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Science Talk April 18, 2007 -- Atul Gawande, Author of Better: A Surgeon's Notes on Performance
Welcome to Science Talk, the weekly podcast of Scientific American for the seven days starting April 18th. I am Steve Mirsky. This week on the podcast, we'll talk with Atul Gawande about his new book Better: A Surgeon's Notes on Performance. Plus, we'll test your knowledge about some recent science in the news.
First up, Atul Gawande and the science of performance. How do you get better at something without breakthroughs or new knowledge, but just by analyzing what you already know and do and figuring out ways to do it better? Atul Gawande is a general surgeon at the Brigham and Women's Hospital in Boston, assistant professor at Harvard Medical School, a frequent contributor to The New England Journal of Medicine and a staff writer at the New Yorker. Last year he received a MacArthur Fellowship sometimes called the "genius grant." He was in New York last week and I met with him in the lobby of the Roger Williams Hotel on Madison Avenue.
Steve: Dr. Gawande, great to talk to you today.
Gawande: Thanks for having me on.
Steve: My pleasure. You are a surgeon and a writer. What's your general background? I know your dad was a doctor, too, from reading the book.
Gawande: My parents are from India, but I was born and raised here and I always knew I would end up one way or another in medicine, though for a long time I tried to avoid it by working in government. I was in the Clinton administration doing Health Policy. I floated around in different kinds of labs, but where I ended up was as a surgeon and my first book was written during my surgical training it was called Complications and it was trying to think about why is medicine imperfect and how do you learn to be good at something that is imperfect and this now tries to take off from there.
Steve: And the title of the book is Better, so not just how you learn, but how do you actually get better once you have learnt?
Gawande: Yeah! So I'm a general surgeon at the Brigham and Women's Hospital in Boston and I only joined the faculty about three years ago. When I joined the puzzle was no longer, How do you become competent at something like medicine? The puzzle became, What's different between people who are merely competent and those who are great at what they do in medicine?
Steve: And one of the really surprising things in the book is that the answer to that is often, I mean, hope for a section called "Diligence" and the answer to that is so often just paying attention to details. It's, you know, it's not huge medical breakthroughs, it's not incredible leaps of knowledge, it's just doing the things you already know how to do, but very carefully and better.
Gawande: Yeah! The striking thing that I found about looking at institutions that were at the top of their bell curve whether it was cystic fibrosis or how the surgeons were saving soldiers out on the battlefield. It wasn't that they were smarter than anybody else, it was that they understood what it meant to be fallible. They were willing to recognize their fallibility and then try to overcome it and so I sort of deliberately start the book with a really mundane story which is about hand washing. Here is a problem where two million people just in the United States who come into a hospital will leave it with a bacteria that that they didn't have before. And that's because of failure of hand washing. Ninety thousand people die as a consequence of the infections they pick up in the hospital. Now what does it mean to be good at hand washing? It doesn't mean that you scrub extra hard or you [are] really like the world expert on getting the stuff from out under your nails, it means that if you have to wash your hands 100 times in a day, that you will do it 100 times in a day, not 90 times, not 40 times and understanding what it means to be diligent, day in, day out is a capacity that we don't think much about in medicine, but turns out to be hugely important in determining whether people live or die.
Steve: You, in the cystic fibrosis section of the book, you profile a doctor who is explaining to one of his patients that the difference between feeling good 99.5 and 99.95 percent of the time on any given day, works out to completely different outcomes over the course of a year. You want to talk about that a little?
Gawande: Yeah! Warren Warwick is the director of a program in Minneapolis that happens to get the best survival rates for cystic fibrosis in the country.
Steve: Way better than other places.
Gawande: The average survival is 33 years in the 117 cystic fibrosis centers we have, and his survival is 47 years for his whole team of doctors and nurses and social workers. Well! I didn't understand what was different about that place and my thought was well they must have a different technology, but it turned out they were following the same guidelines that everybody else follows. They were participating in the same clinical trials, instead it turned out to be a combination of a few attributes that I didn't see until I went to clinic with him and visited and watched him just take care of patients and with this one patient who was a teenager who had simply stopped taking her treatments. What he recognized was that she wasn't taking her treatments because she felt well. You stop taking the treatments and 99.5 percent of the time, a cystic fibrosis patient on any given day will be fine. The treatments, he said, add a little bit—they make it so you're 99.95 percent—likely to make it through the day just fine. In other words, for the average person, they can't tell the difference on any given day. They basically have a 100 percent chance being well. But they need to chart out the calculations on board and it was the difference between an 83 percent chance of making it through the year without ending up sick and in the hospital and only a 14 percent chance, and what he does everyday is set about trying to find that little margin of difference because that's the margin that allows his patients do extraordinarily well. And so with that patient to know, it meant figuring out that she had a new boyfriend (laughs); she wanted to spend time with him, not time at home with getting her treatments, and that also the school had a new rule that the nurses had to provide the medications and she didn't want to go over to the nurse three times a day. So he had a couple of things: He had her move some of her treatment stuff to her boyfriend's apartment (laughs) and he told her to carry her meds around in her pocket and take it even if the nurse didn't tell her to, and it was a fabulous move. It was one that turned her taking care of herself into an act of rebellion against the school.
Steve: It's just got the appeal to a teenage girl.
Gawande: Exactly, and he thought about that not just on the patient level, he thought about it on the systematic level, and so every week he had a meeting with all of his doctors and he'd ask them, "Go through all of your patients with me and tell me what you did." And that allowed a level of consistency and reliability for every patient who came into that institution that they had a whole team of people behind the decision making of one doctor and not just that lone doctor.
Steve: Let's talk about the Iraq section of the book. I had no idea about the medical care going on in Iraq and how again there is no great technological breakthrough. It's entirely a systems approach that has reduced the mortality rate incredibly significantly—so let's talk about that.
Gawande: Well! So when I thought about what was the, what's been happening to military care of wounded soldiers over the last century, what I puzzled over was, How do we make progress? Since the Korean War right through the Persian Gulf War I, the death rate for a soldier wounded in the battlefield has been about 25 percent. The military, of course, the country as a whole wanted to figure out how do we lower that death rate. So the logical thing you do in science is you try to find new discoveries. They invested half a billion dollars in technologies like developing freeze dried blood or blood substitutes for easier transfusion and transport or making miniaturized equipment to try to monitor the heart rate of soldiers. Well! None of this was what turned out to make the difference. The survival rate for soldiers wounded in Iraq right now is over 90 percent—that is, less than 10 percent are dying of their wounds; it's a massive improvement just over the last decade and a half. And the way they did that was instead by relatively mundane seeming things. They looked at the data from the trauma registries and found for example, that soldiers were arriving in the wards without their Kevlar on. They were not wearing their Kevlar. So the health commander is responsible for making sure the soldiers wear their Kevlar. It didn't matter if it was 110 degrees outside or they complained about the 16 pounds of weight of the Kevlar. The Kevlar protected their heart and their lungs and their abdominal organs when a blast would go off or they get shot and that bought them time. There were other critical steps for example, they recognized that the soldiers that were wounded weren't getting to operating tables fast enough, and so they moved the surgical care right onto the battlefield. That means you had to strip it down, you actually had to take technology away. They got rid of x-rays, for example, and the orthopedic surgeons would try to figure out where the fractures were purely by feel,
but by putting them at the bedside, at the battlefield side doing whatever they could with five backpacks of equipment. It allowed them to do operations that were short but incredibly effective in saving lives; and how they did that and how they thought about that is a kind of science. It's a science of performance and it's one we're not used to thinking about or paying attention to, but a world of change. Medical care now compared to half a century ago, we have thousands of things we can do to help people. There is enormous amounts of know-how capability and we haven't thought hard about how we use our existing know-how to produce better results.
Steve: Yeah! One of the amazing things is that battlefield-wounded soldiers and marines may be shipped all the way back to the U.S., basically with their bellies still open.
Gawande: Yeah! So one of the things, you know, one of my colleagues who trained with me was a surgeon who led the first medical team into Afghanistan and the first, and one of the first, medical teams in Iraq. And he described a process where, because they were short on equipment at the battlefield side, there is only so much you can carry with you from place to place, they had to limit the operations to two hours. They would do what they could to stop bleeding. If they had to do an amputation, they did an amputation. If there was a hole in the bowel, they stapled it off, but they wouldn't try to put everything back together; they leave the soldier asleep on the breathing machine, paralyze, the abdomen may be still left open, they pull a plastic sterile drape over it. They tack a note on top and send him off to Baghdad and the note would say, "Here's what we did, please finish." The folks in Baghdad then would continue the operation—either finish it up or do what they could and then they could shift onto Landstuhl, Germany, and then onto Walter Reed. In average, the transport time for a soldier from battlefield wound to Walter Reed is now under three days, and that is an incredibly sophisticated approach. A real change in the way we think about how you make sure someone gets well. It is a team approach, and it has worked unbelievably in this war, and part of the lesson is thinking in terms of teams, but the even larger lesson is the one that says, if we have to only rest on new discovery and we never look to see how we get that discovery to the bedside, we will miss major opportunities to save lives. They cut the death rate from 25 percent to under 10 percent under, you know, horrendous conditions; and you can imagine what we could be capable of, here at home.
Steve: Yeah! With existing technology or, as you said, with actually less technology, just with the systems approach.
Gawande: Yeah! sometimes, there are times when our technology gets in the way and the key step is being able to simply and reliably do what we know how to do. We can add a flourish with a technology that can fine-tune a situation for one out of a hundred people. You know, some special problem that comes in on a rare occasion, but then if it makes it harder to do the care for the 99 out of a 100, we might make things worse and we don't see those patterns. We aren't following those patterns. You know, the interesting thing about the military just is that within 48 hours, you'll know if a wounded soldier lived or died and what has happened to him and you know about it on the Web. You don't have anything like that about American civilian care, and as a result, we ourselves in medicine and surgery don't see the patterns of when we succeed and when we fail.
Steve: Let's talk about the middle section of the book. It's really an examination of morality in [a] lot of medical situations. You have this one fascinating section about within that middle section about doctors or other medical personnel who take part in executions.
Gawande: Yeah! So, one of the things I wondered about was how do doctors actually make moral choices; and so I talked to four doctors and a nurse who participate in executions. They ranged from what I would call a kind of morally inept level of decision making from one person who simply didn't realize that they were being asked a question that had moral consequences to a kind of legal officialistic kind of thinking that said, "Oh Boy! This is a difficult situation, let me call up the board of medicine and find out what the rules are." Two, I thought the most sophisticated level was one of the doctors who participated was against the death penalty, but he thought right through the problem he was faced with; he observed a couple of executions before he gave any kind of answer and he felt that, you know, if people are going to be executed and that's not going to be stopped, that he would help to make sure that this person doesn't suffer. And he felt that was a humane responsibility. Now, this is against our ethics code, and he went against our ethics code—that was something abnormal, I thought, in the way he thought through it. I also happened to completely disagree with him in part because I think he was wrong to think that it is completely inevitable that participating in executions or that executions are just going to happen and that the doctor's role is simply to relieve suffering. The doctor's role here is to execute, and that's become more and more clear; and in the last year, as it has become more apparent, and physicians have been unwilling to participate and help produce the execution, we've had a real plummet in the number of executions being carried out.
Steve: Let's quickly talk about the third section of the book called, 'Ingenuity'. You spent a fascinating 6 weeks, I think, it was in India.
Gawande: It was about two and a half months actually.
Steve: Two and a half months, prior to your taking on your own full life as a surgeon.
Gawande: Yeah! When I finished my training three years ago that was one of the few moments you get where you can disappear for a period of time because you don't have a whole built up practice that you might drop and so I did just that. I went to India for two and a half months doing surgery in a series of eight hospitals across the country, probably just trying to get a glimpse of, you know, in a world which only has twenty dollars per person per year and yet longevity has reached the point that there is a lot of illness that requires surgery: cancer, trauma. What I didn't understand is how they could possibly live and survive and function as doctors and surgeons there and I just wanted to see how they did it.
Steve: And how they do it is amazing, I mean the section is called "Ingenuity," just the things they come up with to and the range of surgical procedures that any one doctor will perform.
Gawande: A part of what I've found fascinating and a story to tell in this book was that these were doctors who were surrounded by [a] chaotic, dysfunctional failing system. And there is only so much they can do about it. They were often demoralized, but they came into work every day with a recognition that there were some things that they could do and what they learnt to do they had a kind of natural bedside ingenuity that they came to by thinking about how do you take what you know when you've been trained as world class treatment and how do you get that to the bedside—and so you saw things like cases, like a woman coming in with breast cancer and there was no oncologist, there are no treatment-infusion rooms where you can put central lines in and give the chemotherapy, but they could get the chemotherapies on the gray market. That's where there are pirated versions of the key drugs that you need in India. They made sure that they found ways to get the medications to the women using all kinds of ingenious ways to work around the limits of their resources. And then they would learn to do things that would never occur to me. I wouldn't know the first thing about how to give a cancer treatment safely. I'd turn to [an] oncologist for that, but they learned how to do that and then on top of it, they learnt how to work old cobalt 60 radiation machines that were used in the '50s and '60s here, so that they could get radiation treatment. They recognized that what they have to be committed to is not new discovery, because there are discoveries—huge numbers of discoveries—that they are simply not using. And they have made it part of their science—an individual science—and I'm not sure they recognize it's a science but a key skill of a doctor. There is that kind of bedside ingenuity and when we think about what we do here, I think it has the same layers, the same levels of possibility—we just haven't quite recognized it.
Steve: We have may be a wealth of options that blinds us to those kinds of opportunity sometimes.
Gawande: Yeah! Part of it is that medicine has changed so drastically. In India they are used to the fact that discoveries are elsewhere and you try to figure out how to use it. Here we imagine—because we produce so many of the discoveries—we imagine that once something is discovered while the machine takes over and simply puts them into practice, but now there are so many thousands of discoveries. Hundreds of new ones that come out each year that can genuinely benefit people, that we almost have an overload of discovery. (laughs) We can't process it. We can't bring it to the bedside in a country where we have 700,000 physicians and trying to take care of 300 million people. How to make it so that that care actually gets from idea to delivery is a science of a kind and there are certain people who I try to describe in the book who have shown or created some of that science that demonstrates how it can be done.
Steve: I am just personally curious. How does somebody carry on a full-time surgical career and be basically a full-time writer at the same time?
Gawande: It's not very (laughs) very easy, and it falls apart all the time. I mean the writing ends up having to take the back seat to the surgical care.
Steve: I should hope so?
Gawande: Right! (laughs) and you know in the last year I produced one article for the New Yorker where I normally produce three to four, and this book was about six months late in getting down and that's just the way it has to be. But I do say, you know, that one of the key attributes of being what I called the positive deviant (laughs) is that the successful folks that I watched wrote something. It wasn't that they were writing a book or that they were writing a research paper every month. Sometimes it would be just one paper or it might [be] a newsletter or it might be a blog, but they were contributing in some way to throwing an idea or an observation they had made about the world and then seeing what people had to say about it.
Steve: I think one of the things about writing is you can clarify your own thoughts to a point that you may be yet not appreciated before if you take the time to write something about what you're thinking, and there is a great quote—I think it was from Scotty Reston [the] former New York Times editor many years ago—who said something like, "How do I know what I think until I have read what I wrote?"
Gawande: My writing, I feel like it helps to question my thinking. I ran a lab where we do work on public health problems and it struck me—the number of ideas that have come from simply writing about a story here, one of the essays here is about a woman named Virginia Apgar who invented the Apgar score for obstetrics and I realized, you know, why that score has transformed obstetrics—it's given them a way to know
if in an objective way whether a child is healthy or not.
Steve: All it is, is you look at the baby when it's born and you sign various scores.
Gawande: Whether it is blue or pink or how it's breathing and so on and I realized, you know, that's been around for 50 years—it's really helped obstetrics. Why don't we have that for psychiatry? Why don't we have that for surgery—to see how, to grade really how well has a patient made it through an operation. And that led our lab to start working on exactly that problem—and that was an idea that wouldn't have come about until I had written about the problem and that forced to me think through what [it] was that they did in obstetrics that made it so much safer over time, and in a way that we hadn't accomplished in surgery.
Steve: Dr. Gawande great to talk to you. The book is called Better and I really enjoyed it and thanks for your time today.
Gawande: You're great to take the time.
Steve: Atul Gawande will be signing books all around the country over the next few weeks, including appearances in D.C., Detroit, San Francisco, Portland, Seattle and Newton, Massachusetts. He'll deliver the commencement address at the University of Pennsylvania Medical School in Philadelphia on May 14th. For a complete list of appearances, places and times, just Google "Atul Gawande" that's G-a-w-a-n-d-e and "2007 book tour" or see the link in the description of this podcast on the SciAm podcast page, www.sciam.com/podcast.
Speaking of Philadelphia, the Franklin Institute gives out its awards recognizing achievements in science and technology next Thursday, April 26th. Honorees include astronomer Steve Squires who appeared on this podcast, April 12th, 2006. We have a segment about the awards scheduled for next week's show, but there are public events starting Monday in Philadelphia that may be of interest including sessions with the scientists for young people. For more info, just Google "Franklin awards" and hit the link on the left for "2007 awards week schedule."
Speaking of awards, our podcast efforts have been nominated for something called a Webby, which the New York Times has called the "Oscars of the Internet," and which I am going to call the Nobel Prizes of the series of tubes—but anyway, we're up against some high-power competition including the NPR podcast and the Onion podcast. You can vote for the SciAm podcast or the other ones, if you are so inclined, by going to www.webbyawards.com and then navigating over to the podcast category.
Couple more notes. On the baseball show,
the April 4th, I talked briefly about Tommy John elbow surgery that about 10 percent of all current major league pitchers have undergone. I happened to catch an excellent report on Tommy John Surgery in kids as young as Little League age on the new edition of HBO's Real Sports with Bryant Gumbel. That episode is going to be repeated a few dozen times on various HBO channels over the next couple of weeks. Just go to hbo.com/realsports to find the time and channel. And Atul Gawande's book, Better, had Amazon sales rank number 127 when I checked Tuesday. If you go down only about 380,000 places, you get to my book, which just came out. It's called Antigravity and it's a collection of my "Antigravity" columns that have appeared in Scientific American magazine for about 11 years now. Again, the book is Antigravity by, shockingly enough, me.
Okay enough self-promotion. Now it's time to play TOTALL.......Y BOGUS. Here are four science stories. Only three are true. See if you know which story is TOTALL.......Y BOGUS.
Story number 1: Regular consumers of the Daily Show and the Colbert Report ranked the highest in their knowledge of current events according to a new survey.
Story number 2: Stephen Hawking will experience weightlessness aboard a zero gravity flight next week.
Story number 3: Injuries involving nail guns have tripled since 1991.
And story number 4: New York City is responsible for 1 percent of the world's greenhouse gas emissions.
Story number 1 is true. Those who regularly watch the Daily Show and the Colbert Report rank the highest along with readers of major newspaper Web sites, in a survey about knowledge of current events done by the Pew Research Center for the people on the press. Other knowledgeable people were the audiences for PBS' News Hour, NPR, Rush Limbaugh and news magazines. Regular viewers of other TV News programs were significantly less well-informed.
Story number 2 is true. On April 26th, Stephen Hawking is getting a ride on the so-called Vomit Comet, the parabolic flight of which will make him virtually weightless for a few seconds. His next book will therefore be a, (funny tone) Brief History of Lunch.
Story number 3 is true. Injuries involving nail guns are up threefold since 1991 to about 15,000 emergency room visits per year, due to nail-gun wounds. Increasing home handymanning seems to be the cause. For more, check out the April 16th edition of the daily SciAm podcast 60-Second Science.
All of which means that story number 4 about New York City being responsible for 1 percent of the world's greenhouse gas emissions is TOTALL.......Y BOGUS. In fact, New York is responsible for 1 percent of U.S. greenhouse gas emissions despite having about 2.5 percent of the country's population. That's according to a New York Times article cited in the April 11th entry of the SciAm blog, and that blog entry is called "The Greenest Place in America." It's over at blog.sciam.com. Cities in general are actually pretty green, mostly because the dense buildings are energy efficient and the vast majority of all trips are on foot or mass transit or bicycle.
Well! that's it for this edition of the weekly Scientific American podcast. You can write to us at firstname.lastname@example.org, check out news articles at our Web site, www.sciam.com. The daily SciAm podcast 60-Second Science is at the Web site and at iTunes, and you can vote for us at webbyawards.com. For Science Talk, the weekly podcast of Scientific American, I am Steve Mirsky. Thanks for clicking on us.
Web site mentioned on this episode includes, http://www.fi.edu/tfi/exhibits/bower/07/schedule.html, www.hbo.com/realsports.