GUY RAZ, HOST:
It's the TED Radio Hour from NPR. I'm Guy Raz. And on the show today, ideas about Rethinking Medicine.
So what do you think is one of the biggest problems with medicine today?
ATUL GAWANDE: We are trained, rewarded and hired to be cowboys. And what the individual clinician says is what goes.
RAZ: This is Atul Gawande.
GAWANDE: We're neither trained, rewarded or hired to be members of teams.
RAZ: Atul's a surgeon at Brigham and Women's Hospital in Boston. He's also a researcher and writer. You might have read his work in The New Yorker. And Atul says medicine's cowboy culture just isn't working.
GAWANDE: My mother had a straightforward knee replacement that she needed. It went beautifully. I hung out with her for the three days she's in the hospital and then the few days afterwards while she was in rehab. And I'm pretty bored. Everything's going well. And so I just decided to count the number of nametags that came into the room, someone who either made a decision about her care or physically touched her and executed on her care. And in the course of that short period of time, it was 66 different people...
GAWANDE: ...Eight different physical therapist, for example. And if they were not on the same page, it could be infuriating. A physical therapist comes in the morning and says, what are you doing in bed? You should be out of bed. And then the afternoon, the physical therapist - a different one comes in. And they could end up saying, what are you doing out of bed? You should be in bed.
RAZ: Yeah (laughter).
GAWANDE: In a world of 66 different clinicians - smart, great hardworking people - having autonomy be their highest value, it's a cacophony of everybody saying, listen to me, listen to me. And you want to scream, who's in charge?
RAZ: But the thing is - medicine wasn't always like this. It wasn't always so complicated. There was a time when one doctor could know and do everything. Atul Gawande tells a story of how that came to be from the TED stage.
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GAWANDE: I want to take you back to a time when Lewis Thomas was writing in his book, "The Youngest Science." Lewis Thomas was a physician writer, one of my favorite writers. And he wrote this book at the Boston City Hospital in the pre-penicillin year of 1937. This was when the core structure of medicine was created. It was at a time when what was known, you could know. You could hold it all in your head. And you could do it all.
If you had a prescription pad, a nurse, a hospital that would give you a place to convalesce - maybe some basic tools - you really could do it all. You set the fracture. You drew the blood. You spun the blood and looked at it under the microscope. You plated the culture. You injected the anti-serum. This was a life as a craftsman.
As a result, we built it around a culture and set of values that said what you were good at was being daring, courageous, independent and self-sufficient.
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GAWANDE: The story of medicine was one of rescue. And it was about, kind of, doctor as king.
GAWANDE: And that changed and evolved as knowledge exploded. We suddenly came into a world where we had not only enumerated all the different kinds of conditions that human beings could have to, now, a number more than 60,000 different ways our human body can fail. But we had generated thousands of drugs. And then we designed 4,000 medical and surgical procedures. And we're trying to deploy that capability town by town to every person alive. And none of us can grasp the entirety of it.
(SOUNDBITE OF TED TALK)
GAWANDE: We have trained, hired and rewarded people to be cowboys. But it's pit crews that we need, pit crews for patients. There's evidence all around us. Forty percent of our coronary artery disease patients in our communities receive incomplete or inappropriate care. Sixty percent of our asthma, stroke patients receive incomplete or inappropriate care. Two million people come into hospitals and pick up an infection they didn't have because someone failed to follow the basic practices of hygiene.
There's another sign that we need pit crews. And that's the unmanageable cost of our care. Now, we in medicine, I think, are baffled by this question of cost. We want to say, this is just the way it is. But as we've looked at the data, we found that the most expensive care is not necessarily the best care. And the best care often turns out to be the least expensive. And what that means is there's hope.
When we look at the ones who are getting the best results at the lowest costs, we find the ones that look most like systems are the most successful. That is to say, they found ways to get all of the different components to come together into a whole. I got interested in this when the World Health Organization came to my team, asking if we could help with a project to reduce deaths in surgery. The volume of surgery had spread around the world. But the safety of surgery had not.
RAZ: So what did you guys do? How did you - like, how did you even know where to start?
GAWANDE: Yeah. You know, so I became fascinated with the question of, you know, medicine is not the only field in which the knowledge and the skill has exploded in ways that have exceeded the ability of the individual. And now you're having to have teams of people come together. One example is construction, right?
GAWANDE: You know, I visited a skyscraper construction site. And on the day I came to visit, there were 500 people on site from 60 different subcontractors. I was like, how do they do this? It's like a patient who has 60 different specialists who are all supposedly there to help them out.
RAZ: (Laughter) Yeah.
GAWANDE: How in the world did they make this happen? The answer was that it wasn't an architect. It wasn't an engineer. It wasn't a contractor. In the middle of it was someone they called the project manager who sat in a room with the checklists of the day. Spread across the wall was a checklist.
The police had to come and shut down the road in order for these giant girders to get delivered. There had to be a receiving team - you know, the electrical people had to be told not to show up until later in the day. And it was all a system that treated it as a project with many moving parts coming together for the sake of their client.
RAZ: And I guess you adopted this idea, right?
GAWANDE: Yeah. So the starting place began with just saying, let's create a checklist for surgery. Part of what the checklist did was it forces you to name and prioritize - what are the most critical, key elements that we can miss?
(SOUNDBITE OF TED TALK)
GAWANDE: So we did this. We created a 19-item, two-minute checklist for surgical teams. We implemented this checklist in eight hospitals around the world deliberately in places from rural Tanzania to the University of Washington in Seattle. We found that after they adopted it, the complication rates fell 35 percent. It fell in every hospital it went into. The death rates fell 47 percent. This was bigger than a drug.
GAWANDE: And it's been slow to spread. There's a deep resistance because using these tools forces us to confront that we're not a system, forces us to behave with a different set of values. Just using a checklist requires you to embrace different values from ones we've had, like humility, discipline, teamwork. This is the opposite of what we were built on - independence, self-sufficiency, autonomy.
I met an actual cowboy, by the way. I asked him, what was it like to actually, you know, herd a thousand cattle across hundreds of miles? How did you do that? And he said we have the cowboys stationed at distinct places all around. They communicate electronically constantly. And they have protocols and checklists for how they handle everything from...
GAWANDE: ...Bad weather to emergencies or inoculations for the cattle. Even the cowboys are pit crews now. And it seemed like time that we become that way ourselves. We've come to a place where we have no choice but to recognize as individualistic as we want to be, complexity requires group success. We all need to be pit crews now.
RAZ: So how do you actually get doctors to use a checklist? And how do you get hospitals to kind of assimilate this idea?
GAWANDE: Yeah. So this has been the interesting part of the last five years of this work. How do you deal with getting groups of people to take on the change?
GAWANDE: And one of the most important components was connecting to people one on one, talking to them one on one, approaching it the way a coach, really, approaches people. You observe. You give feedback. And you try to connect around, what are their goals and how might they achieve those goals as clinicians?
RAZ: And I guess one of the things you actually did was to look into this idea of coaching and how - I guess how that can kind of take the checklist to the next level.
GAWANDE: Yes. I was really struck that in sports people had coaches. I thought that was really interesting. Like, why in sports...
GAWANDE: ...Do they think this is the way to do things? But in other lines of work, they cut you loose and then you improve on your own. And so looking and thinking about how we make that happen, it struck me that there isn't any particular reason we couldn't systematically try to create a cadre of people who offer coaching.
RAZ: And you tried this approach in India, right?
GAWANDE: Yeah. So we decided we would give it a try in childbirth. And it really ended up being about combining two of these ideas together. We had a checklist for childbirth. And we created a small army of doctors and nurses trained as coaches, deployed across 120 health facilities.
(SOUNDBITE OF TED TALK)
GAWANDE: And this center was one of them because coaching helped them learn to execute on the fundamentals. This is a 23-year-old woman. Her water broke in the triage area. So they brought her directly to the labor and delivery room. And then they ran through their checks. Within four minutes, they had taken the blood pressure, measured her pulse and also measured the heart rate of the baby.
Eight minutes later, the intensity of the contractions picked up. The nurse washed her hands, put on clean gloves, examined her and found that the baby was ready to come. She then went straight over to her next set of checks. All of the equipment she worked her way through and made sure she had everything she needed at the bedside. And then, three minutes later, one push, and that baby was out.
GAWANDE: I was watching this delivery. And suddenly, I realize that the mood in that room had changed because that baby did not seem to be alive. She was blue and floppy and not breathing but the nurse kept going with her checkpoints. She dried that baby with a clean towel. And after a minute, when that didn't stimulate that baby, she ran to get the baby mask. And the other one went to get the suction. And within 20 seconds, she was clearing out that little girl's airways. And she got back a green, thick liquid. And within a minute of being able to do that and suctioning out over and over, that baby started to breathe.
GAWANDE: Another minute, and that baby was crying. And five minutes after that, she was pink and warming on her mother's chest. And that mother reached out to grab that nurse's hand. And they could all breathe. I saw a team transformed because of coaching. And I saw at least one life saved because of it. The baby's name is Anshika. It means beautiful. And she is what's possible when we really understand how people get better at what they do. Thank you.
RAZ: Atul Gawande is a surgeon researcher and writer for The New Yorker. You can see both of his talks at ted.com.
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