Thursday, January 14, 2010
New Yorker writer and surgeon Atul Gawande devotes himself to learning how to improve the practice of medicine, from decreasing cost to decreasing errors. In his latest book, The Checklist Manifesto: How to Get Things Right, he examines how people in a wide variety of disciplines have used the deceptively simple checklist to master extraordinary levels of complexity.
MAUREEN CAVANAUGH (Host): As the House and Senate work to merge two very different healthcare reform bills, the final result is still up in the air. But, we are now closer to making significant changes in our healthcare system than we have been in more than 40 years. One man who has been examining the problems with America's healthcare system since the beginning of the Clinton Administration is Dr. Atul Gawande. In addition to being a surgeon, he is also a best-selling author and he's a frequent contributor to New Yorker magazine, most notably, his feature last summer called “The Cost Conundrum.” It examined the high cost of healthcare in a small Texas town. His latest book is called "The Checklist Manifesto: How to Get Things Right." It’s a pleasure to welcome Atul Gawande to These Days, and good morning, Dr. Gawande.
DR. ATUL GAWANDE (Author): Thanks for having me on.
CAVANAUGH: You know, I want to ask you a few questions about our nation’s healthcare reform debate but first, your book, “Checklist Manifesto” is all about how proper organization can save lives. And I can’t help thinking about this gigantic relief effort underway for the victims of the earthquake in Haiti and how in the world is that kind of a huge undertaking organized effectively so it actually helps people and save lives?
DR. GAWANDE: I actually had a chance to talk with folks from the International Red Cross about how they manage these sorts of things, and they have extensive training for their medical personnel and other people. But then all those people go back to regular lives for awhile until a disaster happens and then they’re called back into action. And at that moment, what they don’t assume is that these experts, who know a lot, are going to remember everything they were trained to do and they actually have checklists…
DR. GAWANDE: …specifically designed for them to carry out the tasks that are involved and they expect them to have the discipline to follow through on them. That’s how they keep stuff from falling through the cracks. And yet those same experts, many of them physicians, will go back to their daily life here at home in the healthcare system and not turn to that idea when they’re taking care of problems like heart attacks or depression or operations.
CAVANAUGH: That’s fascinating. And I do want to ask you about the current healthcare debate, if I may.
DR. GAWANDE: Yeah.
CAVANAUGH: The House and Senate healthcare bills, the debate over them is winding down, conference committee, there was a big meeting yesterday at the White House to try to get these two bills together. How do you view these two bills? What’s right and what’s wrong about them?
DR. GAWANDE: Well, in many ways, you know, I watch from my sideline seat in an operating room or in my doctor’s office trying to understand what’s going on. And what – the sense I get of the way the debate is going is partly that there is, in both arguments from both sides of the bill, of the House and the Senate, coverage that is aimed to be provided through still private health plans as being the sole way that they’d be provided, no option for a public, a government, insurance program option being made available to people without insurance. And then there’s some struggle on the cost containment side as, naturally, there’s a huge amount of lobbying efforts to weaken provisions for an independent commission that would have influence over taking knowledge from findings about pilot programs that are showing ways to lower costs. The concern is that that independent commission would have the power to impose further cost controls if they – there turns out to be successful ways to have higher quality and lower cost care. And some of those provisions are still under a huge debate and attack in trying to keep the coalition together.
CAVANAUGH: But you think that that is essential in trying to not only keep costs down but increase the quality of healthcare in the United States.
DR. GAWANDE: I do. At the center of this, what we went through is a recognition that this is not just about insuring that we have coverage for a whole population, something that we’ve been working on for a century, but now that healthcare costs are so expensive and there’s such clear evidence that the – some of the major sources of costs are problems of disorganization of care, lots of intermediaries and over treatment and mistreatment in the care system, it is having the kinds of incentives and plans in place that brings both the private insurers and public insurers to leave room for doctors and hospitals to reorganize in ways that we’re more likely to have higher quality and smoother paths of care for patients.
CAVANAUGH: You have been writing about healthcare and it has been such an essential part of your life and your thoughts and your writings for so long, I wonder, have you been surprised or distressed about the way the healthcare debate has played out politically?
DR. GAWANDE: You know, I haven’t really been distressed. I know it’s incredibly disheartening but that’s the democratic process. If this – In a sense, this whole year we’ve moved from month to month through issue after issue and the fascinating thing is that we’ve kept the ball moving along. We’ve recognized that if we do nothing, we are against a wall, not only having failed to provide coverage for a population, which is now a chance that will be scotched for a generation if we don’t do it, but also that if we do nothing about starting to investigate the ways that we control our costs, we are in economic trouble. So from one month to the next, you know, we went through our death panel…
DR. GAWANDE: …month of fighting and we went through our month of arguing about how do we deal with abortion, and the fascinating thing is that we’ve worked through our contradictions, found ways to move forward. It can never make everybody happy but it is – we’ve been able to find ways to work towards self-correction, taking the steps forward and creating the tools that we’ve been missing for awhile for being able to start changing our health system.
CAVANAUGH: I’m speaking with Atul Gawande. He is a surgeon and a writer, and his new book is called “The Checklist Manifesto: How to Get Things Right.” Speaking about investigating ways to control costs, your article in the New Yorker magazine this summer called “The Cost Conundrum” profiled a town called McAllen, Texas. It has – it’s in a county which has the lowest household income in the county (sic) but it has – it’s the second most expensive healthcare market after Miami. What did you find out was going on there?
DR. GAWANDE: Yeah, this was interesting to me because I didn’t understand how to understand our cost problems until I went there because – and what I compared that county to was another county up the border that is also just as poor. The fourth poorest county in the country, El Paso County, has the same levels of illegal immigration, same levels of diabetes, coronary artery disease, smoking, those kinds of problems, and yet McAllen, Texas cost twice as much for Medicare patients per person as El Paso did. And when I went to the county and actually asked the physicians what they thought was going on, what they described was a place where care was extremely fragmented, disorganized, and the business of medicine had held sway. People were following the incentives where they took them which meant very poor provision of mental healthcare, primary care, but lots of centers like orthopedics and cardiovascular centers owned by physicians or imaging centers that had cropped up, home healthcare agencies on every block, and the sense that you had had a system that had followed the incentives to the nth degree was a cautionary tale about where the rest of our country was going.
CAVANAUGH: Right, and you contrasted what you called the McAllen doctors’ entrepreneurial spirit with how the Mayo Clinic operates. Tell us how they’re different.
DR. GAWANDE: Yeah, and in one sense you can’t compare, you know, a poor Texas community with a place like the Mayo but what you see is that there are about a third of our communities which are lower cost than average and actually higher quality. And what the Mayo symbolizes is that – is the recognition that the places that are getting the best results are actually often the places that are among the least expensive in the country. And at the Mayo Clinic, by having a system where they’ve actually salaried their physicians, they organized them to work together much more collaboratively, sometimes actually taking – arriving to take care of a patient all on the spot and standing there at the same time with the different specialties putting their heads together, led to smoother care, less likelihood of over use of surgery, radiology, better chances of being on top of things in ways that keep people from going into the hospital or bouncing back into the hospital, and that had led them to be among the places that, for Medicare, are the lowest cost communities in the country with remarkably high quality results.
CAVANAUGH: And even though McAllen’s system was spending so much money on so many procedures, what was their success rate? How healthy were the people in McAllen, Texas?
DR. GAWANDE: Well, I mean, this is a sick and a poor county in many ways for, I mean, the people in the county. And so, you know, they hadn’t fared extremely well there but the striking thing was that you compared it with El Paso where people were starting off in the same position and even though McAllen spent twice as much, the signs were that the quality of care was actually better in the place, in El Paso, where the hospitals were spending less. And what you begin to see is that the problems of over treatment can lead to complications of care, damage to people from overdoing what we’re capable of.
CAVANAUGH: I’m speaking with Dr. Atul Gawande and we’re about to talk about his brand new book “The Checklist Manifesto: How to Get Things Right.” In your new book, doctor, “The Checklist Manifesto,” the premise almost seems too simple. It addresses the ways that large, complex endeavors, whether that’s in a hospital or in an airplane cockpit can be made safer by the use of a simple checklist. You referred to this when we were talking about the Haiti relief effort just a few minutes ago. What prompted you to start thinking along these lines?
DR. GAWANDE: There’s actually a link here between where we are with reform and why I’m suddenly talking about, of all things, checklists. The underlying reason we have such a struggle with healthcare is that our biggest problem isn’t the insurance issues, it is the enormous complexity of making medicine work now that after a century of discovery we have more than 6,000 drugs identified, more than 4,000 medical and surgical procedures, and we need to organize these, and they’re very complex to provide and we’re trying to provide it county by county, town by town, consistently for every person in the country. And what has emerged as a huge problem is we’re not well designed for it, not to produce as high quality as we’re capable of nor avoid being wasteful with our resources. And so, for example, 40% of coronary disease patients receive incomplete or inappropriate care, 60% of pneumonia patients. And in surgery where we have over 150,000 deaths a year from complications of surgery and have recognized that at least half are avoidable in research that’s done using existing knowledge, what we did was devised a checklist for the operating room that we worked with Boeing to learn how to make them well for high stress settings…
DR. GAWANDE: …implemented them in eight hospitals and found we had an average 36% reduction in complications, fewer deaths and saved money.
CAVANAUGH: Yeah, in fact you use the story of a B-17 Boeing, that they wanted to produce for the Defense Department, to illustrate why we need checklists. What happened in that case with that Boeing plane?
DR. GAWANDE: Yeah, what was interesting to me was the moment when airplanes adopted checklists and it was in 1935 when Boeing designed a plane with four engines on it instead of the usual one or two, and it was the runaway likely winner of the army’s competition for their new long range bomber. This model 299, as it was called, however, crashed at its initial flight competition run, killing two crew onboard, including the top, the best, pilot in Boeing. And the investigation unveiled that it wasn’t a mechanical problem, it was that the four engines on the plane had made the plane more complicated than the pilot could hold together in all of his training in memory and he forgot to release the elevator controls before they took off. Well, the army scuttled the plans for the plane saying it was too much airplane for one man to fly but later pilots were convinced they could fly this extremely complex plane but they needed a different way of handling it. It wasn’t the usual way we focus on, which is just train people more, yell at them a little bit, get your act together.
DR. GAWANDE: Instead, especially when the top pilot was the one who was killed, they didn’t think they could be any better skilled than that, so they made a checklist. And using this one-page checklist, they were able to fly the plane two million miles without a single mishap. The army then reversed itself and ended up purchasing more than 13,000 of them. This became our B-17 bomber and was the backbone of our aviation superiority in World War II.
CAVANAUGH: So you’re talking about, you know, those scenes in those old movies where they go, you know, altimeter, check, goggles, check, that kind of thing, that kind of a checklist.
DR. GAWANDE: Exactly, and there was a moment when that happened. It was the moment that airplanes went from being simple enough that, you know, just one engine, you ran it down the runway. It wasn’t any harder than backing your car out of the driveway, although a little more nerve wracking, to something where even the best trained experts couldn’t handle it without having an aid that they turned to.
CAVANAUGH: Now the intensive care unit in any hospital is really a great example of what you call the problem of extreme complexity. Describe what’s going on in an ICU and who are the players and what is it that they have to know?
DR. GAWANDE: Yeah, I mean, the fascinating thing is that one of the places that we’ve made possible the saving of people from incredible problems ranging from, you know, a ruptured aneurysm to having major heart attacks to people being blown up by bombs, is the combination of surgery but then really the intensive care unit where people’s multiple organs in failure can be rescued by walking through numerous kinds of steps and tasks and care. But an engineer studying that world found that for the typical patient, to keep them alive for 24 hours, teams had to perform on average 178 different tasks correctly without error. And, in fact, we do very well with only a one to two percent error rate but given that you’re doing almost 200 tasks, that means that there are two to four things that end up going wrong in any given day. And what we – what a researcher, an IC researcher named Peter Pronovost at Johns Hopkins, introduced was really trying to take that aviation idea, apply it in the Intensive Care Unit and actually measure what could be accomplished. He did it with just making sure they don’t pass infections to patients when placing intravenous lines, and having the teams always walk through a five-step check when they put in the lines: make sure they wash their hands, put on a hat and mask, glove, gown, put a sterile drape over the patient, washed the site with chlorhexidine soap, and then put a sterile dressing on. The first thing they discovered when they implemented it in the state of Michigan was that 30% of the time doctors skipped one of those steps. The second was that with a checklist in hand and work to change the culture of the ICU so the nurse actually had the power to walk the doctor through the checklist and make sure they didn’t miss a step, that with that in place, they lowered the infection rate in the entire state by two-thirds. They saved 1500 lives that first year and $200 million.
CAVANAUGH: You do tell the story of a patient named Anthony del Filippo – de Filippo, that is, who almost lost his life because of a central line infection in the ICU that you basically are saying now could’ve been avoided simply by a checklist.
DR. GAWANDE: Yeah, and this was a patient of mine. And I really didn’t think about, you know, our patients, especially when they’re enormously sick like this not uncommonly have complications and you just think, well, that’s part of the risk and the difficulty of this job. But then what Pronovost’s work made me recognize is that thinking back on this patient who was nearly well and then ended up having a week in the ICU because – and nearly dying because of an infection we passed to him, that if we’d have used the checklist when we were placing the lines he needed and actually been able to be more self-disciplined, we very likely would have avoided putting him through what he went through.
CAVANAUGH: I’m speaking with the author of “The Checklist Manifesto,” Dr. Atul Gawande. And I’m wondering, Dr. Gawande, what makes a good checklist? I know that you attempted to create your own and your first attempts were not very good.
DR. GAWANDE: No. And there are a lot of bad checklists out there, ones that make conditions worse rather than better. And what we did in designing the checklist for surgery was actually visited Boeing and I tell the story of what the checklist factory there looks like. They actually have a place headed by a man named Dan Bormann who designs their checklists for pilots. They make over 100 revised or new checklists a year, and these are designed for situations that often the pilot may only have two or three minutes in a crashing airplane to handle the situation. And they’ve designed checklists that actually make those folks in those situations more likely to be successful than otherwise. And the techniques are ones that recognize that, you know, some simple things. Really long checklists clearly don’t work and we have to be disciplined about making a focused enough checklist on what they call killer items, only those key critical steps that, if missed, would cause disaster. But then the second thing is that they focus on the idea that since you can’t put everything down—and there is no recipe for how you handle everything in a complex situation—that you have to have focus on the checks that would make sure the team is prepared to handle the unexpected. And so in our surgery work, we took ideas from the cockpit such as asking that, in our checklist, that the team be introduced by name and role, that everybody in the room make sure they know each other. We have more than half a dozen people involved in an operation typically and often they’ll be some people who you don’t quite remember their name. And by not knowing their name, they are then much more likely, in studies that have been done, to not speak up when a problem arises or to stick to their narrow area of work, the med student who barely thinks they belong in there and, therefore, doesn’t say when they see something going wrong. By having the team brief each other, be introduced, make sure they discuss the goals for the operation before the incision is made, those were the steps that turned out to be some of the critical components to leading to that more than one-third reduction in deaths and complications.
CAVANAUGH: That’s fascinating, just these very, very simple things. I’m wondering, though, Doctor, don’t a lot of people just think they’re too smart to have to need something like that? You know, that they know all this stuff already and they don’t have to go through the rigamarole of a checklist?
DR. GAWANDE: Absolutely, and I was one of them. You know, the way we’re trained in most lines of expertise, is you spend years working at gaining the knowledge and experience to know what to do in key situations. And the whole point, you feel like, is so that you don’t need a checklist. A checklist dumbs things down. Those are for people who don’t know what they’re doing. But that becomes wrong in a world where the amount of knowledge we’re grappling with in many lines of our work has exceeded our own individual abilities to, you know, remember them and also to make sure a whole team of people don’t have it together. I use the checklist in my operating room that we designed only because we were implementing it at eight other hospitals and I didn’t want to be a hypocrite but did we need it at Harvard? No.
CAVANAUGH: Yeah. Right Right.
DR. GAWANDE: You know, I didn’t think so.
DR. GAWANDE: I haven’t gotten through a week of surgery in the last two years since we adopted the checklist that the checklist has not caught a problem that has helped improve the care, anything from an antibiotic not given to a medical problem that I hadn’t been made aware of or someone else on the team hadn’t been made aware of. And I know of at least one instance in which I’m positive a patient’s life was saved because we went through that two minute check.
CAVANAUGH: So is this a hard sell for the medical profession? How is the checklist doing in being accepted?
DR. GAWANDE: Well, the sign that it’s a hard sell is that it took 75 years for this concept to come from aviation into our world.
DR. GAWANDE: And then the further sign of the hard sell is that we have just a few tiny pockets where we’ve started to make these kinds of checks but there are 13,000 different diagnoses for which we know there are steps that are missed, I mentioned pneumonia, I mentioned coronary artery disease. And even the surgery checklist that we’ve designed and tested and have published results is only in about 20% of American hospitals. We have some countries that have really embraced it full bore, the United Kingdom and France have full implementation in all of their hospitals. And what they’re focusing on now is how to really start improving and changing these checklists and having them implemented in ways that make it possible for experts to do even better. And I’m convinced it’s time for us to catch up.
CAVANAUGH: I’m wondering, this might be an odd question to end with, but I’m wondering, Doctor, you know, we started talking about healthcare reform, and I wonder if perhaps we should start assembling any checklist to know how healthcare reform is working. Are there any points that we should begin marking down that this tells us that these reforms are actually doing what they should do?
DR. GAWANDE: Yeah, one of the principles that I learned from the Boeing folks and also people who construct skyscrapers about how they handle that complexity is that a successful checklist has what they call a pause point, a moment when you can actually stop and take an assessment of where you are.
DR. GAWANDE: And we clearly are going to need to do that in about one to two years from now. What health reform provides is coverage, which will slowly come into place over the next four or five years but it only provides – it provides a toolkit as well for beginning to work on these problems of raising quality and lowering cost. And there can be no master plan that says this is exactly the way that communities should be taking care of people and that doctors and hospitals should be making their decisions. Instead, it provides some incentives to really change the way doctors and hospitals organize themselves and are paid so that we work on making these improvements. And my check would be that within the next year, the first thing that I’d love to see is whether we have at least one county that has committed to saying that they will raise their quality and lower their cost, not just bend the curve but actually have lower costs than we currently do.
CAVANAUGH: Well, I think we have to leave it there, Doctor, but that’s a good way – place to start. Thank you so much for speaking with us today.
DR. GAWANDE: It’s great to be on.
CAVANAUGH: I’ve been speaking with Dr. Atul Gawande and we’ve been talking about his book, “The Checklist Manifesto: How to Get Things Right.” You can comment on this segment, KPBS.org/thesedays. Stay with us for the second hour of These Days coming up in just a few minutes.