A Conversation with Atul Gawande

Surgeon, Writer, and Public-Health Researcher

BY MANJU BHASKAR, NINDS

“Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.” — Atul Gawande, Better: A Surgeon’s Notes on Performance

Surgeon. Writer. Public-health researcher and one of the most prolific commentators on the state of medicine and health care. Atul Gawande has definite ideas on how a more systematized health-care system will go a long way toward eliminating medical errors and improving patient care. He visited NIH recently for a conversation with NIH Director Francis Collins about “Systems Science and Innovation in Health-Care Delivery.”

Gawande, who’s based in Boston, is a surgeon at Brigham and Women’s Hospital, a professor at Harvard School of Public Health and at Harvard Medical School, and founder and executive director of Ariadne Labs, a center for health-systems innovation. He has been a staff writer for The New Yorker since 1998 and is the author of four New York Times best-sellers: Complications: A Surgeon’s Notes on an Imperfect Science (2002); Better: A Surgeon’s Notes on Performance (2007); The Checklist Manifesto: How to Get Things Right (2009); and Being Mortal: Medicine and What Matters in the End (2014), which was also featured in a Frontline documentary.

The following is an edited transcript of the conversation that took place between Collins and Gawande on June 13, 2017, in Masur Auditorium (Building 10). Some questions were submitted by NIHers in advance and some came via Facebook and Twitter.

COLLINS: How did you travel the path from scholar, surgeon, writer, and health-care commentator?

GAWANDE: I was involved in different kinds of work—ranging from doing a radio show in college, working in a microbiology lab on Epstein-Barr virus in medical school, and earning a political and philosophy degree at Oxford. I was always interested in the intersection of health-care delivery and access to health care and in understanding how to create better outcomes of care. I enjoyed probing the problems through journalism and writing about the failures of the health-care system. My first article for The New Yorker was “Why Do Doctors Make Mistakes?” (1999), in which I addressed issues like “How do we manage to reduce the risks and errors and still enable learning?” I was also writing for an Internet magazine in the mid-1990s and was probing questions of public importance, testing answers to these questions, and addressing the failures of health-care delivery and the cost of health care. Now, I run Ariadne Labs, which is a center for health-care systems innovation where we do the experiments at a population scale.

COLLINS: How do we reduce errors and address the failure in health-care delivery?

GAWANDE: There are two reasons why we fail to save lives. One is ignorance, which we address by doing research in the laboratory in search of breakthroughs in science and innovation. The past century has given us an enormous volume of those breakthroughs. But the second reason is ineptitude—we don’t apply science to the delivery of medicine the same way we do for breakthroughs. Instead, we impose mandates such as pay-for-performance programs and malpractice regulations, but they only have modest effects. What we need to do is systematize, and that requires applying science to the follow-through in what we do.

COLLINS: How do you systematize discovery and delivery?

GAWANDE: In my book The Checklist Manifesto, I described how we designed a surgical safety checklist based on the critical components of care. In a study in South Carolina, we found that high-performing teams performed better surgeries because they made sure that they had a verbal checklist before the operation to take on the big killers like infection, management of bleeding, and unsafe anesthesia. This model was piloted locally and later tested in eight sites globally—from the most impoverished region of the world to the University of Seattle. In every hospital, there was an average reduction in complications of 36 percent and an average reduction in deaths of 47 percent. Hence, we can apply science to systematize discovery and delivery.

COLLINS: What role does transparency of outcomes play in rendering precision delivery and precision medicine? I know you are getting strong messages from providers that they don’t want their outcomes to be viewed by anyone but you.

GAWANDE: You cannot do science and learn without the data. We do have fields that have been transparent for a long time. We’ve had public information about the infant mortality rate and the maternal mortality rate since a White House report in the 1920s. That information has been crucial to the success of our delivery of knowledge into obstetrics. We went from pregnancy being the number one killer of women in the country to being one of the rarest causes of death. Even in the 1920s, people understood that the maternal and infant mortality rates were a property of the health system and not attributable to the specific physicians. In a recent study on C-section rates—which can vary from seven to 70 percent depending on the hospital—we found a fivefold variation depending on which nurse you get. It’s a system property.

Over the past half-century, 4,000 medical and surgical procedures and 6,000 drugs have been developed. The volume of knowledge and skill has exceeded the knowledge of any one clinician and his or her ability to manage it. We are all part of groups of people delivering care. We need data to see how the group is doing and be able to intervene in that system just like you’d intervene in a cellular system to see how to enable the pathways that are the right ones that get you the best possible result.

COLLINS: NIH’s “All of Us” research program will have an unprecedented million-strong longitudinal cohort of Americans. What kind of information will be most helpful in moving from precision medicine to precision delivery, and what can NIH do to help manage the transition?

GAWANDE: Applying science to the system is key. A huge amount of data on biologic, genomic, and laboratory results are being collected from a million people. It’s important to see the interconnections such as what kind of care patients have received; how it affects their physical, cognitive, and emotional functions; what level of well-being they are getting from the care; how much does their well-being fluctuates and change over time. All such information collated together truly represents precision medicine and its delivery. Where the system is most organized, care is better and costs less.

COLLINS: Where did we go wrong with electronic health-records system?

GAWANDE: The system was developed for billing purposes so it takes only five seconds to put a bill through. But inputting data on allergies and other medical conditions takes time. The system isn’t optimized to make it easier to deliver care. We need to come up with systems that are more effective and user friendly. The best example of a computerized system that’s working well is the prescription order-entry system, which has led to a 95 percent reduction in medical errors.

COLLINS: How do we tackle the opioid epidemic in this country? In the late 1990s, the medical profession recommended that no patient should be allowed to have pain, and it was thought that treatments with Oxycontin would not lead to addiction.

GAWANDE: About six to 10 percent of patients put on opioids after surgery will become addicted to opioids later. We didn’t know in the 1990s that the addiction rate was that high. And we did not know how few opioids were needed for good pain control. In a recent study, it was demonstrated that mastectomy patients on average used less than 10 pain pills, and that 80 percent could be covered with a prescription for 15 pills. But the prescriptions for opioids, on average, were many times that. Knowing that data, then, has led people to shrink the number of pills they are using. Another problem is that we tend to give longer prescriptions because we don’t want to leave our patients in pain. If a patient runs out of pills, they are required to go back to the doctor for a paper prescription. But what if you are calling after hours? Now what’s supposed to happen?

There are systematic steps that can be taken to address this problem. New York State, for example, has successfully implemented an electronic-prescription approach that tracks every prescription and gives the physicians an efficient and controlled method of ordering narcotics. If you prescribed too few, the patient could call you and you could order five more pills and they would be ready at the pharmacy for pickup. I think there is an incredible role for NIH being able to define those patterns and support the innovators who are making those kinds of systems come into place.

COLLINS: In your New Yorker article “Big Med,” you wrote about how in some communities there is a central ICU-monitoring facility that’s not actually in an ICU. How broadly is that kind of technology catching on?

GAWANDE: We know that having a dedicated ICU intensivist-trained person in a critical-care unit leads to substantially better outcomes for the patients. But there aren’t enough intensivists to go around, and community hospitals don’t have the volume of patients to be able to afford them. A central ICU-monitoring facility provides a hub where an intensivist can consult with the nurses and physicians at multiple sites and demonstrate better outcomes. It’s just one example of how we can take advantage of technology. The newest area has been in doing hospital-at-home care—monitoring from a distance for people who have acute illnesses such as pneumonia.

COLLINS: Do you think people are beginning to recognize that maybe we’re spending vast amounts of money on the last few days of someone’s life and it’s not what the person wants?

GAWANDE: My book Being Mortal, when it was published in 2014, was considered a death-panel work. The belief was that it was forbidden to even to have discussions about what kind of care would be better for people as they come to the end of their life. What I came to understand is what the world perceived, and what I perceived as a surgeon, was that these discussions were about do you want to fight or give up. It is really a question about if you want to fight, what do you want to fight for—the best possible day today or to sacrifice your day today for the sake of possible time later while we treat you in different ways?

In doing the journalistic investigation for my book, I learned that a ton of research from NIH and other organizations have demonstrated how people, including the seriously ill and the frail, have goals besides just survival. They have goals for the quality of life, their purpose, and what a full life looks like. And they want our medical capabilities to enable those core goals. The most reliable way to find out people’s goals is to ask them. But we ask less than a third of the time. When you don’t ask, it’s not a surprise that the care we deliver is out of alignment with what matters most to people. And then you get suffering. Now people are beginning to recognize that they need to take control of their care by voicing and demanding that clinicians know what their goals-of-life are. Our research shows that just having such conversations is incredibly powerful. We’ve distilled into a checklist what the conversation from highly skilled palliative-care and geriatric physicians looks like and how to bring it to non-palliative-care physicians. We’re now deploying the system across the country and learning how to drive it into practice. The goal is to make sure you know you will get cutting-edge care for the quality of your life and for the quantity of your life.

COLLINS: Any advice for young scientists, medical students, and physicians-in-training?

GAWANDE: I think the cool thing about where we are is that we’re in a transition around our science and our policies. The power of the past century in science has come from reductionism—focusing on a single area and understanding a component of what happens; and identifying the gene, the neuron, the molecule, the drug, the device, and the specialized operation. What we are now recognizing is that it’s the interconnection among these that you need to understand—how the genes connect to create a disease and interact with the environment; how the neurons connect to produce consciousness or dementia; and how the drugs and devices and the specialists fit together successfully to produce better outcomes. In the future, we’re switching from the century of molecule to the century of the system. And it’s becoming the science of the interconnections, whether it’s at the molecular level, at the physiologic level, or at the population level. The biggest insights and biggest gains in health and understanding are going to come from those interconnections.

To watch a videocast of Atul Gawande’s conversation on “Systems Science and Innovation in Health-Care Delivery,” which took place on Tuesday, June 13, 2017, go to https://videocast.nih.gov/launch.asp?23354.