Dr. Gawande, speaker at the Health Forum and AHA Leadership Summit in July, writes about medicine to become a better surgeon.
|David Ollier Weber|
At the age of 27, his only credentials a pair of political science degrees (from Stanford and England’s Oxford University, where he had been a Rhodes scholar) and two years of medical school at Harvard, an ex-campaign aide named Atul Gawande found himself propelled to the heady center of a new president’s effort to overhaul his nation’s patchy, wasteful and inordinately expensive health care system.
The son of Indian physicians who had met in the United States, married and settled to practice in the placid college town of Athens, Ohio, Gawande had cut his political teeth as a campus activist for a variety of liberal causes both in California and the United Kingdom. In 1988 he went to work on Al Gore’s first unsuccessful presidential run. Then he researched health care issues as a member of Tennessee Rep. James Cooper’s Washington staff.
Health Care Revolution Failure
When the Democratic governor of Arkansas sought the presidency in 1992, Gawande joined his team as a key health care policy advisor. And when that candidate, Bill Clinton, was elected and decided to tackle health system reform as his first major initiative, young Gawande was elevated to command a 75-person committee charged with designing national health insurance benefits, subsidies and universal coverage mechanisms.
The enterprise, history records, was doomed.
“Our political system is not built for revolutionary change,” Gawande observes in retrospect. “It’s built for incremental change. We have never done anything of that extent in this country without being in crisis. The deeper reason the 1992 plan failed is that the public feared the change more than they feared the health system crisis.”
At a surface level, the reason the reform effort foundered was a perfect storm of partisan political opposition; egregiously distorted if not mendacious portrayals of the evolving plan in influential media; and the unwise bureaucratic insistence by first lady Hillary Rodham Clinton, who led the effort, on dotting every “i” and crossing every “t” in secret deliberations before presenting the proposal to a skittish Congress. (These are all judgments by the writer, not assertions by Gawande.)
Chastened by that experience—“for 15 years we didn’t even talk about health care reform [in this country], we’d blown it so badly,” he acknowledges—Gawande eagerly hied back to medical school. Becoming a physician like his parents, he told an interviewer at the time, “was where my heart was in the long haul.”
He chose surgery as his specialty, with research as a strong secondary interest. Today he practices both—at the Dana Farber Cancer Institute and at Brigham & Women’s Hospital in Boston, where in addition to maintaining a full operating schedule he heads his own Center for Surgery & Public Health. He is also on the faculty of Harvard’s schools of medicine and public health.
No Average Joe
Atul is a fairly common Indian boy’s name; it means “matchless” in Hindi. Perhaps “breathless” would be equally apt as a sobriquet. Somehow Gawande has managed to reconcile a remarkably eclectic breadth of interests with a 24-hour day, to rack up an extraordinary range of first-order achievements.
As an undergraduate he doubled down on majors, meshing biology with poli-sci, for which he was awarded a combined B.A.S. degree. After earning his M.D. at Harvard, he added a master’s degree from its school of public health for good measure. In addition to winning a prestigious Rhodes scholarship for postgraduate study, in 2006 he was named a MacArthur Fellow—one of a select group of mid-career “geniuses” honored each year with a $500,000 five-year unrestricted grant for their “exceptional creativity [and] promise for important future advances based on a track record of significant accomplishment....”
Although a typically overworked and strung-out junior surgical resident, Gawande succumbed to the urging of an editor friend and agreed to write a diary of his clinical experiences for the online magazine Slate in 1997. He had never written for publication before, but the pieces grew into a regular column. It attracted the attention of editors at The New Yorker. After several of his “medical dispatches” were published to acclaim in the magazine, he was engaged as a regular staff writer.
Gawande had added a third—for most people full-time—occupation to his daunting schedule.
In addition to his New Yorker pieces, Gawande has since published two notable books, Complications: A Surgeon’s Notes on an Imperfect Science (Metropolitan, 2002) and most recently Better: A Surgeon’s Notes on Performance (Metropolitan, 2007). He also finds time to contribute occasional op-ed commentary on health care reform and practice improvement developments to national newspapers. (He does not, however, advise any candidates or take any direct hand in politics, since that would conflict with his role as a journalist.)
And, oh, yes, he is a husband—he was married in a Hindu-Episcopalian ceremony in 1992—and a parent with his wife, Kathleen, a former editor, of three children, ages 12, 11 and 9.
“I don’t think I manage particularly well,” Gawande demurs when asked—during a break between surgeries—how he juggles so many demands.
“I’m constantly stealing time from different places. I have an article I’m working on in my back pocket right now, and I’m carrying around 50 medical studies I’ve pulled up that I have to read. I spend two days a week in clinic, two days in the operating room and one day for everything else. I write on weekends in the morning, and whenever there’s a cancellation. Two vacations were given up for my last book. But surgery still comes first. Research is second. Writing comes third—although it may be the longest-lasting thing I do.
“My hope,” he explains, “is to keep extending myself through writing about things I’m curious about—usually puzzles I haven’t understood or solved.”
Moreover, he told another interviewer recently, “Without the chance to step back and see things from 30,000 feet in the way my writing lets me, I would burn out in the trenches. If you don’t have some way to pull yourself back from the grind, you fail.”
Much as his subjects vary, there is a unifying theme to Gawande’s books, journalism and research. “I keep gravitating to the question of why failures happen in medicine,” he notes, “and what we can do to deal with its extreme complexity.”
The glory of 21st-century medical technology, he points out, is that “we are able to help people almost regardless of the problems they have.”
Astonishingly precise surgical techniques, sophisticated instruments, powerful machines, magic pharmaceutical bullets and step-by-step protocols for their complex interapplication have been developed to give physicians realistic hope of saving soldiers blown apart on battlefields, victims of terrible automobile collisions, little girls without a pulse dragged from the bottom of icy ponds, and patients riddled with cancers that were once untreatable. (Gawande himself is a highly regarded expert on the removal of thyroid and adrenal tumors.)
And yet, he admits, “the fact of our ability has started to feel extremely chaotic to the average person doing this on the ground.... If you talk to anybody in health care, you won’t find a single person who feels in control of the situation.”
M.I.S.S. (Make It Simple, Stupid)
It was Gawande’s recognition of this dilemma that focused his writing and research on ways state-of-the-art medical care can be systematized and routinized.
“At the pointy end of the system, it’s just you and the patient in the office trying to sort out a century of information,” he says. “I realized I could do everything [I thought was right] and still get terrible results for the patient.”
At Brigham & Women’s he and his team decided to look at the reasons foreign bodies like instruments and sponges only too frequently (never + n = too frequently) end up inside patients who have been carefully sutured and triumphantly wheeled to recovery. And this despite the fact that simply accounting for the whereabouts of surgical paraphernalia eats up one of every seven minutes a patient spends on the operating table, they documented. What’s more, miscounts—requiring halts to resolve the discrepancy—occurred in fully two-thirds of all the surgeries they studied.
In response, Gawande’s team has tested a bar-coding system for surgical sponges (developed with an outside company and recently approved by the FDA). And they are working on a camera-based, computer-automated system for tracking all instruments in the operative field. They have also devised a post-surgical scorecard that helps objectify the safety of a given operation, measure the patient’s condition immediately afterward and predict the likelihood of serious complications.
Gawande patterned the scorecard after the one used to evaluate the hardiness of newborn babies introduced in 1952 by pediatrician Virginia Apgar. Adoption of that simple innovation as a care standard throughout the United States, he observes, “moved us ahead of the world in [maternal and infant survival in] childbirth.”
No chauvinist, Gawande maintains a strong interest in bringing the whole world up to best-practice clinical speed. He chairs the “Safe Surgery Saves Lives” campaign sponsored by the World Health Organization—with special emphasis on improving surgical care in developing nations.
Indeed, inexperience on the part of the doctor who recommends and performs an operation is the leading cause of avoidable injuries to surgical patients wherever they are, Gawande notes. So he and his team are examining a promising consultation protocol based on pairing doctors who contemplate a relatively unfamiliar operation with a veteran surgeon from a hospital where the procedure is routine.
It is rudimentary, head-slap-in-hindsight tools like these for chopping the iceberg of medical complexity into more potable chunks that capture Gawande’s enthusiasm, both as researcher and writer.
A few months ago, in The New Yorker, he described a set of short checkoff lists designed by Johns Hopkins critical care specialist Peter Pronovost, M.D., to reduce intravenous-line infections, untreated pain and ventilator-associated pneumonias among patients in intensive care units.
So effective was the first checklist in trials begun at all hospitals in Michigan in 2003 that within a year ICU central-line infections statewide had dropped by two-thirds overall (to zero at most hospitals), saving 1,500 lives and $175 million. Similar results have been seen with the other Pronovost checklists. They have averted more deaths than any highly touted drug or apparatus that has emerged from a laboratory in the past decade.
And yet, Gawande noted, although prominently described in the medical literature, these cheap and easy fixes have not been snapped up by hospitals elsewhere in the country. Even in Michigan, use of the checklists was halted briefly over misplaced concern that it was an experiment requiring cumbersome authorization by an institutional review board.
To be sure, some interest has been expressed by hospitals in New Jersey and Rhode Island. But it is Spain that is likely to be the first country to embrace the life-saving Pronovost checklists nationwide, Gawande reported.
Why Spain, he is asked, and not the vaunted United States?
“There’s no profit to be made from a checklist,” Gawande replies. “We’ve not been very good in America at making people get things that aren’t going to make somebody a profit.” (Never mind that Pronovost estimates it would cost less than $3 million for all the hospitals in the United States to adopt the checklists in their ICUs—and that the first Michigan hospital to do it alone banked almost as much in avoided care costs over a two-year period.)
Secondly, he says, “We’re not in a top-down system like Spain’s. We value individual physicians being able to do things ... even though it means there are big pockets where people don’t even do stuff like wash their hands.” (That, incidentally, is the first of the five elementary actions a clinician must check off on Pronovost’s ICU infection-prevention cheat sheet.)
Feeling the Pain
A pivotal feature of the Michigan program, according to Gawande, was a requirement that each hospital assign a senior executive to visit the ICU at least monthly to monitor implementation of the protocols and help remove stumbling blocks. It was not a popular stipulation in administrative offices. But it proved essential when it turned out, for example, that the necessary soap and sterile drapes specified in the checklist were unavailable at many hospitals.
These, pointed out Gawande, were problems only an executive could solve. And in fact, because wingtips were on the ground, the problems were promptly acknowledged and made to go away.
Gawande will be a featured speaker at the 16th Annual Health Forum and American Hospital Association Leadership Summit in July. He says he feels the pain (as his one-time boss put it) that will be prevalent throughout the audience.
“The life of a hospital administrator, I’ve come to imagine,” he says with a sympathetic sigh, “is one of trying to figure out how to make thousands of people care. It’s a revolution administrators are being held responsible for ... not only providing money but also making a huge staff work together, both as individuals and to meet scientific standards, so that incredibly complex [procedures and interactions] go well ... and if not well, then better than they did the last time they didn’t go well.
“There’s a tremendous amount of ferment,” he says. “We’re in an age of complicated experimentation.”
And that, of course, promises to keep Dr. Gawande happily occupied on at least three fronts, for at least a while.
David Ollier Weber is principal of The Kila Springs Group in Placerville, Calif. He is also a regular contributor to H&HN OnLine.
Atul Gawande, M.D., is speaking on Friday, July 25, at the 16th Annual Health Forum and American Hospital Association Leadership Summit. The event is being held at the Manchester Grand Hyatt in San Diego. For more information, please visit www.healthforum.com and click on the “Conferences” toolbar.
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