process, however, has gotten us to a place where we have lower and lower and lower and lower death rates, faster and faster recovery of people, people doing better and better, and higher and higher expectations of ourselves. Yeah.

about what we can pull off. 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 this kind of continuum between the two. In fact, it's like there's some shame to not

being able to admit that you have something that you-- so the irony is surgeons are very confident people. You can't go into an operating room and do an operation without a kind of slightly absurd sense of confidence in yourself.

Sometimes wrong, never in doubt, it would be our mantra. But in that room, there's a kind of humility expected that is, you know, it's not cool in that room to like, you know, flagellate yourself over the whole thing. It's in a way a kind of emotionless presentation of

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. Yeah.

the nurses' fault, the anesthesiologist's fault, whatever. But then the problem is that you didn't bring them in the room. Like they should be here as well if they're a part of it. They should have been there. 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 on it. Now, creating that space is a combination of...

It's been surgery couldn't get off the ground in the early part of the century without creating that place where you could work on engineering. Why are so many people dying? How do we cut down the infection rate? What do we do about making this very complicated thing work? And so we developed that culture. The making that be not punitive culture

So the minute it starts to become something where, and you're chucked out, you know, we're going to use this again, 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 opposite is the toxic organization where admitting failure just opens you up to attack and removal. So it's...

There are structures that can make it – that are important to that, like not making it so that you're sued for your – for talking about these things. But it is so much more about the culture that you build. And in the country at large, we don't live in that space. We still are in a space where presidents acknowledging mistakes –

is seen still as a kind of weakness. 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. And I was like, it's remarkable to me how these people have so much intelligence and so many different domains, but how 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 pilots example is one where NASA also has a protected space where if you submit a report

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 get out of jail free card. So by reporting on it, you are not 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, um, falsify information. Um, you hide information. You, um,

or you are actively subverting the system or 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 fallibility, human weakness, the, 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 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 the leader has made it so people can actually speak up, a woman named Amy Edmondson has done a lot of research on how you create psychological safety. And it's creating a place where you know it because everybody is speaking with an equal voice. People from the highest level to the lowest level, they have all been able to contribute.

And when that exchange is the way 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 that

that people in the room all discuss the case, the anesthesiologist, the nurse and the surgeon to discuss what are the medical issues of the patient, what's our plan for the day, what are our worries, what are the non-routine things that can go wrong, is the equipment and everything else in place.

At the start, we ask people to introduce themselves by name and role. And it's like coming into a meeting room and everybody goes around and introduce themselves. And what we found is that that activates the likelihood that everybody will speak up. And if it's run well, then everybody has spoken. And we can see that the places where that ability from the medical student to the most experienced clinician in the room

It's not... You can see places where it's the surgeon doing all the talking and you can see places where it's the nurse doing all the talking. And the power differential has gotten out of whack. Why do you think that is? Just the mere matter of kind of introducing yourself with your role, is it because we identify with our roles? What is it behind that that gives you the confidence to be like, oh, no? I think... So...

Now, not well studied in the operating room, but the reasonable evidence from psychologists looking at this question that when people have gotten to speak in a room, just by introducing yourself saying, here's my name, here's where I'm from, 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, okay,

I'm here. This is who I am. That removes your barrier of wondering whether I'm even allowed to speak in this room. Right. So it's that psychological. It's almost like giving you permission to speak. 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 to get better at surgery? I know you wrote a New York article about hiring a coach. Yeah. Can you expand on that? Yeah. So, you know, what's interesting about the work as it's gone along is –

The first step is trying to make sure you don't do the stupid things that people already know about that demonstrably get to better results. Do your checklist. Don't make the dumb mistakes. 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.

The pedagogical theory is you go to Juilliard, 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 technology,

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, um, 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. It's certainly true in sports that when you've had teams, you know, you go back to the first football games, American football games,

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 coached. We just know. Right. And, uh, Yale won something like over the next,

a 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 article 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. You had plateaued. I'd plateaued. 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 Including where I was standing and how I used the light in the field and you know these things that I had That I couldn't see for myself and it's an important part of what a coach does is they provide an external Check on your understanding of your reality. It's different from a mentor a mentor is a

A lot of coaches that I hear about, the 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 some way to get an external fix on your reality. Well, we've actually now at Ariadne Labs, we've launched

funded by our malpractice insurer to pilot bringing coaches 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 those things. Like in sports, you know,

We've scaled coaching all the way down to Pee Wee League baseball. Yeah. We have not remotely figured out how to do that as a routine part of being inside complex organizations or doing really complex things. And we're now trying to learn how to make that part of what we do and push the upper end of the excellence 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 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, right?

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 I distinguish between the coach and the mentor. And there's a distinction between the coach and the teacher as well. Oh, yeah. Let's go into this. Yeah. So the teaching technique would... 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 you

But then the second thing is then you are picking that goal. A little more complicated if you're the coach on the basketball team because they can bench you. Right, yeah. They're not working for you. Yeah. 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, uh, 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 to you, you know,

think about what other instruments to use. But 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 micromanager. 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. But

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. 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 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. Like, here it is. Instead, I'm like literally trying to get in the habit of counting in my head one, two. It's so hard. I can never get to 30. Yeah, well, it's the same way as 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 parenting where, 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? As you know, you're asking your child. What do you want to do? What 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 gonna give it to you. Yeah, and then and then they have to connect the dots and

That's ultimately the hard part is that they have to learn it. So related to that, I want to talk about the duty of care to the patient. And as I understand it, it's to give the patient the best possible care, which 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, and so it's a short-term, long-term question. We will be unable to provide the best possible care to a given patient.

patient over time if we are not also training people 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 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 or

the process whether I fail to Train anybody in that process whether nobody learns anything out of it 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 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, losing it all? The way I look at it is what really pisses people off about training is if you're going to learn on me, but not somebody else. If there's a privileged 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's

There are some people who will be the people who, you know, the medical student does their first suturing, you know, of their, of their, the cut on their, you know, on their face. And then there are the people who the chairman of surgery comes in and he or she is, you know, no one's going to touch them except for, you know,

XYZ person. And part of getting to a better place is that we now, A, it's simply not permissible in American healthcare to have trainees 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 to be taken care of by a trainee who has not got supervision. And so that's

changing remarkably.

Now, though, you have to create the safe space that the people can actually learn. And that means our acknowledging that teams take care of people, that there are appropriate, you know, basically we have this term, oh, I'm going to forget the term, because it's not a totally memorable term, but it's basically that you have arrived at a place where you have

kind of certified ability to do this part of things and maybe it's to you know, you've reached the stage where 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

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 healthcare and lower the costs is we start pushing down the components of things that really don't need somebody with 50 years of experience. That you have the team members who are...

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 and,

Yeah. In the system. And meanwhile, there seems to be, you know, 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 we need the most experienced people on how are all of these conversations

components working together or not working together and then making that happen. You mentioned sort of rising 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 from the inside looking out, there's something wrong with medicine. But what's wrong with medicine? Well, there's a couple of things to separate here. The fact of rising health care costs is not the problem.

What is the problem is how much of the costs are rising 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 healthcare 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 tests and procedures ranging from 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 active harm to do these things.

And it turned out that between 25 and 42% of Medicare patients, of all Medicare patients, 25 to 42% 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%.

is waste sounds incredible, but in fact, my experiences as well as lots of data is that that's the case. And so our ability to begin, 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 the

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. In back surgery, we have a bunch of studies showing that when you do back surgery for pain, spinal surgery for pain, 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? Lo and behold, they're showing the same thing. But seeing now in our system,

Our surgeons are getting no benefit for this operation and reducing people's disability or pain at nine months after this procedure. So now we have information that suggests our system's just not working. Right. And so we need to, we need to, and we can manage against that endpoint. And we can, you know, it 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 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 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 health care spending on average will be after you're age 65. So that's a huge chunk. 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 do you think about that? How do you think we should think about that as a society? 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 $100,000 to extend somebody's life for a week?

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. When you look at studies outside the U.S., it's also fairly typical that it'd be around 23 to 25 percent of spending after age 65 in the last year of life. And

When you understand 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. There's tremendous uncertainty. And how we manage that uncertainty is the great difficulty. And we manage it really badly. And so this is the second part of it, is that we assume that, hey, if I'm going to spend $100,000...

Um, that the problem is that we're, um, uh, we're just not, you know, we have to make a, uh, brutal decision and say, look, it gives, 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, which would be a, a,

You mentioned brutal. It'd also be almost unpalatable. Yes. Well, and that's why discussing end-of-life care and talking about what we do when people have serious life-limiting illnesses 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 and what it feels like instead is it just feels like bad decision making. And this is what we found.

Basically, there's some key lessons. And I'm a little embarrassed that it took me interviewing 200 patients and scores of practitioners to figure this out, 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 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 not just surviving. Those goals and priorities differ from person to person and change over time for people. And so 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 budged. 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 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.

but also as a 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 quantity of life

Now, there's further studies that have been shown, including a randomized trial at the Mass General Hospital with stage four 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 two months earlier, 50% lower likelihood that they would still be on chemotherapy two months before the end of their life.

They spent about a third less money and time in the hospital and time in the ICU and had more time at home. And the kicker was they lived 25% longer, which meant that making that last ditch operation, the last ditch, fifth 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 we're finding is 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 better outcomes including they just feel better. 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 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 between quantity of life and quality of life? There are certainly situations. So a classic case in point is a patient who's in the ICU on a ventilator,

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 that. And by the way, it's not life to me. So

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 or two. But it's a week of suffering. 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 for whom they would say, I still want that week. And that's okay. But it is not the vast majority. It's over 85% who say that there are limits to what they are willing to endure for the sake of longer life. Yeah.

Two questions left, one easy and one more philosophical and self-reflective. We'll start with the easy one, which is 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 role of the clinician is

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 are 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 they should then be able to help you understand, here are the options. Here's 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...

is that you need to help the clinician understand your goals and to be as clear as you can about that. You know, my father, when he had his brain tumor, 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 it 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

And we have no idea what, like there are eight different combinations. As much as they try to explain, cannot understand 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 I 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 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 that.

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 goals and desires. It's a matching problem, yeah. And it's more complex than a simple algorithm or just knowing what the studies show. You know, understanding a person and 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 the, 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 some of the most gratifying work you do as a clinician 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, I, you know, um, a lot of what I do is really just try to figure out the simple stuff. And, um,

And understand how you make that go. And I think I sometimes get credit for... I get a lot more credit for discovering things or making insights than I deserve. It's... I'm mostly connecting...

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. Uh, I think another thing is that I don't sleep. I get, I get plenty of sleep and, um, 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 OCD control freak. So anybody who has to work with me, one of my colleagues here, knows that it's not easy actually working around me. But, you know, it's...

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

Because I just, I'm ruthless about prioritization. Yeah. 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 of months so I 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 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 farnamstreetblog.com slash podcast. That's F-A-R-N-A-M-S-T-R-E-E-T-B-L-O-G dot com slash podcast. You can also find information there on how to get a transcript.

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