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Wednesday, January 5, 2011 Previous | Next

Dr. Atul Gawande on Obama’s "Frustrating" Record on Healthcare Reform and "The Checklist Manifesto"

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Dr. Atul Gawande, surgeon at Brigham and Women’s Hospital in Boston, staff writer at The New Yorker magazine, associate professor at Harvard Medical School. His latest book is The Checklist Manifesto: How to Get Things Right.

Renowned surgeon and author Dr. Atul Gawande discusses his frustrations with President Obama on healthcare reform, the ethical conundrums of learning and practicing medicine, and his most recent book, The Checklist Manifesto.

Part 1 of interview
Part 2 of interview

AMY GOODMAN: Our guest is Dr. Atul Gawande, surgeon at Brigham and Women’s Hospital in Boston, staff writer at The New Yorker magazine, associate professor at Harvard Medical School. His latest book is The Checklist Manifesto: How to Get Things Right. It’s out in paperback today.

Dr. Atul Gawande, we have talked about this before. It is such a simple concept, and yet one that rarely is taken seriously in the places where it can have the most important beneficial effect, where, amazingly, a checklist can be a matter of life and death. Talk about how it’s used in the operating room, or how it hasn’t been used.

DR. ATUL GAWANDE: Yeah, we rebel at the idea — I rebel at the idea. When we started putting these checklists in, I was doing it in rural Tanzania and in Delhi and, you know, Seattle. But do I need it at Harvard? You know, I’m a patient safety expert; I don’t need this in my operating room. I didn’t want to be a hypocrite, so I put it in my operating room. And from the very first day, our team, my team, were catching errors. I have now been using a — this two-minute checklist for three years, and we have not gotten through a week of surgery without catching an error for a patient.

The simple idea behind it is that, you know, these are 19 checks that are focused on just the killer items, as we call them. And what they are is interesting. It’s things like make sure everybody in the room knows each other’s name; make sure that the surgeons actually brief the team on the goal of the operation and what the length of time is expected to be and how much blood loss would be expected, so they’re prepared.

SHARIF ABDEL KOUDDOUS: But, I mean, on the — what the surgery is, you say sometimes they don’t know which leg or what part of the body they’re operating on. And just a simple, quick discussion.

DR. ATUL GAWANDE: That’s right, that there are — everybody has an idea. Everyone has an assumption. But there are half a dozen or more people in the room and a lot more information and knowledge than is in just in the head of the surgeon. And having the team function as a team requires a series — almost a script. You know, you’re assembling a team that’s always new every day, and you’re trying to make them into a team. It’s like walking into a conference room with half a dozen people around the table and not introducing yourselves. How do you even get things done?

AMY GOODMAN: Why do names matter? Why does knowing everyone in the room?

DR. ATUL GAWANDE: Well, one of the fascinating things is that a checklist contains a set of values. Those values are humility, the recognition that anybody can make mistakes; discipline, to do things the same way every time. And what you do when you go around and just start by introducing everybody in the room is you flatten the hierarchy. An operating room is a highly hierarchical place. The surgeon walks in, starts the operation. He’ll often — sometimes, in some cultures, the only person allowed to even speak. And that is where errors occur. Simply allowing people to hear their voice in a room or around a conference table allows them to — makes them much more likely they will speak up later when they recognize something, when they see an issue, when they have an idea. "Hey, how about this?" And that is far more beneficial than not.

It’s interesting. The most difficult item on our 19-item checklist that people have a hard time with are the introductions. That’s the ones that my fellow colleagues often want to skip or belittle. "We know each other." And it matters.

AMY GOODMAN: Keep going on the list.

DR. ATUL GAWANDE: Well, so, you know, the core fascination, to me, with checklists, in general, is that they are the tool of this particular century. We’ve come through a century where there’s been enormous amount of discovery, to the point that we ask ordinary people to do all kinds of extraordinary things — build skyscrapers, do operations, maintain oil rigs in the Gulf. And the idea that we can have it all in our heads, that we can all just — you know, it’s all about training, and I’m an expert, and now I know how to do everything — is a kind of a hubris. More and more, what we see, as you watch aviation, you see how a great kitchen runs for a great restaurant, is that — where they have a recipe, a kind of checklist — is that the checklist is the tool that helps the expert become even higher performance. And it is a measure of our difficulty with humility and understanding what a hero is, in this day and age, of where our central problem in our individual lives, and in making social institutions work, is difficulties with ineptitude, with just the sheer volume of complexity that we are all coping with. And given the reality that science and discovery has not made our world simpler — it’s given us much more information to cope with and tasks to accomplish — the history of how the checklist even came to exist and then how they make a difference in our lives and how to make them turns out to be really a story of our struggles to make all kinds of institutions, including healthcare, work.

SHARIF ABDEL KOUDDOUS: I want to ask you about some of the writing that you’ve done. I mean, you’ve done some of the best writing explaining what goes on in a surgery room, to the lay person. And in your books Better and Complications, you write, I found very interestingly, about how doctors learn and your experiences being a resident surgeon in Boston, and that — this somewhat ethical conundrum, that for new doctors to learn, they have to practice on people. Talk about what you found and what that tension is.

DR. ATUL GAWANDE: Well, thank you for being so kind about my writing.

You know, I’m fascinated by failure. And you can tell from all the range of things we’ve been talking about this morning. I’m obsessed with failure on the individual level and our institutional level. And it really comes back to how I learned to be a surgeon, even. That very first day, you’re asked to put a knife to someone’s skin, and you find that, you know, the skin is so rubbery that your first cut doesn’t barely go through it, that you have to press hard when you open somebody up. There is a lot of learning before doing that we need to do more of in medical education, so that we aren’t just practicing on people. But at a core level, as human beings, we all have to learn on other human beings. And it’s a fundamental ethical conundrum because we hide that, behind curtains and behind language. I, as a resident trainee, would walk in to patients and say, "Hi, I’ll be assisting your surgeon today," when, in fact, the surgeon, she will hand me the knife, I will raise the bed to my six-foot height, I will, you know, cut along a line. At the same time, she’ll draw that line for me. And the ethical question I was asking was, can we be honest about what’s really happening?

The formative experience for me as a resident was that in the first week of my training my child was born and turned out to have a heart defect. And so, I would go from my one part of the hospital across the bridge to the children’s hospital in the same day and then listen to a surgeon tell me, "Well, I’ll be assisting in your son’s operation today." And I knew exactly what was there. And I wanted the best. Who does not? What bothers me about the way we have trained is that we get our practice on often the down-and-outs in society. Am I going to be the one standing there and having the knife and cutting along that line, or having the first time I thread a tube into a patient’s nose down to their stomach, be with the chairman of surgery’s wife? Or is it going to be with the homeless veteran at the VA hospital, or with the Spanish-speaking-only family that’s in our resident clinic? The honesty in our system requires mainly that we be willing to have the same treatment for everybody. Practice is absolutely necessary, but it is — and there will always be some hiding behind the curtains of language. But what we cannot have or where you lose trust in the system as a whole is a system that treats different people differently.

AMY GOODMAN: Finally, as your book has come out — it’s now out on paperback — you have traveled the world, I presume, not to mention spent many hours in surgery. What have you learned most in the year since The Checklist Manifesto has come out?

DR. ATUL GAWANDE: I’d say the thing that has really struck me has been a debate that happens in policy in lots of ways, which is whether you mandate something like the checklist or other kinds of policy, or you let it grow up from the bottom. And what I’ve learned is, you need a period where these can voluntarily move into place. And as you get a quarter, a third, of people who are really learning how to do these and make this go right, you then get a base of people who have gotten through the learning curve and can be the backers.

The United Kingdom mandated, from the very first day our study was published, that the checklist go into the National Health Service. And there was an enormous backlash. "Who are you to tell me how to do my operation? This is one study in eight hospitals. This is ridiculous." And it was stymied for a while. On the other hand, after six months, then they achieved near 100 percent coverage in the country, and we’re seeing remarkable reductions in death rates. We, in the U.S., have gone entirely voluntarily. We’re at about a quarter of hospitals, and many of them still skip the checklist during the operations. And I think we’ve reached the point we’ve climbed the early learning curve, and this needs to become mandatory.

SHARIF ABDEL KOUDDOUS: One last question. It seems to me, talking about healthcare, in general, that in this country we’re very good at covering the high end, at the high end kind of medical procedures — a lot of breakthroughs, very high-tech surgeries that are amazing. But at the low end, at primary care, at geriatrics, at end-of-life care, we seem to be far behind a lot of industrialized nations. Why do you think this is?

DR. ATUL GAWANDE: It’s centrally the way — partly our history of how things develop, but we are a society that has been absolutely fascinated by technology and innovation. And I think — and we’ve been the source of discovery of many of those procedures and technologies that have now moved into practice, and they’ve saved lived. I mean, creating the hip replacement has improved — and replacing aspirin for people with arthritis is a huge breakthrough. But when we got — we’re so obsessed with the new, we have neglected the old-fashioned need for time with a patient, a primary care relationship over time that isn’t sexy and dramatic, but saves lives.

We’re discovering, under health reform, there’s an entire new resurgence of what’s happening in primary care with incredible innovation in how primary care doctors are discovering how to make it possible for people to be in the hospital less, to not need to go to the emergency room. A lot of these innovations are in service and in delivery and things like that. And I’ll be touching on that, actually, in an upcoming New Yorker article. And so, one of the striking things, I think we’re about to enter a period where primary care is about to be cool again. There is such interesting innovation going on, it will eclipse and save as many, if not more, lives than some of our technological breakthroughs.

AMY GOODMAN: And yet, the system that we have in this country, that’s being debated in Congress right now — you told us about the beginning of Medicare and how it was a real battle.

DR. ATUL GAWANDE: Yeah.

AMY GOODMAN: What was the clincher that secured Medicare, which they do seem to be trying to unravel right now, even now, 40 years later?

DR. ATUL GAWANDE: Presidential leadership. I told about the president sending inspectors into the South and confronting the hospitals that were — basically a stare-down that occurred. But with the physicians, he was more conciliatory.

He had this amazing moment where the president of the American Medical Association came to the White House to explain that the AMA was going to vote on potentially boycotting Medicare as a whole. And the president sat down with the leaders, and they came to the Oval Office. And so, he sat down, and almost — they were about to start talking, and he stood up. And when the president stands up, you stand up. And so, they all stood up, and then he sat down. And then they sat. They were about to talk again, and then he stood up again, and he scratched his belly, and they waited, and then he sat down again. And then he did it a third time, and suddenly it was clear who was in control of this meeting.

And before they could even start talking, he said, "You know what I’m worried about? I’m worried about Vietnam. You know, the citizens there, the civilians, we see terrible healthcare problems there. Do you think the American Medical Association would be willing to help us with a volunteer corps of doctors to help the civilians in Vietnam?" And the president of the AMA said, "Absolutely. We’d be happy to do that." And he said, "Great! Let’s call the press in here, have a press conference right now." Got the press in, explained that the AMA is going to back this voluntary program to send doctors to Vietnam.

And then, of course the next questions from the press were, "Well, what about this boycott we hear is going to happen?" And the president says, "You mean to tell me that these doctors, who would volunteer to help the poor in Vietnam, wouldn’t help our elderly here at home?" and turned to the president of the AMA and said, "You tell them what you think." And the president of the AMA said, "Well, we will support Medicare." And they entered a period of several months of a negotiation that led to "improving" amendments, but moved them from total opposition to talking about how to get them under the fold so that you could make this thing work.

Only thing that can move the public to recognize the value and the meaning of what we have with policy — we will have the battle back and forth between pro and con and so on — but the only person who can lead that same kind of experience is going to be the president.

SHARIF ABDEL KOUDDOUS: Well, what did you think of his leadership in the healthcare reform debate?

DR. ATUL GAWANDE: I was frustrated by it. The leadership with Congress was incredible — getting the votes, getting the detailed understanding of what you need to get everybody together. It was a Lyndon Johnson masterful performance. In fact, the whole year has been an incredible Congress that has been able to pass all kinds of blocked reforms that have been important to make some progress on. But you also have a role — there’s leadership needed to give meaning to the policies for the public and to explain what the value is. And that communication, from one of our great communicators in the campaign — I’m not sure the reasons why; I understand the energy is divided between trying to focus on the congressional job and so — but it allowed the opponents to brand every one of those policies as failures, even though they passed. And that — and it’s not just about branding. It’s about being able to tell the story of where we have been, where we are going, and help people understand the vision of what we — of what we need for the economy, for healthcare, and so on.

AMY GOODMAN: Following up on what Sharif just asked, about who gets and who doesn’t, one of the people who led in his campaign to repeal healthcare, Andy Harris, who is a congressman, who then — Andy Harris, who ran for Congress and got elected, who said he would lead the fight to repeal Obama’s healthcare legislation — when he came for his freshman introductory session — all the freshman Congress members — when he was told he would have to wait — what was it? — 30 or 60 days to get his healthcare for his family, he stood up in rage and said, "What do you mean I have to wait?" He was going to be getting government health insurance for his family.

DR. ATUL GAWANDE: Yeah, in fact, the congressmen get a range of private options through, you know, this complex government, essentially, exchange, very much like what the health reform passed. You know, there are the details. And as ordinary people start seeing the details, two things can happen. One is that it can just seem confusing, because the details is about what happens with my family. And he, himself, was not making the connection with — between what’s happening for his family and what’s happening on this broad policy level, that he had not seen the connection between the meaning of the policies and his daily experience. And when we — as we continue to trudge through the details of what’s going to be happening, I think that level of confusion and disconnection will just constantly be there.

One of the real threats to this program is the reality that making — bringing in insurance coverage for a large population of folks, making changes that improve the healthcare delivery system, trying to bring in discussions for end of life, has a rollout phase that’s going to be three years instead of, under Medicare, it was one year. And that waiting until 2014 for implementation means that we’re going to be battling out the meaning of these policies until people actually receive them. And it is a very difficult political test.

AMY GOODMAN: Why do they wait? Why did they say 2014?

DR. ATUL GAWANDE: For several reasons. Number one is the cost of making these programs come into place is substantial, and needing to see that we’re — basically, it built in cost provisions that — it was one of the most responsible pieces of legislation we’ve had in the entire year. You know, the Republicans have attacked for failure to reduce the deficit. But this bill was one that actually did reduce the deficit. And building in the cost savings was one of the reasons for delay.

But the second reason is, it takes time. This bill allowed states to create their own systems and have much more local experimentation, which means you have to give time for every state to create their programs and build up their Medicaid programs, etc. And already, you had the Utah governor, just this week, complaining that the time line is too fast, at the same time that you had the argument that, you know, why don’t we just put this in now?

AMY GOODMAN: Well, Dr. Atul Gawande, thank you so much for spending this time.

DR. ATUL GAWANDE: Alright, thank you.


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