Ep. 26: Atul Gawande on Priorities, Big and Small
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The surgeon, researcher, and celebrated writer joined Tyler for a conversation on why Watson will never diagnose your illness, what George Church’s narcolepsy teaches us about CRISPR, what’s missing in medical education, Michael Crichton’s cultural influence, Knausgård versus Ferrante, indie music, why Gawande is a terrible patient, and the thing that makes him “bawl like a baby.”
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TYLER COWEN: I’m here up in Boston with Atul Gawande, and we’re going to talk about health, healthcare, healthcare policy, and Atul Gawande himself.
On artificial intelligence and CRISPR
Let me start with a question about artificial intelligence. How far are we from having an AI that is capable of actually doing diagnosis to people? That is, they might speak into a Skype connection, something like Watson would hear what they say, and they would then diagnose the person well enough that this would be a usable form of healthcare? Is that far, close?
ATUL GAWANDE: Massively far. I think it’s one of the hardest things. You want me to tell why?
COWEN: Tell us why, yes.
GAWANDE: OK, the diagnosis process—people imagine what it is, is that people come to you with a crisply defined problem. “I have symptom one, two, three. I have data to add to it, and now give me the answer.”
The reality is, first of all, people come to you often unable to explain what their problem is. “I have pain.” “Where?” “Hmmm. Well, it’s sort of here.” And they’ll point with a hand. “Well, do you mean there under your rib cage, or you mean in your chest, or . . .”
So you have this probing process that is part of it and how they tell the story. Then there’s also how their story had evolved over time, and they often have to put it in their words. It’s more of a narrative than it is a straight set of data. That’s problem one.
IBM Watson put their AI on this problem, and it would never be the problem I would have put them on. The second part of it is that it changes over time, and you’re adding data along the way. You’re integrating it with a little bit about your view of the understanding of the person and their likelihood to even say that something is a major symptom or not.
There is no question that you can augment the human capability. But the idea that you pull out your phone and it would give you the diagnosis—it is still one of the hardest problems in reducing error in medicine, is the fact that we still have a high rate of error, and the sources of the error have to do with the human being rather than the calculation.
COWEN: But say you only get 15 minutes with your doctor, which is pretty common, and as you know, those conversations don’t always run so well. People are intimidated, they forget the right question to ask. You could have three hours talking to something like Watson. Maybe 80 percent of the dialogue is nonsense, but at the end, you apply machine learning.
And keep in mind, the alternative now is that people use Google, which is in a sense the world’s number one doctor. So AI only needs to be better than Google, which is already a form of AI. In that sense, isn’t it just around the corner that it would be a marginal improvement on what we have today?
GAWANDE: Yeah, one is the replacement question. Can I simply have something that will make the diagnosis? And lots of reasons why that’s difficult. But to augment the human capability, absolutely. There already are programs. One example is called Isabel, where the clinician, having elicited all of this information, can simply put the observations into a list. It will allow them to recognize, “OK, fine. You think that what they have is diagnosis one, but here are eight others in rank order of consideration compared to the one that you think.”
There have been plenty of studies, and it’s been around for more than a decade without the need for AI. This is just crunching some basic data to begin with that can add real value. I think the puzzle of it is that you need that capability to integrate information coming from the person interpreted and be able to get it into these kinds of systems. And in many cases, people may be able to do some of that over time for themselves.
COWEN: How worried are you about CRISPR? Imagine parents sitting down, trying to shape the children they will have, using advanced technology of some kind or another. Will those parents on average make the right choices, improving choices? Will this be a disaster? What’s your view?
GAWANDE: So CRISPR. The great thing about this podcast is, I’m going to presume we don’t need to explain what gene editing is for this audience here.
COWEN: We don’t need to explain. We put links in.
GAWANDE: There are plenty of reasons to be worried about CRISPR in my mind. The one you just named is not one of them. Just like in the days of the first in vitro fertilization and baby Louise who was the first test tube baby, and now what’s going to happen, and we’re going to destroy humanity and all of those kinds of things. I don’t think that’s the case. Yes, there will be some forms of selection. We already have massive amounts of sex selection in the world.
COWEN: And that is a problem.
GAWANDE: Which is a serious problem. That’s very harmful, but it has nothing to do with advanced technologies. It has to do with the basic capabilities of ultrasound and selective abortion going on all over the world.
The issues with CRISPR have to do with the capacity to add . . . First of all, there’s unpredictable things that people will discover that you can try to do with gene editing, and then you couple it with capabilities. For example, CRISPR enables gene editing that basically is fairly fixed. But if you now can propagate that edited gene in a mosquito or in another organism, now you can have rapid cycle diffusion of those kinds of capabilities, and I don’t think we’ve thought through that in the least.
George Church, famous genomics pioneer, biotech researcher, who’s had tremendous influence and has been one of the most creative forces in the field, has narcolepsy. And he attributes a lot of his insights and capabilities to the fact that he falls into a deep REM sleep at the drop of a hat and then wakes up with ideas.
…And there’s lots of ways in which he is unique, and a parent might think, “aberrant person,” and wouldn’t select for what he has brought to the world.
COWEN: But won’t parents discriminate against having strange or weird or unusual children that, as parents, will be too risk averse? So maybe a stranger person has a higher chance of being a genius. A lot of parents, they just want kids who are sort of 15 percent better than they are, and more or less along the same dimensions.
GAWANDE: There’s a great article this week about George Church’s narcolepsy in STAT News. The danger to me isn’t CRISPR, the danger is the larger culture that it goes into, of which CRISPR is just one of many capabilities. So George Church, famous genomics pioneer, biotech researcher, who’s had tremendous influence and has been one of the most creative forces in the field, has narcolepsy. And he attributes a lot of his insights and capabilities to the fact that he falls into a deep REM sleep at the drop of a hat and then wakes up with ideas.
COWEN: During seminars often.
GAWANDE: During seminars.
COWEN: Yes, the best time.
GAWANDE: Right, right. He had to stop driving because of what happened during driving. But he would drop into these dream states and then wake up with unbelievable ideas. And there’s lots of ways in which he is unique, and a parent might think, “aberrant person,” and wouldn’t select for what he has brought to the world. And there are lots of neuroatypical phenotypes.
The CRISPR capability is just another bullet in the holster that can be fired, but we are narrowing that neurotypical range in lots and lots of different directions, whether it’s how we employ people, what kinds of options we put out there for people to have their aberrant thinking recognized and taken advantage of, to the ways we medicate and control people. And I think CRISPR—it actually will be exceedingly difficult to be able to pick many of these capabilities out, in part because they’re multigene. These are not conditions that very often have to do with point mutations that you just adjust. They are interactions among many genes of a network.
COWEN: You run big data in every generation. The chance of outliers falls by 1 percent. And then over time, it’s going to make a big difference, right?
GAWANDE: That’s right.
COWEN: It’s not that you control the kid who’s going to pop out of the womb in nine months, but over time, it seems it will compound.
On operating room culture and the importance of checklists
COWEN: It seems more and more patients are awake during surgery, right?
COWEN: Awake procedures. How is this changing the culture of the operating room?
GAWANDE: Oh, yeah, it’s been very interesting. One of the things I brought into surgery with our team has been running a checklist, just like a pilot’s checklist, in the operating room. And one of the things you realize is that, when you have an awake patient in the operating room, they can be part of the team, not just someone sitting there who is annoyingly awake, and they’re actually piping up to tell you they’d like to change the music you’re playing.
COWEN: That’s what I would do. [laughs]
GAWANDE: Right. [laughs]
In neurosurgery, they’re actively part of the operation because they’re often speaking and telling you things so that you know if you’re causing any difficulties. But what we’ve found even in the kinds of operations I do, which are not brain operations, is that being able to ask them from the very beginning of the operation to be part of the team by saying, “Are we on the same page about what your medical issues are, what your goals are for the operation, what we have to look out for in addition to the usual safety things, but also what are the key things?” “Oh, I tend to have a bad back, and I don’t want to lie in this position for too long.” In many ways, having people awake can be far safer.
The other thing though is that there are people who, when they’re awake, don’t handle it very well. [laughs] And you have to be able to adjust on the fly, and people have to understand that you may need to.
COWEN: Why do surgeons sometimes leave sponges behind in the bodies of patients who are being operated on?
GAWANDE: You zeroed in on one of my very first projects in creating intervention.
COWEN: Great paper.
GAWANDE: We had done a case control study of this problem of surgeons leaving sponges inside people, and got it published in the New England Journal [of Medicine], partly because of our whole method of going about solving this problem, which was, we studied 60 people who had sponges left inside them, compared to 240 people at the same institution at the same time with the same operation who didn’t have sponges left inside them.
That was an interesting problem to me because the rate of sponges being left inside people had been steady for 30 years. We had not made it go down at all. It was right around 1 in 1,000 to 1 in 3,000 or so operations. A sponge would be left inside, and it would be a disaster. You would have to go back. About two-thirds of the time, people had become infected. One of the 60 was a patient who died because a small sponge had been left in their brain.
The usual way that we track these things is by counting everything at the beginning of the operation twice and everything at the end of an operation. What we found was that it wasn’t because people were skipping the steps along the way. The nurses were consistently counting everything at the beginning and counting everything at the end, so it wasn’t a broken system. It was a fallible system. It’s like counting whether you have 52 cards in the deck, and you have 51 or you have 53 at a predictable rate of getting the count wrong. And sure enough, about 1 in 1,500 to 1 in 3,000 times, they would just get it wrong and not know it.
So we, in that case, identified that we would need to create a technological solution. In the end, we came up with a barcoding approach. It’s an interesting economic problem. At the time we were doing this, it was a $140-million sponge industry, for which there was half a billion dollars spent per year on lawsuits for sponges being left inside. From a pricing point of view, it worked out to about a penny a sponge. So you had to have a solution that could double the price to two cents or three cents, but you had to increase the costs a lot if you’re going to stick a microchip or a RFID system on there.
So we just put barcoding on there, kept the cost pretty minimal, and it completely eliminated the problem because now you have a team scanning them in as they do the operation at the beginning of the operation, and then scanning all those sponges out. And the only fallibility is that people will ignore the machine. Those are the only times there have been sponges left after tens of millions of these kinds of cases.
COWEN: Do your awake patients ever come in with a checklist and at the end say, “Hey, have you got all your sponges?”
GAWANDE: [laughs] I’ve not had people come in with a checklist, but invariably, and we actually tell you about it . . .
COWEN: But they should, right?
GAWANDE: Well, it’s not that you want people to come in with their checklist because each place has a flow and a way that they do it. But what you want to know is, does the place you go to, do they use a checklist? Now they will always say that they do because everybody does at some level. But the key is, does the checklist have them stop before the incision? Not to check that you have the right person and the right side of the body, which is something everybody standardly does, but to actually make sure everybody in the room is introduced to one another, and they’ve reviewed the goals of the operation and your key medical issues, as well as the key points of the operation, like what equipment are needed. Those are the big parts that the teams skip, but make a really big difference.
COWEN: What are the biggest mistakes on how checklists are used? Keeping in mind, most of the people who do or could use them, they’re not people like you who’ve written books on checklists and who know many, many different things, but they’re highly imperfect, fallible people who are making mistakes anyway. And if allowed to codify their mistakes in the form of a checklist, can it make things worse rather than better? What’s your main worry about checklists?
GAWANDE: Yeah. Basically, we rolled it out in our initial trial in eight cities around the world, and found a 47 percent reduction in death when the teams took up the checklist.
The main barrier since then has been that it either becomes a tick box effort or no one uses it at all. It was designed to turn people’s brain on by enabling a conversation about the critical events and concerns of the operation. What we see is a couple of things. For example, we had people send in the version of the checklist that they’re using, and about 150 places sent them in.
Part of what was interesting is, almost 100 percent changed the checklist. You have to change it to fit into your environment. For example, in England, you put the patient to sleep outside the operating room, and then you roll them in. So the checklist . . . the order of it has to change. So one concern is that, if you just use it out of the box, you’re not really using it. You have to adjust it to your environment.
We’d see places that had turned our 19-item checklist — the most extreme example, they turned it into an 81-item checklist. It was impossible to use. We’d specifically designed it to be something you could run through in 60 seconds or less at each pause point, so you weren’t distracted from the main operation. And you could see that the administration in the hospital had got hold of it, and they were using it to try to impose their ideas.
The second concern, looking at these 150, we’d see places that had turned our 19-item checklist—the most extreme example, they turned it into an 81-item checklist. It was impossible to use. We’d specifically designed it to be something you could run through in 60 seconds or less at each pause point, so you weren’t distracted from the main operation. And you could see that the administration in the hospital had got hold of it, and they were using it to try to impose their ideas. And essentially, the clinical team was not the team that were designing and controlling the checklist. Invariably, you look at that and you know that everybody is completely ignoring it, and it has become just a tick box effort instead of an enabler of greater capability.
COWEN: Let’s say one of your kids further on is thinking of getting married and says, “Dad, should I use a checklist?” Yes or no?
GAWANDE: Well, I think every wedding planner . . .
COWEN: Not for the ceremony, for the choice of spouse.
GAWANDE: Oh, for the choice of spouse. That’s a very good question. I suppose the first question is, is it an arranged marriage or not an arranged marriage?
GAWANDE: Because if it’s an arranged marriage, that’s practically a checklist process. Right?
GAWANDE: But if it’s a love marriage, love does not follow the checklist.
GAWANDE: Although there are probably some mistakes I could put on the checklist that would be really smart to consider along the way.
COWEN: Exactly. So you’re leaning back towards the checklist?
GAWANDE: Yeah, I am, I am.
On the (dis)connection between healthcare and health outcomes
COWEN: There are so many papers—you probably know all or most of them—that appear to show low marginal values for health treatment on actual healthcare outcomes: Amish people who don’t get that much healthcare, they have good life expectancy. Christian Scientists. There’s the old 1970s randomized control trial study, where free healthcare only made the poorest of people healthier. There’s the Oregon Medicaid paper. There’s a few papers, when the doctors go on strike, more people don’t die when they’re sent to the hospital. What do you make of all of this strand of literature? And why does it seem to be such a weak connection between healthcare and health outcomes?
GAWANDE: I think it depends on what you measure and over what period of time. There’s been an accumulation of enough data about, for example, coverage expansions like the ACA, like the Massachusetts reforms, etc., that I think there’s actually some good understanding what there is. First of all, they consistently show that people get a range of services that they get increased access to. Primary care, specialty care, medications, chronic illness care, emergency care. There are elements of it that are much more powerful than others. And so chronic illness care, primary care, and mental healthcare seem to produce really substantial improvements in people’s self-reported health, their physical health, and their mental health.
COWEN: But self-reported health is tricky. You look at life expectancy, you look at the Amish. It’s hard.
GAWANDE: Well, I’m going to say two things about that. Number one is, it’s not obvious to me that that may not be a primary goal. So first of all, that your reported well-being about your physical and mental health is in fact when people come in to see clinicians, what they’re trying to optimize. The second part of it though is, in terms of survival, then what you see is, it takes time. So the Oregon study, for example, was on average . . .
COWEN: That’s only four years, I think.
GAWANDE: It was not even four years. It was under a year and a half for a small group of people, and the death reduction was nonsignificant, but the amount of death reduction you’d have to achieve would have had to have been greater than 50 percent reduction in death, which is a massive level. In fact, it measured a 16 percent reduction in death, but it just wasn’t significant.
The subsequent studies that have looked over longer periods of time, they see two things. First of all, there are significant reductions of death. The estimates are from 1 in 300 to 1 in 800 people who gained coverage will per year have their life saved, which is a high level of value—translates into tens of thousands of lives.
Second is that you wouldn’t be surprised that people getting treatment for their HIV, for their cancer, for their chronic diseases, like high blood pressure and diabetes and so on—it takes time to accumulate, and it appears to be some years. So like the Massachusetts data . . . basically, what they show is that the strength of the value gets higher as time goes on.
There’s a further underlying point, which is, though, that we are not actually maximizing by any reasonable measure those outcomes. The biggest killer in the country is high blood pressure. A third of adults have high blood pressure. Sixty percent are receiving incomplete and inappropriate care within the medical system. So they’re not actually getting the biggest killer under control.
COWEN: And they don’t follow instructions.
GAWANDE: Well, that’s a mix of not necessarily getting the right treatment in the first place, not getting the right follow-up, and yes, it might be not following instructions. But when we poke into why, well, there’s copays and deductibles that can block out being on those medications, so then people are making choices. Some people are having side effects that lead them to stop it. Some people are just way disorganized.
CVS has been able to track why people stop medication. They have six different kinds of patterns with which people are not adherent to their medications, each of which actually have effective solutions to target. So the big point is, high blood pressure is one of the simplest things that we can take on. We are terribly organized to be able to deliver on it. It’s the biggest killer in the country.
Kaiser followed through on being able to take it, instead of from only 40 percent appropriate care, to greater than 80 percent, and saw their entire population flip from the number one killer being cardiovascular disease. They also worked on improving statin use, and flipped from it being number one to no longer being the number one killer. Cancer now is the number one killer in their population.
Minnesota followed through on a similar program, got adherence up to 70 percent, and made the same flip as well. And now we have several states where cardiovascular disease is no longer the number one killer, by getting some of these basic measures under control. And that’s just about healthcare being good, but having really poor reliability, given the amount of money we spend in healthcare.
On what’s missing in medical education
COWEN: What’s the number one thing missing in medical education today, for doctors?
GAWANDE: I think the number one thing is an education around the fact that we are no longer a craft. It’s no longer an individual craft of being the smartest, most experienced, and capable individual. It’s a profession that has exceeded the capabilities of any individual to manage the volume of knowledge and skill required. So we are now delivering as groups of people. And knowing how to be an effective group, how to solve problems when your group is not being effective, and to enable that capability—that, I think, is not being taught, it’s not being researched. It is the biggest opportunity to advance human health, and we’re not delivering on it.
COWEN: The famous late 19th-century doctor, William Osler, he once said—here’s the quotation: “Look wise, say nothing, and grunt. Speech was given to conceal thought.” True or false?
GAWANDE: False, but there’s a grain of truth. One of the things that I learned in writing my last book, Being Mortal, was talking to palliative care clinicians and geriatricians and others who really have a different kind of approach to practice. Examining the way I practice, what they would say I do is talk too much, and as one put it, “Your problem, Atul, is that you’re an explainaholic.”
Our model of what a clinician does is that they are Dr. Informative. They give you data about what condition you have, data about the options. Here are the option A, option B, option C. Risks, benefits, pros, cons, and now what would you like to do? It’s a conversation where we do 95 percent of the talking, and then the patient does 5 percent.
What they point out is that they, the clinicians of the future, really need to be oriented in a counselor mode, where they are not just telling you what the options are, but also eliciting from you very clearly what your goals are, and then making a recommendation about what most matches your goals. What are your priorities for your quality of life as well as quantity of life? People have priorities besides mere survival.
…the clinicians of the future really need to be oriented in a counselor mode, where they are not just telling you what the options are, but also eliciting from you very clearly what your goals are, and then making a recommendation about what most matches your goals. What are your priorities for your quality of life as well as quantity of life? People have priorities besides mere survival.
When we don’t ask and don’t know how to ask what those priorities are, the treatment is often mismatched with those priorities, and that’s where you get suffering, and that’s where you get lots of hot air from doctors, and you have total misalignment. When you are able to elicit those goals and then align the care with it, you have massively better outcomes, both for quantity and quality of life.
COWEN: Do you ever worry that doctors become corrupted by their own authority? Not corrupted in the sense of taking bribes, but they have such authority, people look up to them. They say “Take off your clothes, sit on the table.” People do it—people are in the mode of obeying.
A lot of patients, frankly, are probably a pain, so doctors in a sense can manipulate patients to make each interaction easier because they’re such high-status figures. And then doctors fall into this mode of being used to doing that with people in general. What do you think are the main psychological dangers of corruption that can stem from being a doctor and having such high status? Control over life or death. “You can cure people, the gods cannot.” That’s what Sir Thomas Browne said, right?
GAWANDE: [laughs] I think that the health system of every country is a demonstration of our corruptibility. Kenneth Arrow’s 1960s essay on asymmetry of information used healthcare as its prominent example that sellers are more powerful than buyers when we not only control the decision set, we control the option set. And the opportunity and ability of the individual to understand all of those, to be able to make choices among them, is hindered especially when you are sick.
The most powerful tool that a clinician has is their pen, and has the power to order medications to test, to doing an operation. So yes, the power . . . Look, it’s an unusual profession in that yes, we can ask you to sit on the table and make yourself the most vulnerable in the most vulnerable way possible—not only to ask you to take off your clothes, but then to actually have permission to cut you open and do what I choose to do inside you. That is a tremendous power.
And the ways in which we see that just the payment incentives alone dramatically affect whether my tendency is to give you overtreatment in certain situations and undertreatment in others, is a reflection of our failure to follow through on being able to deal with the variability in that, and how we use that asymmetry of information.
On liberalizing the FDA
COWEN: A lot of critics have charged that to get a new drug through the FDA, it takes too many years and too much money, and that somehow the process should be liberalized. Do you agree or disagree?
GAWANDE: I generally disagree. It’s a trade-off in values at some basic level. In the 1950s, we had no real FDA, and you had the opportunity to put out, to innovate in all kinds of ways, and that innovation capability gave us modern cardiac surgery and gave us steroids and antibiotics, but it also gave us frontal lobotomies, and it gave us the Tuskegee experiment and a variety of other things.
The process that we have regulation around both the ethics of what we’re doing and that we have some safety process along the way is totally appropriate. I think a lot of lessons about when the HIV community became involved in the FDA process to drive approaches that smoothed and sped up the decision-making process, and also got the public enough involved to be able to say . . . That community said, “Look, there are places where we’re willing to take greater risks for the sake of speed.”
People are trying to treat the FDA process as a technical issue. When what it is, is it’s an issue about what are the risks we are genuinely willing to take, and what are the risks that we’re not?
COWEN: But the bigger risks seem pretty invisible. Some drug you’ve never heard of—it doesn’t even exist yet—you never get it and you die. That’s not very salient to people. It seems, insofar as the public judges the risk, maybe they’re getting it wrong.
GAWANDE: No, that’s right. The way to think about it, though, is that we have a certain speed with which we have accelerated passage through the FDA. We are doing surveillance afterwards, and then finding that the approval process leads to drugs being withdrawn from the market. That is a decision, that we have decided to accept acceleration, especially of drugs that’ll have to be tested on small numbers of people, and then we’ll monitor afterwards to be able to catch problems after they happen. And some of the disasters that have occurred, like Vioxx and others, where there were substantial cardiac affects happening to many, many thousands of people, there’s been a backlash against that.
On the whole though, I think we have decided to trade . . . letting lots more drugs through and a little bit more quick process, but then try to have surveillance afterwards. Of course, one of the results is, we’re not investing very much in that surveillance.
The worst of all worlds is, speed drugs through and then close our eyes to what harm is being done after the drug has hit the market. And that, of course, is where all of the incentives are from the drug-maker point of view. And then, when the public’s not paying attention, that’s where we start dialing back. And that’s one of my fears in the current regime is that, “OK, fine, we speed up the approval process, but then gut the ability of the FDA to hold the medical community to having surveillance of what happens and then pull the drugs on the market that are actually causing harm.”
COWEN: New surgical procedures, should the FDA have a greater ability to regulate them than it has right now?
GAWANDE: Yes. One of the really interesting things is that basically surgical procedures are not easily protocolized.
GAWANDE: So we’re still in that sort of craft world in surgery. So I, as a surgeon, can kind of do whatever operation I deem appropriate. And the only thing that’s regulating me is the threat of being sued for malpractice and colleagues saying that what I did was way outside the standard of care and made absolutely no sense.
The challenge is that, in a certain sense, operations are crafted for each person, and so the devices you use and the drugs you use are highly regulated, but the procedures you use are not. I don’t think it makes sense for the FDA to regulate the procedure. However, I do think it makes sense for the organization to be held accountable for tracking what kinds of outcomes people have for procedures.
So the part that gets to me is that, for a given procedure, proven procedures, we have at least 250 percent variability in the outcomes, depending on the institution you go to. It is primarily a function of the institution, not the individual surgeon. And we have no tracking, virtually no tracking, certainly no transparency, about what those outcomes are and what the factors are going into them. And I think that’s where we need to have much more information.
On things under- and overrated
COWEN: There’s a middle segment of all of these conversations, overrated versus underrated. You’re free to pass on any of these, of course. But I’ll toss out a few things, and you tell me what you think. Underrated or overrated?
GAWANDE: Hmmm. I think he’s now become underrated. He might have been overrated at one point, but now he is significantly underrated.
COWEN: And what’s his best album?
GAWANDE: Oh gosh. [laughs] I’m going to have to pass on that because I lived in the world of singles. “Sir Duke” was my favorite song.
COWEN: Songs in the Key of Life?
GAWANDE: Yeah. What I might go to is going back to that era. So Songs in the Key of Life, I would say, bring that back.
COWEN: Michael Crichton: doctor, Harvard, writer. What do you think?
GAWANDE: Where is he now? I would say he might be . . . I think he’d been overrated. I say this as someone who was totally inspired by Michael Crichton. The fact that he graduated from medical school, and then a year into his residency, left to do everything from directing movies like Coma to writing The Great Train Robbery, and then onward to Jurassic Park. But as a kind of influence on medical writing and on writing writ large, I think that his power is waning. His power is now . . . Well now, see, I’m switching from over to under . . .
GAWANDE: And I just realized, the critical way he’s underrated was in creating programs like ER, which showed how it really has become now that the medical procedural, just like the criminal procedural, is now a mainstay of television, and I think ER created that. And that was a brainchild of Michael Crichton. So yeah, I’ve reverted.
COWEN: The idea of nudge.
GAWANDE: I think overrated.
GAWANDE: I think that there are important insights in nudge units and in that research capacity, but when you step back and say, “What are the biggest problems in clinical behavior and delivery of healthcare?” the nudges are focused on small solutions that have not demonstrated capacity for major scale.
The kind of nudge capability is something we’ve built into the stuff we’ve done, whether it’s checklists or coaching, but it’s been only one. We’ve had to add other tools. You could not get to massive reductions in deaths in surgery or childbirth or massive improvements in end-of-life outcomes based on just those behavioral science insights alone. We’ve had to move to organizational insights and to piece together multiple kinds of layers of understanding in order to drive high-volume change in healthcare delivery.
GAWANDE: Wearables. I think underrated.
GAWANDE: Wearables right now don’t do terribly much. What we see right now are wearables that might, say, track your heart rate and catch variations in your EKG and so on. What the problem is, is that the wearables have not been able to be integrated into the practice of medicine in a really critical way. Right now, the way a wearable is used, whether it’s for tracking cardiac events or your mental state or other things like that, is that then it says, “Notify your doctor.” Or it’s a dump of a ton of data that a clinician is supposed to use and know how to integrate into practice. It hasn’t been able to be used in such a way they’re actually demonstrating major improvements in people’s outcomes.
However, we are entering this phase where we are now starting to be able to track—take your genomic data, take your laboratory data, take your imaging scans you’ve done—couple it with information from wearables, like how you’re doing over time, whether you’re getting the medications you should be getting.
Our team here is actually deploying a version of a wearable, which is turning on the sensors in your phone to track patients after surgery, to see whether we can define how long their recovery pathway is, how long before they are back in their normal sleep habits, or back mobilized and moving around much more. I think that ability to have knowledge of the well-being of people that goes beyond whether you had a complication or a death. Success of what we do for people can be enormously improved followed by wearables. And then that creates these incredible learning loops, where we can maximize those right-now-invisible indications of the outcomes of care.
So I think the wearables are being used on the diagnostic side, where it’s semi-powerful but not critical, as part of how you’re doing in your care and whether we’re helping you achieve the goals—very powerful.
COWEN: Karl Knausgård?
GAWANDE: Knausgård. Overrated. I’ve read about half of the trilogy. I’m totally absorbed and loved them. But I feel like Elena Ferrante is an example of someone who was doing much the same—deeply mining the territory of somebody over a history of time—but managed to do it by fixing them in a place and a time and a history, and a dramatic change in social conditions, and everything else that took it to this whole another level in my mind.
COWEN: What makes you weep?
GAWANDE: What makes me weep? What invariably makes me weep is when . . . It might be a movie, or it might be seeing someone tell the story of devoting years of time to a problem, or to something they’re trying to do at great pain, but sticking with it and then actually getting to the end. I’m going to give two examples. The movie Bliss, this Australian film based on Peter . . . Oh my gosh, I’m blanking on the Australian writer’s name.
COWEN: Peter Weir?
GAWANDE: No, Peter . . . Did Oscar and Lucinda.
COWEN: Peter Carey!
GAWANDE: Peter Carey. Has this moment where the man is in love with a woman and plants the seeds of a forest. And it takes the next decade or more before she realized this thing he built out of love, and it grew. That’s when she realized that, in fact, he loved her. And that was just extraordinary, and of course made me bawl like a baby.
Then this coming week will be our surgery graduation. And it’s eight people who have given the last decade of their lives to try and to craft and become who they are. And they will tell the story. They each get 15, 20 minutes of time to tell their story of what they have gone through. And they had families, and had family tragedies, and they’ve had things that they’ve missed along the way.
And it always makes me cry because that ability we have to commit ourselves to something larger than ourselves over a long period of time, not knowing whether it will turn out the way you think it will—that is, I think, the most incredible thing that human beings do.
On personal flaws, including as a patient
COWEN: You’ve written about yourself that you are highly indecisive by nature, and you will agonize over many choices. Is there any way in which you feel this—what you describe as your weakness—is actually your strength?
GAWANDE: Yes. I chose surgery, and I wrote in the passage you might be reflecting on that I chose surgery, in part, because I was drawn to the character of people who had that kind of decisiveness, took action when inaction was the worst thing, and then lived with the consequences. Took responsibility for whatever happened, learned from it, and then brought it to the next time.
So I’ve brought to surgery my particular persona, which is to want to have more planning and more deliberation inserted into situations where there doesn’t seem to be time.
And one of the really striking things is, we get this complaint, for example, that using a checklist in surgery, “Well that’s fine, but in emergencies, we don’t have time for that kind of thing.” And we demonstrated that in that situation, taking the one-and-a-half minutes for the very beginning part of it has enormous value. It’s, in fact, the group in whom we have the highest reduction in death are those in which the time is the most pressing. And so I think I’ve flipped my weakness into a strength where I can, but by battling with it to a certain degree.
We get this complaint, for example, that using a checklist in surgery, “Well that’s fine, but in emergencies, we don’t have time for that kind of thing.” And we demonstrated that in that situation, taking the one-and-a-half minutes for the very beginning part of it has enormous value. It’s, in fact, the group in whom we have the highest reduction in death are those in which the time is the most pressing.
COWEN: So are you a good healthcare patient?
GAWANDE: I’m a terrible healthcare patient. [laughs]
COWEN: What do you do wrong?
GAWANDE: For starters, I don’t see doctors. [laughs]
COWEN: OK. We share this.
GAWANDE: I don’t go in, hardly at all. And I haven’t had to. I’ve crossed 50, and I have never had to really be in the hospital or have a major event. But to the extent that the minor conditions I’ve had addressed, I invariably come way late in the game when the mild infection has become a much more significant one. And it’s partly because I know too much about the ways in which healthcare really is pretty unreliable.
I think of ways in which I am good at being a patient is, once I’m in the door, I pick my team—I’m really careful about picking my team—and then I turn myself over to their process. I’m trying to pick them for their ability to run a process that seems appropriate. I think the interesting thing about doctors is that they do tend to not micromanage their doctors very much.
COWEN: Do you feel you’ve underachieved in life?
GAWANDE: That’s a hard question. [laughs] I know objectively that it’s kind of ridiculous that I would think I’ve underachieved, and that I’m proud of all the random things that I’ve been able to be part of. But I bear a kind of chronic dissatisfaction and sense that I’ve got much more to follow through on than I’ve managed to. So yeah, I think “underachieved” is the wrong word, and yet I don’t feel I’ve achieved nearly enough, and that half of what I’ve achieved, I wish I could go back and fix. [laughs]
COWEN: I’m of the view that Clinton-era welfare reforms were mostly a good idea, but they’ve come under more and more criticism lately, and you had a hand in that earlier in your career. What’s your 2017 view of all that? How has it gone?
GAWANDE: Well, I think the fact that we have the number of people who are living on under, what is it, $4 a day in income? And that that number has skyrocketed, that is unconscionable and a fundamental error and failure. There were a variety of things that we sought not to punish people for being married, that we sought to not punish people for working, the shift to the earned income tax credit. There’s a deep and fundamental—and maybe this is the midwesterner in me—belief that we need to reward work. It’s one of my core concerns, that the people who are at the 30th and 40th percentile are served by none of the major political agendas on the Left and on the Right.
COWEN: I agree.
GAWANDE: Even Obamacare provided its great aid to those under the 20th percentile, but people at the 40th percentile are not getting the subsidies, still don’t have a system that works for them, and actually had to pay more into the system along the way. So the welfare failure that is my great concern is the number of people that are subsisting on horrendously little. But the value of taking away the things that were punishing people for moving in the right direction still feels like an important agenda.
On the Atul Gawande production function
COWEN: There are many smart people in medicine, in surgery, in writing books—for that matter, in writing medical books. What would you say is the Atul Gawande production function? I asked Raj Chetty this. I said “Raj, you get a lot done. What’s the skill you have that other people don’t have?” What would your answer be to that question?
GAWANDE: I think part of it is that I’m pretty clear about my goal, which is I’m trying to have impact and to try to do stuff that feels cool along the way. My team knows that my mantra is “I want to do cool stuff that lasts, and let’s see if we can do that.” So I think that from early on, I was always iterating against that set of goals, and that I more or less organize my life around it. I don’t watch that much TV. I get enough sleep.
COWEN: So you’re decisive? [laughs]
GAWANDE: Well, I’ve learned that I say yes too much, and so I’ve learned to say no a lot to various things.
COWEN: Like saying yes to this podcast? [laughs]
GAWANDE: Yeah, sometimes, I guess.
GAWANDE: It’s serving some part of that production function. It’s cool; will it last? We will have to test that question over time.
COWEN: We don’t talk about Obamacare too much. We want people two years from now to still consider the content fresh.
GAWANDE: That’s how I write my New Yorker piece. My ideal is that my New Yorker pieces, I’m always thinking about, “Am I writing them in such a way that in five years, they could still justifiably be read?” And I hope would be that way while trying to address something that feels really sharp and of concern in the moment as well.
COWEN: But those are your goals, that’s your framework. What’s the talent you have that, say, your competitors don’t?
GAWANDE: When I get into our hospital settings, whether we’re working in surgery or medicine or childbirth or other areas, invariably, the main thing we have to work to do is identify, what are your priorities? And people in the system, number one, usually can’t say what that is. And then if you observe what their priorities are, it’s actually far away from delivering the best possible care to patients at the lowest possible cost. That actually is a very tiny portion of the healthcare industry that’s trying to deliver that. So in my individual capacity, I think it’s that I’m able to spend a really high percentage of my time on my priority. I think that’s all it is.
COWEN: We’re in Boston. We’re at a place called Ariadne, which is well known, but maybe not to all of your readers. It’s become one of your major projects. Could you tell us just very briefly what is Ariadne?
GAWANDE: Well, it stems out of the recognition that we . . . It is a center for health system innovation.
COWEN: It’s a for-profit, nonprofit, part of Harvard? How does it fit into the universe?
GAWANDE: It is an academic center that is part of Harvard Chan School of Public Health and the Brigham and Women’s Hospital. But it sits as a platform we’ve created for people who want to do experiments in how we bring science and innovation to the delivery of healthcare in the same way that you bring science and innovation to biological sciences. We have people come here from all of the different hospitals in the area, from the business school, from the School of Public Health, from economics department, and then really built it as a place to enable capabilities to do large experiments.
Like the experiment we just finished with the state of South Carolina: five years of working with them to see whether you could get the surgeons in the state to adopt the safe surgery checklist without regulations because it’s a red state and they didn’t want to mandate it, but without financial incentives because they didn’t have the money to pay for pay-for-performance. And we got a program that successfully got 40 percent of the population through adoption, lowered the death rate 22 percent. But to get the other 60 percent on board, we believe you would have to bring on some mandate or other component. So that’s the kind of thing we could do.
COWEN: You’re the director here?
GAWANDE: I’m the director here. We launched, it’ll be five years this year. We launched in 2012. We now are running about 20 projects in surgery, childbirth, and end-of-life care, improving how you come into the world. The surgery—the average American has eight operations in their lifetime. It’s the highest-risk, highest-cost, highest-failure moment in your lifetime. And then how you leave the world, end-of-life care. And about half of our experiments are in the United States, and half are abroad for demonstrating ways to get better and better.
COWEN: So there’s a lot of people here; it looks great. If you’re the director, you play some role in hiring. We all want people who are smart, have experience, dedicated, cooperative, diverse, and so on, but what’s the quality you look for that you think other people doing hiring are undervaluing? What’s your entrepreneurial secret to hiring well?
GAWANDE: I think it’s again, that thing: What is your goal?
COWEN: What is your priority?
GAWANDE: Yeah. The secret to the hiring is actually, before you ever meet anybody, know what the heck you’re trying to hire. The hardest part sometimes to get people to understand is, what is it you are asking them to do? In two years, give me the list, their score card. What are the five things that they will have accomplished? And then make sure you show it to them when they come in the door.
And ask yourself as you are interviewing them, and then assessing who you’re going to pick. Not “Do I like this person?” or “Would they be fun to be around?” or all of those kinds—those are factors. The ultimate question is, will they be successful in this list of things that you said would define their success in two years? And being again faithful . . . Maybe it is my focus talent. [laughs] Intend. Do what you intend to do, and do it with intention. Over and over, that’s what people fail to do.
We’ve got up to now 90 percent consistency in delivering on people who, as we call them, A-players. And most of it is in that front end, before they’ve even walked in the door, being clear about that step. And then, they don’t tell you all of it, and that’s how you talk to their references. That’s the other real big mistake people make.
On indie music
COWEN: Last question. According to your chat with Ezra Klein, you’re a big fan of what you might call contemporary independent music, but define it as you wish. What would be a musical group that you love or is meaningful to you that maybe the rest of us haven’t heard about, that you would recommend?
GAWANDE: Oh, gosh. I think one of the most underrated bands is Frightened Rabbit. Do you know them, out of Scotland?
COWEN: No. Tell us about Frightened Rabbit.
GAWANDE: Frightened Rabbit—they’re the bards of sorrow and nonetheless sticking it through. Their album Midnight Organ Fight is the great break-up album of all time. You have to listen to it. Now, they’re Scottish, so there’s a whole lot of cussing going on.
GAWANDE: It’s painful, and it’s dark, and all those kinds of things. But I always find there’s this glimmer of hope that runs through it, despite their ability to express pain and heartbreak and disappointment and being betrayed, while still nonetheless waking up and sticking it through the next day.
COWEN: On that note, we close.
Atul Gawande, it’s been a pleasure. Thank you.
GAWANDE: Thank you.