Atul Gawande Redux
While Steve's at the conference of the World Federation of Science Journalists in London, we look ahead to some of the programming coming your way in the coming weeks, and we replay our 2007 interview with surgeon Atul Gawande, whose recent research in The New England Journal of Medicine and writing in The New Yorker have caused a big stir in the medical and health care reform communities. Web sites related to this episode include http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande?yrail and http://content.nejm.org/cgi/content/full/NEJMsa0810119
Steve: Hey, Steve Mirsky here for Science Talk, the weekly Podcast of Scientific American posted on July 1st, 2009. This week, we're going to have a slightly different episode from usual because I'm in London this week, where I am speaking at the conference of the World Federation of Science Journalists. I just want to tell you about some of the things we have planned for you. In the next few weeks, we're going to have a series of interviews, actually, with the research and development team from Blue Sky Studios, which I conducted a couple of weeks ago. If the name Blue Sky Studios doesn't mean anything to you, perhaps the Ice Age movies will [mean] something to you, with the voices of Ray Romano and John Leguizamo and Queen Latifah. Well, the R&D guys at Blue Sky Studios [are] the scientists, the computers scientists, the physicists, the folks who make all that animation magic happen; and I spent a full day up at their office—[which] is up in Greenwich, Connecticut—a couple of weeks ago. And one of the founders of that company, who used to be a nuclear physicist working on weapons, and now makes cartoons, actually took his doctorate with Louis de Broglie, and if that name means something to you, then you'll know how knocked out of my socks I was when I heard that. We're also going to play for you, in the coming weeks, an interview with Jeff Wolfe, who is the CEO and founder of groSolar, one of the most successful solar energy companies in the country. I still have stuff that I haven't even mined from the AAAS conference back in February, and we're probably going to come back with some material from this science journalism conference in London, which we'll also share with you in the coming weeks. In the meantime, surgeon, Atul Gawande has been in the news quite a bit lately. He had a very influential article in the June 1st issue of The New Yorker about healthcare costs and how the culture of medicine can make such a difference, the individual cultures in individual hospital settings can make such a difference, in the costs that happen at those individual institutions, and it's gotten quite a bit of attention. I think its kind of required reading through[out] Congress right now. Atul Gawande also had a very influential article in January in The New England Journal of Medicine on keeping checklists as a surgical procedure that can really cut-down on adverse effects and complications, and we had Atul Gawande on the podcast a couple of years ago after the publication of his book, Better. And I thought this week, since I'm out of town, I would share with you that interview, which we conducted at the time of the publication of the book, when he was coming through in New York City on a book tour. So, you're going to hear Atul Gawande from 2007 and check out the recent work by Gawande, which you can find quite easily on the Web. If you go to The New Yorker's site, the entire text of the article on healthcare costs is available for free; and pay attention because, I think Atul Gawande might be your surgeon general someday. So, without further ado, here's Atul Gawande and me back in 2007.
Steve: 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 learned?
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 the difference 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, a section is 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 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 your 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 [of] being well. But they neatly charted out the calculations on [a] 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 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 got [to] 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, [and] 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 their 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 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 [our] world [has] changed. 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 [and] 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 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, paralyzed; 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 on to 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: 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 hundred, 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 has 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." To, [what] 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 [the] ethics code [and there] was something admirable, 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 six weeks, I think it was, in India.
Steve: Before ...
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; [partly] 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 require[s] 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 everyday 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 maybe 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 [them]. Here we imagine, because we produce so many of the discoveries, we imagine that once something is discovered, why, 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 seven-hundred thousand physicians and trying to take care of three hundred 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 a newsletter or it might be a blog, but they were contributing in someway to throwing an idea [out], 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 maybe [had] 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, 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, no question, my thinking. I run a lab where we do work on public health problems and it [shocked] 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 assign 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 its 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 was [it] 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. Thank you.