The Knowledge Project with Shane Parrish - #42 Atul Gawande: The Path to Perpetual Progress

Episode Date: October 2, 2018

The world-renowned surgeon, writer, and researcher Atul Gawande shares powerful lessons about creating a culture of safe learning, the critical difference between a coach and a mentor, and how to ensure constant improvement in key areas of your personal and professional life.   Go Premium: Members get early access, ad-free episodes, hand-edited transcripts, searchable transcripts, member-only episodes, and more. Sign up at: https://fs.blog/membership/   Every Sunday our newsletter shares timeless insights and ideas that you can use at work and home. Add it to your inbox: https://fs.blog/newsletter/   Follow Shane on Twitter at: https://twitter.com/ShaneAParrish   Learn more about your ad choices. Visit megaphone.fm/adchoices

When we all have a piece of care or a piece of a problem, very often none of us can actually see what the outcome is and the owner can't see the function of the system. And so then you start finding things like data really matter. Hello and welcome. I'm Shane Parrish and this is another episode of the Knowledge Project, a podcast exploring the ideas, methods, and mental models that help you learn from the best of what other people have already figured out. To learn more about the show, go to fs.blog slash podcast. My guest today is Atul Gawande.

A tool is a globally renowned surgeon, writer, and public health innovator. He's written for 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. Attila's dedicated his career to not only building but scaling better health care delivery. Shortly after this interview is recorded, he was named the CEO of the health care initiative between J.P. Morgan Chase, Berkshire Hathaway and Amazon.com. Commenting on the initiative, Amazon.com, CEO Jeff Bezos, said the degree of difficulty is high

and success is going to require an expert's knowledge, a beginner's mind, and a long-term orientation. A tool embodies all three. This interview almost never happened, as my flight to Boston was canceled because of weather more times than I can count. I think you'll see how persistence was rewarded when you listened to this wide-raging conversation. Let's get started. I'm going to ask you a question. I was debating on the flight over here today, how I wanted to start this interview. And I think we're going to go back to like med school, which, 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.

Some in science. I worked in a lab. Some, you know, I tried everything in college. I was in a band. I learned to play guitar. I wrote music reviews for the student newspaper. I joined Amnesty International. I worked on Gary Hart's very short-lived campaign for president as a volunteer. And then when I got out of Stanford, I went on to do a master's degree in politics and philosophy economics at Oxford, out of hope that I could maybe do a graduate degree in political theory or something like that. And I just found I wasn't very good at those questions. And a lot of the things that I tried, I just wasn't really made for or cut out for. And I kept coming back to medicine as a place where I was familiar, I was comfortable. it wasn't for the best reasons, right? It was a place that I knew and I could thrive. What I also liked about it was you didn't actually have to decide

what you wanted to be when you grew up. So it deferred all kinds of decisions while I figured out everything else along the way. So when I got out of graduate school and decided just stop with a master's degree in philosophy, and then I worked actually in politics for a couple of years on the hill and found I didn't want to just work in politics. I kept finding myself gravitating back to medicine where you could have skill.

The values were at the core of it for me, that it was about grappling with how science meets humanity in a place where and policy and the world and all the complexities of life. in a place where you could really think about the individual in front of you, but also the system as a whole. And I wanted to somehow connect on both levels. It's interesting to hear you say that you felt like you weren't good at something

because from the outside looking in, you're a surgeon, a prolific writer on multiple subjects, at the New Yorker, multiple books. And so it looks like, and a researcher on top of all of that, right? Not to mention a husband and a father. So it looks like failure is not really in your vocabulary. Well, but A, it doesn't mean I do all of those things well. And B, you know, I like having a lot of irons in the fire.

I like being a jack of all trades. And finding the edges between things is often where I have something to add. You know, I'm not, if you look at what I contribute in these spaces, it's not genius ideas, a checklist for surgery. It's just taking an idea from one domain and saying, let's bring it over to the other and see if it can work. Or, you know, understanding what people's goals are when they face mortality in the end of life. A lot of them just come from digging in deep enough to understand the gap between what we're aspiring. for and the reality of what we're doing and then trying to figure out where the bridge is to narrow that wide gap and so most of my value just comes from saying and pointing out wow we don't

live up to what we say we're going to do it's it's not for usually not for evil reasons it's usually for really complicated reasons and then unnotting the complexity um and just taking time to do that, I find in each line of work, whether it's surgery, our public health research center, where we're sitting today, Ariadne Labs, or my writing, I'm just doing the same thing over and over again, actually. Was it conscious to apply ideas from other domains, or was there an, 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 handlehold was through science.

My parents were doctors. And that gave me a way of seeing and thinking about the world. But then my parents were also people who are deeply. involved in the community in trying to deal with the challenges in a community that had a college, but was also the poorest county in Ohio. And so, you know, my brain worked in such a way that I loved the understanding the ideas at a 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've been learning about.

In your book Complications, one of the things that you explore is what makes a good doctor. Can you expand on that for us? Well, in some ways, I think I've been interested in that from the very beginning. So Complications was written out of my early New Yorker articles where I was a trainee in surgery and I was very interested in what does it mean to be good at what we do as a doctor. When I'm still learning, I'm practicing on human beings. One of 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 to 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.

They were factory. They did a dozen hernia's a day. 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, you know, 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 cost? What does it mean to be good with care at the end of life? What does it mean to be good at what we do when the science is exploding faster than we can understand it? What does it mean to be good when, you know, there's a new piece of data that comes out that says, this is the latest, greatest breakthrough drug, but now I've been around long enough to have seen where some of them don't turn out to work in the long run.

So is it good to be conservative? Is it good to be, you know, take the first thing out of the box? There's so many interesting questions in the space. And I feel like they're very general questions. Medicine is just a place where you're applying these very basic questions in a space that you have lives on the line and you have a lot of money and you have a lot of complexity. And so it makes it a really interesting kind of and meaningful domain to people, even though I think a lot of the things I'm asking about apply widely.

What's changed in your mind about what it meant to be a good doctor since you were a resident writing that and today? I think it's evolved. 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, 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 then becomes what you start thinking about. Of course, it was, you know, not coincidentally turning 50, not coincidentally having a dad who was diagnosed with a brain tumor,

not coincidentally having more than a decade of having to talk to people about these kinds of situations and not feeling like I was doing very well. And again, it was recognizing, boy, there's a gap here between what we think should be happening in the ways we deal with mortality and how we understand it and the reality of what we do day to day. And digging in there was where I've gone. And so it's just this progressive process. And I feel like now for the last five, six years, it's actually gotten harder to write about in some ways. I'm really trying to wrap my mind around how you change systems. So checklist manifesto was, here's a solution that, boy, if you did X, Y, and Z, use this checklist and surgery. It'll 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 they feel it's part of what they're doing you know we we are um since we published our initial results as 2009 we um had demonstrated in eight cities a 50 percent reduction of mortality you know i think we're passed in that time a hundred 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 health care, economics, schools, work at scale. What have you learned about what we know about changing systems, not only in maybe the medical field, but other systems or other large organizations that would have maybe not

sort of the same consequences as medicine, but similar complexity? Well, I think that there's 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 challenges implementing that. And we've learned a lot about the components of implementing it. There's a pathway of implementation like doing a big bang, as we call it, you know, saying everybody in our hospital is all going to use this checklist tomorrow and we're going to do

that in a big bang. Just it's never worked. We've never seen it work at all with thousands of places are rolled out, never seen a work. Instead, you have to do a process of gather a team, a team of champions. They have to look at this thing that you want to do and ask questions. 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 making it happen. And 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 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 doc. Not me. Like, you know, who's responsible for making sure the supplies arrive? Well, there's a supply clerk.

Who's responsible for, you know, the nurses knowing what to do? Well, the nurses are responsible for that. But who's responsible making sure the system that all of those things come together? There is no owner. So creating an owner is one of the, 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, 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 suddenly you're into all these really unsexy things. You've got owners and managers and you have data like. But the lives are unlike. Like you don't 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've 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 Raphaelah Sedun, 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. One, do you hire for talent and their ability to achieve your main goals and objectives? 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 a checklist for the key things that you are your key targets and what you're trying to accomplish? And we now 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 health care, they keep on going. And the only thing we have going for us is the schools are even worse on our measurement scores. I want to go back to something you said about the New England Journal and how every week there's something coming out that's new and novel. and yet we're attracted to that and we're not attracted to the boring, more fundamental things that make a quantifiably make a larger difference. Why do you think that is? Well, so, I mean, I've called it that we've been fantastic at breakthrough innovation

and we've had no real understanding of follow-through innovation. And I think it's partly that the follow-through innovation can seem like it's only about 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 break, through 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. 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 eyes 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 two 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. 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-bady 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. 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 reference. which was Samuel Gorvitz and Aleister McIntyre about human valuability

or necessary fallibility. And they kind of said we fail for two reasons. One is that we're ignorant, the other is that were inept. And at the time, I was working for an intelligence agency. And I started to see all of these parallels between our failures and failures in medicine. And also all of these parallels in organizations and trying to systematize getting better and basic improvements

and how far they can go, but also in terms of this necessary valuability. You're never going to be 100% correct. You're never going to have all the answers. And at any point in time, retrospectively, you'll always be able to look back and say you should have done something different, even though in the moment that decision might have been the right decision.

You'll have this hindsight that allows you, to take a different path. I'm wondering, why is it applying knowledge that we have so brutally hard to these problems, which is speaking to the failure of ineptitude? Well, so first of all, I want to just call out again, Gorvitz and McIntyre. 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 you know and they and you mentioned it as a study but in fact it was just two philosophers

who were thinking about why do we fail at anything we do and you know the the big deal to me about that paper was it pointed out it helped me think about where we were also in history as well for most of human history for for like 99.99% 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. We haven't answered all the questions. But we have equally now a problem of ignorance and of what they called ineptitude.

I prefer to call failure to deliver, a little less judgmental, which is that 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, 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 and ever to be able to drive that and so grappling that 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 right like you know if an individual or a group of individuals fail to apply the knowledge that exists correctly they're just inept right but but there's all kinds of issues of justice and things that go into it too because that failure to deliver when you do the wrong thing and somebody dies we want to hold responsive people responsible and we should and 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 and 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 it's a, in that meeting, we bring the complications, which is to say the cases that had things go wrong, 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 some of them can be prevented and some can't. And part of what's interesting to me is the culture of that. There is a space that it's actually a legally protected space for us to be open every week about what went wrong and what happened to people, including, you know, terrible things.

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. 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, you know, 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 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, there's some shame to not being able to admit that you have something that you, you know, so the irony is surgeons are very confident

people. You can't go into an operating room and do an operation without, you know, a kind of slightly absurd sense of confidence in yourself. You know, sometimes wrong, never endowed it would be our mantra. But in that room, there's a kind of humility expected that is, you know, it is it's not cool in that room to like you know uh flagellate yourself over the whole thing it's a um it's in a way a kind of emotionless presentation here's where you know where where ex person did something wrong and you know here's what i think i should have done differently it's it's a kind of you you have to take some ownership and and there's always a temptation to want to blame someone not in the room, the nurses fall, the anesthesiologist's fault, whatever. But we, you know, but, but then

the problem is that you didn't bring them in the room. Like, they should be here as well. If they're part of it. They, they, that we should, that we should, you know, we bring the people who are part of the team to be part of the discussion so that everybody's, everybody's on it. Now, creating that space is a, is a combination of, um, culture. It's been, surgery couldn't get off the ground. around in the early part of the century without creating that place where you could engineer you could work on engineering why are so many people dying how do we cut down the infection rate what do we do about you know making this very complicated thing work and so we develop that culture the making that be not punitive so the

minute it starts to become something where and chucked out, you know, we're going to use this again, where the information you use becomes weaponized. Yeah. 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, you know, there are structures that can make it that are important to that, like not making it so that you're sued for your ability, you know, for talking about these things. Yeah. 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, um, uh, you know, 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 it was like, it's remarkable to me how these people have so much intelligence and so many different domains, but these 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 on an error or on a what they call a near miss, it didn't crash the plane, but it couldn't. of you get a get out of jail free card so by reporting on it you you are not subject to investigation now 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 what's happened or falsify information, you hide information, or you are actively subverting the system more malicious in certain ways, and 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 all of those things or you just, you don't, you weren't thinking. 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 in 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 people in the room all discuss the case, the anesthesiology, the nurse, and the clinician, and the surgeon to discuss what are the medical issues of the patient,

what's our plan for the day, what are our worries about, you know, what are the non-routine things that can go wrong, is the equipment and everything else in place. At the start, we ask people to introduce themselves by name and roll. 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, than everybody has spoken. And we can see that the places where that ability from the medical student to the most experienced clinician of the room, it's not, it's not, you know, you can see places where it's the surgeon doing all the talking

and you can see places where that's a nurse doing all the talking. And, you know, the power differential has gotten out of whack. Why do you think that is? Like just the mere matter of kind of introducing yourself with your role, is it because we identify with our roles? Like, what is it behind that that gives you the confidence to be like, oh, no? I think, so now not well studying the operating room, but the reasonable evidence from psychologists looking at this question that when people have gotten to speak in 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, 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. That's that, you know, do your checklist. Don't, 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 teaching in business 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 will have blind spots when it comes to your own improvement and you need a coach. Yeah. 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 we've had, teams you know you go back to the 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-class-a very uncool like you know gentlemen don't need to be coach we just know right and uh Yale won something like over the next a couple of decades won all but a couple of the of the games and then Harvard got a coach and so applying that idea we have you know I was writing that New York article I was just trying it out for myself I had one of my former professors who I 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 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 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 a project 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, yeah. We have not remotely figured out how to do that as a routine part of being inside

complex organizations are 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 excellent scale. Is it fair to say that the largest value of a coach is actually being outside of that ecosystem and then showing you different perspectives on it because you're in that ecosystem. And I'm trying to relate this back to like first year physics, right, where you're the guy standing on the train with the ball in your hand. And it's like, how fast is the ball moving? And you're like, well, relative to me, which is what you see, it's not moving at all. But if

you're outside of the train, it's moving at the speed of the train. And then the coach is the person outside of that train going like, hey, there's more to this system than you're seeing because you're so involved in what you're doing. Well, I would describe coaching slightly differently. So 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, you know,

what you described would be a teaching technique. Okay. A coach has a few things. They offer you an external version of your reality. They also work with you to set a goal. So here is where what I, I see are the gaps in your performance or what's going on. What do you want to work on?

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 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 the most part, you've got to be willing to work with them.

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 goal. are you've got to buy into them and then you're the agent of making closing that gap right now the coach may bring some teaching let me model for you how to really make this shot or let me suggest to you where you should move your feet and that kind of thing or in the operating room let me suggest you you know think about what other instruments to use but um 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, it with me on like, so if you want to be better at teaching people and get some better ratings on my teaching, 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 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 kid struggle and you're like you want to cut it off and give them the answer it's much like much like parenting where so so that's a difference like a parent isn't teaching sometimes is the teacher. But it's much more, what do you want to do? You're asking your child, what do you want to do? What's important to you? And will you be willing to have me give you feedback and some outside perspective on this? Sometimes not, and I'm still going to give it to you. And then they have to connect the dots. 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. 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 over time if we are not also training people. Right. And giving people opportunity to learn.

So I want the most experienced person. Well, the most experienced person is going to age out pretty soon. And so we have to have that way to make that happen. And so it's like a lot of things in medicine. My primary duty is to the benefit of this patient now, regardless of whether I use the entire world's resources in the process, whether I fail to 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 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 privilege somebody who doesn't get it. And so when we say, well, we'll learn on the homeless people. So the underlying social strata you see during training is 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, uh, the cut on their, you know, on their face. And then there are the people who the chairman of surgery comes in and, um, he or she is, you know, no one's going to touch them except for, you know, X, Y, Z person.

And part of getting to a better place is that we now, A, it's simply not permissible in American health care 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, you know, changing. remarkably now though you have to create the safe space that that the people can actually learn and that means are acknowledging that that teams take care of

people that there are appropriate you know basically we we we have this term oh I'm gonna forget the term it's because it's not a totally memorable term but it's basically that you have arrived at a place where you have a kind of certified ability to do this part of things and maybe it's to you know you've reached the stage where I've observed you you've done some practicing before you've done it on people now we've practice 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

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 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 the, the irony is the most experienced people are doing some of the most mundane crap in the system.

And meanwhile, there seems to be, you know, 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 components working together or not working together and then making it, making that happen. You mentioned sort of rising medical cause.

So I want to grab onto that and kind of run with it a bit. And maybe from the outside looking in and from doctors that I've talked to you from the inside looking 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 health care is waste. It's going to things that are either much higher administrative costs that add no value or are actual treatments and tests and procedures and drugs that are of no benefit or actively harmful, you know, I've written about, for example, there was a study of 26 different tests and procedures ranging from EEG for headaches. Eegs are good for detecting seizures. There are 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, 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 no benefit for disability or pain at about nine months or so. Okay. That the average person is not benefited. 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.

Yeah. 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. And so we need to, and we can manage against that endpoint.

And we can, you know, goes back to those management metrics we talked about. Now I have a measure. Now I have a target. Let's not make that. let's make it so the average person has significant benefit when we operate. And 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 your 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% of spending after age 65 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, that the problem is that we're just not, you know, we have to make a brutal decision and say,

look, it gives people an extra month of life, and sorry, you just don't get it, it's not worth it. There's a, there's, which should be 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 in, 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. Yeah.

And what it feels like instead is it just feels like bad decision making. Yeah. And there, 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, but 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.

Exactly. This is all part in the journal book. 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, a 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, that you measure lower rates of anxiety

and depression and getting pain under control better and avoiding nausea and all these things that actually matter to people. They are more functional. They're able to be at home and do the things they want to do more. and they live equally long, if not longer, in 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 too. 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. Two questions left, one easy and one more philosophical and self-reflective. I'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 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 risk, the benefits. But the role of a clinician does 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 the, you know, what they understand about them. But then help me match what my goal is

with which one might give me my best shot at achieving that without sacrificing things that are important to me. And your role is that you need to help the clinician understand your goals and 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 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 option would allow him to do surgery, not lose his ability to do surgery or when he did lose his ability to do surgery. Then his goal was, well, what I still love is being with people. And so I want to be able to sit at the family dinner table and be around with family or friends and actually still have enough energy to converse

and enough mental capacity to do that. Which ones would have such severe side effects? I'd be too wiped out or have to be in an institution or would be struggling to get to that dinner table. Those became the guideposts. And I think the critical thing for people to understand, this isn't just about the end of life. Life is the accumulation of illnesses,

most of which you'll survive. and now have to manage as time goes on. And you'll have medicines you'll need to be on and they'll have side effects and there'll be things that they help you do and things that they might hurt you from doing. You have to help us understand what your priorities and goals are

for what matters in your life. And then you have a right to ask and demand that we help you pick the choices that will best to change. 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 is 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 would be too heavy. I think, what are the greatest misperceptions? One might be that I'm smarter than I am. You know, a lot of what I do is really just try to figure out the simple stuff 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, it's, um, I'm mostly connecting ideas that none of which I've created and just try to

make them a little more salient in 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, uh, and then I think, uh, maybe enough. Another one is that is that 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. Um, but, you know, it's, it's, uh, I get to do really cool stuff and I feel really lucky that I'm in a phase in my life where I spend all my time working on things I want to be working on and, um, but, um, uh, it's all hard work and it's all, you know, putting in the hours and, uh, and then deciding that, um, you know, the reason I get my sleep is because I just, I'm ruthless about prioritization. Yeah. I, I just only just try to do no more than a couple of

couple of things at a time, I may do something different in a couple 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 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 Farnhamstreetblog.com slash podcast. That's F-A-R-N-A-M-S-T-R-E-E-T-B-L-O-G.com slash podcast. You can also find information there on how to get a transcript.

And if you'd like to receive a weekly email from me filled with all sorts of brain food, go to Farnham Streetblog.com slash newsletter. This is all the good stuff I've found on the web that week that I've read and shared with close friends, books I'm reading, and so much more. Thank you for listening. This is the I'm going to be the I'm going to

I'm going to You know, I'm going to be. Thank you.