Better: A Surgeon's Notes on Performance | Atul Gawande | Talks at Google

Collection of medical stories. And I like telling stories, but it's taking on a different task, a kind.

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Goal of trying to understand medicine as a kind of performance, and whether by looking at how people do their jobs in medicine, you begin to have ideas and lessons for how performance really works. At something that's high risk, at something that's difficult and that's something. And in a job that's very human, it pushes us in ways that we aren't necessarily pushed in other walks of life. The idea of what it means to think of medicine as a performance has come to me over and over again through experiences in medicine. And I wanted to read a little bit from the beginning of a case that brought home exactly what the difference is between a kind of ordinary, competent performance and great performance. Several years ago, in my final year of medical school, I took care of a patient who has stuck in my mind. I was on an internal medicine rotation, my last rotation before graduating. The senior resident had assigned me primary responsibility for three or four patients. One was a wrinkled 70 something year old Portuguese woman who had been admitted because I'll have to use the technical term here. She didn't feel too good. Her body ached, she was tired all the time. She had a cough, she had no fever. Her pulse and blood pressure were fine. But some laboratory tests revealed her white blood cell count was abnormally high. A chest X ray showed a possible pneumonia. Maybe it was, maybe it wasn't. So her internist admitted her to the hospital and now she was under my care. I took sputum and blood cultures and following the internist's instructions, started her on an antibiotic for this possible pneumonia. I went to see her twice each day. For the next several days I checked her vital signs, listened to her lungs, looked up her lab results. Each day she stayed more or less the same. She had a cough, she had no fever, she just didn't feel good. We'd give her antibiotics and wait her out, I figured, and she'd be fine. One morning on seven o' clock rounds, she complained of insomnia and having sweats overnight. We checked the vital sheets. She still had no fever. Her blood pressure was normal. Her heart rate was running maybe slightly faster than before, but that was all. Keep a close eye on her, the senior resident told me. Of course, I said, though nothing we'd seen seemed remarkably different from previous mornings. I made a silent plan to see her at midday, around lunchtime, several hours before. I'd usually see her on my afternoon rounds. The senior resident, however, went back to check on her himself, twice that morning. It is this little act that I've often thought about since. It was a small thing, a tiny act of conscientiousness. He had seen something about her that worried him. He'd also taken the measure of me on morning rounds. And what he saw was a fourth year student with a residency spot already lined up in general surgery on his last rotation of medical school. Did he trust me? No, he did not. So he checked on her himself. That was no two second matter. She was up on the 14th floor of the hospital. Our morning teaching conferences, the cafeteria, all the other places we had to be that day were on the bottom two floors. The elevators are notoriously slow. The senior resident was supposed to run one of those teaching conferences. He could have waited for a nurse to let him know if a problem actually arose, as most doctors would. He could have told a junior resident to see the patient. But he didn't. He made himself go up. The first time he did, he found she had a fever of 102 degrees and needed the oxygen flow through her nasal prongs increased. The second time, he found her blood pressure had dropped and the nurse had switched her oxygen to a face mask, and he transferred her to the intensive care unit. By the time I had a clue about what was going on, he already had her under treatment with new antibiotics, intravenous fluids, medications to support her blood pressure for what was developing into septic shock from a resistant fulminant pneumonia. Because he checked on her, she survived. Indeed, because he did, her course was beautiful. She never needed to be put on a ventilator. The fever stopped in 24 hours, and she got home in three days. You begin to understand, when you look at someone like that resident, why this question of what it takes to be good at something is particularly interesting in medicine because it's a place where failure is easy, failure is effortless. And what's striking about the people who do a better job than others is that they're not geniuses. Jamie's not smarter. That's the name of that resident. His name is Jamie Winshaw. And Jamie is not smarter than other people. What he had was something more than competence. Competence is your ability to know how to do things in general. So he knew how to diagnose a pneumonia. He knew the textbook answers about how to treat a pneumonia. But he knew something more than just that. He knew what it was to treat a pneumonia and find it in that particular person, in that particular place, in that particular moment, with the resources and the strengths and weaknesses of the people that he had around him. We're used to looking to athletes to understand performance, and there's a lot they have to teach us about hard work and perseverance and the importance of practice. But what I'm trying to get people to think about as they turn to something like medicine is that there are dimensions to be found in what we do as human beings in medicine that are not to be found on a playing field. And those dimensions might teach us about other things we do. One dimension, for example, is that lives are on the line. That because we are taking responsibility for other people, the enterprise becomes a moral enterprise. The second thing is that medicine is dauntingly ambitious. It is an effort to bring the science and technology that we have available, that's been discovered and make it available on a person, by person basis for everybody in a country, if not around the world, somehow, for 300 million people to get that know how to you. The third dimension is that this is not an individual enterprise. It's not just whether I, as a surgeon, can sew really well, can make a good diagnosis. The ability to deliver requires actually hundreds of people for the care, sometimes of a single person. So all the nurses coming in on each shift, the cafeteria worker whose responsibility is to deliver the right tray at lunchtime, the one without the concentrated sugars for the diabetic patient, the one without too much protein for the kidney patient, you have everybody. The engineer who has to make sure the oxygen works, the IT person making sure the computers we now depend on are actually up and running all the way down to the doctor. So it's hundreds of people somehow who have to make this go well. And then beyond all of that. So we are, you have, an ambitious moral enterprise. We need to work consistently and reliably, despite being all kinds of people. Beyond all this, we have the expectation that we do this work humanely with gentleness and concern. And so it's not just the stakes that it lives on the line that makes it intriguing. It's also the complexity. And that's precisely what also makes it a disturbing place to think about. I think a sign of how hard medicine is to make it, how hard it is to make it go right is the fact that we have a bell curve in medicine. And that's something we have a hard time acknowledging. We have a bell curve in the sense that there is a wide gap between those who are great at what they do, either as individuals or institutions, those who are merely mediocre at what they do, and those who are down at the bottom end. And more to the point, there's not only a wide gap, but most of us are grouped around the center, with only a few who are really at the top. Now, this is not what the public imagines about medicine. What we imagine is, you know, you've gone through four years of medical training. You have got people who then spend multiple years in residencies working in hospitals to develop their specialty capability. And then most people have some experience under the belt afterwards. And so you would think, and what the public expects is that most of us have. That the shape of the curve would be called, is what I've called a shark's tail, that most of us would be grouped around the very best outcomes at the top of the curve, and that all we have at the bottom is just a few crappy doctors who are kind of the bad apples. And if we knew what we were doing, we would chop them off at the knees and that would solve the problem problems. But instead, the discomfort is we have a bell curve. And I can give you several examples. I wrote in my first book, Complications, about the very first operation I learned to do, which was a hernia repair. It's an operation where you have a weakness in your abdominal wall and the insides start bulging out. It's kind of like getting a tear in a couch cushion with the stuffing coming through. And what you can do to repair it is you can either sew it back up or you put a patch on it. And I visited in that I described visiting in that first book a hospital in Toronto called the Schuldeis Hernia Hospital, which was kind of like a factory for hernia repairs. Each of the surgeons there do 700 to 1,000 hernia operations a year. That's all they do day in, day out. They do more hernia operations in a year than most of us will do in our entire careers. And the result is that they have a less than a one in a thousand chance that you will have a hernia return. That is that your hernia would come back after you've had it repaired. What is the national average for a return of a hernia? It's 5%, a 1 in 20 chance. And if you look at the bottom end of the bell curve, you'll find that there are few institutions and individuals who have a 15%, 20%, even higher likelihood of a hernia coming back. It's a bell curve. Another example, in vitro fertilization. That's kind of become the wild west of medicine. You have hundreds of fertilization centers. There's probably one in your neighborhood cropping up. Now, if you ask, what is the likelihood that a couple going to an IVF center to achieve a pregnancy, what's the likelihood they will have a successful pregnancy? It varies from 5% to 75%, depending on what institution you go to. And the average is 45%. And that's where the bulk of the centers are clustered around. It's a bell curve. I could give you lots of examples.

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But the one that intrigued me the most was the bell curve for cystic fibrosis. And the reason is because cystic fibrosis care is the way we want all of care to be in medicine. Children born with cystic fibrosis have a genetic defect that's a terminal illness that glues up their lungs, makes it hard for them to digest food in a way that to keep a normal weight. And we've concentrated the care for these children in 117 centers around the country. These are centers that have a high volume of experience. They're kind of like factories for cf. They all have super specialists who are pediatric pulmonologists who focus especially on cf. They follow detailed guidelines, more detailed than we have for most of the rest of medicine. They all participate in clinical trials. And yet they have a bell curve, a wide bell curve. The difference between the average center, that average center survival, and the top center survival is 14 years. The median center has a 33 year survival for children with CF, but the best one has a 47 year survival. So I wanted to find out, you know, if we were making centers work that just the way we want to in cf, why would there still be such a wide difference? Differences that really matter if you have a child with this disease. And so I went to a hospital that was in the middle of the curve. The University of Cincinnati Children's Hospital actually was just a little bit below the midpoint. And I went there looking more or less for trouble, and they were kind enough to let me in. And what I found was a place that actually was a terrific hospital. They are one of, they're routinely listed in one of the top 10 hospitals in the country for children's hospitals. It's the place where the Sabine polio vaccine was discovered, which is the oral vaccine that we depend on for the global eradication of polio. And in cf. The director of their center is someone who has devised several of the guidelines that we depend on nationally. He's a person who's written the chapter on cystic fibrosis for the textbook Nelson's Pediatrics which is kind of the bible of pediatricians. And yet there they were, they were in the middle at best. So that's fine. They have all the window dressing, they have a great reputation, maybe underneath. That's not really how it works. So I spent a day in clinic and I found care just the way you'd want it. Conscientious people who were knowledgeable, had great expertise and good bedside manner. They were devoted to their patients and the patients were devoted to them. They were convinced they were getting great care and yet still that 14 year difference. So then I thought, what I need to do is go to the best place and see what I was sure was going to be a secret drug. Because how else to explain that they were getting such fabulous results? Well, it turned out the best place, the place at the top of the curve, is somewhere called the University of Minnesota center for Cystic Fibrosis. It's in Minneapolis, it's run by a guy named Warren Warrick. And it turns out they don't have a secret drug. They are using the same guidelines, everybody else is using the same treatments and they're getting different results. So one possibility was maybe the kids have a different form of cystic fibrosis. They have a weaker gene and there's a most severe form called the Delta F508 mutation. But as you start looking at their panel of patients, they're actually more likely to have that most severe form of cystic fibrosis. The so the genes didn't turn out to be a great explanation either. And I really didn't get it until I went to clinic with him and watched him take care of patients and began to realize how different everything they did there was from what everything I was used to expecting. I want to read a little bit from that visit so that you might have a picture of what I'm talking about. So in the clinic one afternoon I joined Warren Warrick as he saw a 17 year old high school student named Janelle who had been diagnosed with CF at the age of six and had been under his care ever since. She had come for her routine three month checkup. She wore dyed black hair to her shoulder blades, blue black Avril Lavigne eyeliner, four earrings in each ear, two more in an eyebrow and a stud in her tongue. Warwick was 76 years old, tall, stooped and frumpy looking, with a well worn tweed jacket, liver spots dotting his skin, wispy gray hair, by all appearances a doddering mid century academic. He stood in front of Janelle for a Moment, hands on his hips, looking her over. And then he said, so, Janelle, what have you been doing to make us the best CF program in the country? And she muttered, it's not easy, you know. They bantered. She was doing fine. School was going well. Warrick pulled out her latest lung function measurements. There'd been a slight dip. Three months earlier, Janelle had been at 109% of normal for her lung function. She was actually doing better than the average child without CF. Now she was at around 90%. That was still pretty good, and I knew from looking at the charts in Cincinnati that some ups and downs in the numbers are to be expected. But this was not the way Warrick saw the results. He knitted his eyebrows. Why did they go down? He asked her. Janelle shrugged. Any cough lately? No. Colds? No. Fevers? No. Was she sure she'd been taking her treatments regularly? Yes, of course. Every day? Yes. Did she ever miss treatments? Well, sure. Everyone does. Once in a while. Well, how often is once in a while? And then slowly, Warrick got a different story out of her. In the past few months, it turned out she'd barely been taking her treatments at all. He pressed on. Why aren't you taking your treatments? He appeared neither surprised nor angry. He seemed genuinely curious, as if he'd never run across this interesting situation before. I don't know, she said, and he kept pushing. What keeps you from doing your treatments? I don't know. Up here and now. He was pointing at his own head. What is going on? I don't know, she said. So he paused for a moment, and then he turned to me, deciding to take a new tack. He said, the thing about patients with CF is that they are good scientists. They always experiment. We have to help them interpret what they experience as they experiment. So they stop doing their treatments. And what happens? They don't get sick. Therefore, they conclude Dr. Warrick is nuts. But let's look at the numbers. He said all this to me. Still, he was totally ignoring Janelle. He went to a little blackboard that he had on the wall. It appeared to be well used. He said, a person's daily risk of getting a bad lung illness with CF is 0.5%. And he wrote that number down. Janelle rolled her eyes. She began tapping her foot. He went on. The daily risk of getting a bad lung illness with CF plus treatment is 0.05%. And he wrote that number down. So when you experiment, you're looking at the difference between a 99.5% chance of staying well and a 99.1% chance of staying well seems hardly any difference, right? On any given day, you basically have a 100% chance of being well. But it's a big difference. He chalked out the calculations. He said, sum it up over a year, and it is the difference between an 83% chance of making it through the year without getting sick and ending up in the hospital and only a 16% chance. He turned now, finally back to Jamel. He said, how do you stay well all your life? How do you become a geriatric patient? I can't promise you anything. I can only tell you the odds. And. And in that short speech, I realized, was the core of Warwick's worldview. He believed that excellence came from seeing on a daily basis the difference between being 99.5% successful and being 99.95% successful. Many things we do as human beings are like this. Catching fly balls, manufacturing microchips, delivering overnight packages. Medicine's only distinction is that lives are lost in those slim margins. And so he went to work on finding that margin for Janelle. Eventually, he figured out that she had a new boyfriend. She had a new job, too, and was working nights after school. The boyfriend had his own apartment, and she was either there or at a friend's house most of the time. So she rarely made it home to take her treatments at school. New rules required her to go to the nurse for each dose of medicine she required during the day. So she skipped going. It's such a pain. She said. He learned that there were some medicines she took and some medicines she didn't. One she took because it was the only thing that she felt actually made a difference. She took her vitamins, too. Why are vitamins? Because they're cool, she said. The rest she ignored. Warrick proposed a deal. Janelle would go home for a breathing treatment every day after school and get her best friend to hold her to it. She'd also keep key medications in her bag or her pocket at school and take them on her own. The nurse won't let me. Don't tell her. And thereby deftly turned taking care of herself into an act of rebellion. So far, Janelle was okay with this. But there was one other thing he said. She'd have to come to the hospital for a few days of therapy to recover the lost ground. She stared at him. Today? Yes, today. How about tomorrow? We failed Janelle, he said. It's important to acknowledge when we failed. And with that, she began to cry. There are in people who are at the top of their curve in institutions that are at the top of what they do, certain attributes that make them different. And you could see it just in that one visit with Warren Warrick. One attribute is diligence, attention to detail. And you could see it in the way he dove down into the details of her life and understood how the boyfriend she had was making a difference in recognizing just the fact that she wasn't taking her medicines. And if you think that's diligence, you should see what it was like to go to the south of India with a World Health Organization physician who was responding to an outbreak of polio. It was a single case. It was the first one in years in that part of India. And it threatened to undo the entire campaign to eradicate polio. So he had to oversee a vaccination process that would deliver vaccinations to 4.2 million children door to door over a 50,000 square mile radius. And he had to do that within 48 hours. Anything less than a 90% success in delivering the vaccine, person by person, would have been a failure, and the polio would have continued onward. And his team achieved a greater than 95% penetration in a place where the health system had broken down. He had to grasp exactly where the failure points were that were critical and then somehow remedy them. And how he did it was fascinating. But at core, he had that attribute, diligence. A second attribute that people have is surveillance. That is, they look for failure. You saw that, Warwick, the very first way that appointment and that whole discussion started out was that he asked and looked at what their lung function measurements were, and he saw that they went down. And he didn't dismiss that as a little blip. He was looking actively for the possibility of failure on behalf of this young girl. Another example I talk about in the book I wrote about in today's New York Times a little bit is why did Walter Reed fail in the scandal of the carer in the outpatient arena, and yet also managed to be the place that saved more soldiers on the battlefield than ever before in history. And the answer was in one part of Walter Reed, they had surveillance. They looked for failure, and the other part, they didn't. So on the battlefield, they were tracking on a weekly basis how many soldiers were wounded and how many died. And then they asked hard questions about whether they could lower those numbers. And they lowered the death rate from 25% in the Persian Gulf War 1 to less than 10% today. And they found all kinds of interesting things. They found, for example, that soldiers at first were coming in with heart and lung injuries, bullet wounds, bomb injuries, when they should have been protected by their Kevlar. It turned out they weren't wearing their Kevlar. And so they held the commanders responsible. They put in a new rule, say the commanders would hold them responsible for wearing their Kevlar regardless of whether it was 110 degrees outside and they couldn't stand the heat or they hated that 18 pound weight around them all the time. And that saved lives. They discovered that the transport times from the battlefield to the operating table was too long and they were losing people along the way. And so they did an odd thing. They had to move the surgeons nearer to the battlefield, but in order to do that, they actually had to strip away their technology. They made do with less. The orthopedic surgeons had no X ray equipment working in those battlefield tent facilities. They had to find the fractures by feel. And yet doing this, they saved more lives. And they saw it in watching the numbers go down, go out to the outpatient arena. They never asked after they saved those soldiers, whether six months later, a year later, were they doing well, were they backsliding, how many of them actually were getting on out of rehabilitation and into their lives again. And, and as a result, the failures were invisible and they were horrific. Facilities that were degraded, people being left without food for a couple of days. You wouldn't imagine it in the same place that could save so many lives so diligently. And it's the difference of surveillance. A third attribute that the people had at the top of the curve who were great at what they do, was they learned to do right despite even moral obstacles. That visit I described to you with Warren Warrick and Janell, that was a 20 minute visit. He's under the same insurance rules, crazy insurance rules, and working in that same system that all the rest of us have to work in. He understands perfectly well the ways in which it holds him back. He takes care of the uninsured patients he lives with when he has to that 20 minute limit. And he's found ways, when he has to, to work around it. He does right, finds a way to do right despite the obstacles. And that kind of moral clarity is also something you find in people who are doing the excellent work. The final attribute, which in a way Google is known for and we've kind of lost touch with in parts of high risk work, medicine, other fields, is the idea that there is a real value on a kind of bedside ingenuity, a day to day creativity. And you saw that in small ways with Warren Warrick, when sitting down with Janelle, he came up with that brilliant insight of having her stick her medicines in her pocket at school and take them herself. Not only did it get around the nurse's rules, but got her deftly allowed her to rebel by taking care of herself. It was a brilliant psychological insight, and it was just one moment of many. There was another sense that he thought larger than that. He is the head of a center that has eight different physicians who are all responsible for the cp. And if he did a fabulous job and the others didn't, it wouldn't make. Wouldn't do any good. And so what he has is. Has his whole team sit down once a week, a couple hours a week. They aren't paid for this, but everybody has to show up and they review every single patient they saw over the course of that week and ask what were their problems and what did you do for them? And they could discuss it, they could think through. They could get people back on a better course if it wasn't a seemingly good course. And imagine if you went to a physician, a lawyer, other people that you depend on, and you didn't have the benefit of just that one person you saw, but the benefit of the whole department behind them and the wisdom that was available to them. It would be better care. And he recognized that. He also was willing to let ingenuity take the path wherever it needed to take him. So when he started in his career in the 60s, the average child with CF died before the age of six. But then in the 70s, into the 80s, he began to see teenagers, and the problems were different. For example, one of the treatments is you have to beat on the back of a child with CF in 14 different places three times a day. A mother or father has to do this and take responsibility for it. And that allows for the secretions that glue up the lungs to be mobilized and coughed out. Well, what teenager wants to see their mother three times a day, let alone have her touch them? So he decided he needed to come up with something. And he came up with a vest that would inflate very rapidly. It would inflate and deflate. Inflate and deflate. They could wear it right around their chest, and it would have the effect of essentially shaking them, to shake those secretions loose and let them cough it all out. And it allowed the patients to have independence in high school, in fact, go on to college and not be tied to home, go on and live in the working world. He has patients who are now in their 60s who are being able to continue with independent life, something that was just not possible before. And the interesting thing, the vests turn out to be better than the parents. For one thing, they don't get tired and they also don't get angry when, when the teenager won't listen to them. Well, as you think about these attributes from a high risk profession, there are certain implications that begin to come out of this, larger implications that I didn't really realize until I was in the operating room one day talking with an anesthesiologist across the drapes. The case was going well and I got chatting, as I tend to do, and I had the music going and I was puzzling over this bell curve in CF and trying to understand why is there such variability between the different centers and the different doctors and how well they do. And I was trying out different ideas on him. His name was mark Simon. He's 29 years old. He was a second year resident helping with that case that day. And strangely, he was becoming very uncomfortable with this line of conversation. And finally he confessed that he in fact has cystic fibrosis. I had had no idea to that point, but what he told me of was being acutely aware of how sick this disease could make him. He was 29 years old and he knew very well that the life expectancy for people was 33 years. When he was in college, things went well. In medical school, things went well. But then in his fourth year of medical school, he had a pneumonia and an exacerbation of his cystic fibrosis that landed him in the hospital for a month. The next year, in his first year of internship, he spent six weeks in the hospital. And here it was halfway through his second year and he had already spent another month in the hospital. And our discussion changed. The question we began to worry about to try to figure out was how do we save his life? What do you do to save his life? The answer most of us would come to is he needs a cure. That what we need to invest in is basic science and an investment to find him a cure. And that's what the Scientific Cystic Fibrosis foundation has done for two decades. That's what the National Institutes of Health have done for a long time. That's our approach for the U.S. government as a whole. And in 1989, when the gene for cystic fibrosis was found, you would have thought that this had paid off because surely a treatment, a cure would be just a few years away. But now it's two decades later, and a cure is still not in sight. So then what? Where he had put his hopes was in the recognition that if there is a bell curve, then the knowledge already exists in the world to save people and help them live longer. That up there at the top of the curve is the know how to help people live 47 years on average, and perhaps the collective know how to have people live even longer with a terminal illness. And that recognition is an important insight. There was an essay by two philosophers named Samuel Gorevitz and Alastair MacIntyre on the nature of human fallibility. And what they pointed out was that there are two sources of fallibility in anything we do as human beings. The first they called ignorance, meaning that there is a general lack of knowledge about the particulars of how the world really works. And that can be one reason we fail. The second reason we can fail is what they called ineptitude, meaning the knowledge is there, but an individual fails to apply it correctly. Now, the revolution of our time is that ignorance is no longer our only problem. It's not even necessarily our primary problem. Go back 50 or 60 years, and we were in a world where ignorance was the primary reason people did not survive. We didn't know how to prevent heart disease. We didn't know how to treat high blood pressure. We didn't know how to treat strokes. Most infectious diseases we didn't know how to manage. Fast forward to where we are today. We have 6,600 drugs, thousands of surgical treatments, hundreds of ways to diagnose problems. We have demonstrated ways that we can make people's lives less miserable and better, regardless of the condition they're in, Even if we can't necessarily cure everything. But do we deliver it person by person, consistently, reliably, humanely? And the answer is, there's a bell curve. And understanding that ineptitude is now our struggle. Or the nice way to put it, performance is now our struggle is something that we are only slowly coming to in medicine. And I don't think we've come to at all in other walks of our lives. In this complex world, of all the endeavors we take on, whether it's policy and government, whether it's business, whether it's teaching and how our schools work, work well for all the science and technology that we have in medicine, that's made it possible for people to live 80 years now, on average, that made it so that you can have a life that's better than it would have ever possibly been. For all of that science and technology, the interesting thing Is that medicine has become more human because the decisions that we make, that when that moment comes, when you need that science, technology, what you come to is just an ordinary human being, a doctor, and you trying to sort out how to access all of that. And that world that makes performance possible is more intricate and fascinating, I think, than people have realized. I think there's also then a lesson from how medicine overcomes fallibility for all of us, something that might teach us how we can all do better. I want to thank you for your time, and I'd be delighted to take you any questions you might have. So is there someone who might have any questions? Right here, There's a microphone that will come right down the road gradually.

So I'm intrigued by what you said with respect to the quality of the care impacting performance more than what human knowledge actually is. And I was wondering, you know, let's assume that from now on we discover no new drugs, no new treatments, nothing else, right? We have only the data and that the diagnostics, procedures and whatever that we have sort of today, what kinds of tools, I guess you can envision, that can actually improve the quality of that care. And where I come from is it seems to me that technology, apparently from a layman's point of view, have sort of helped that area tremendously. And yet I don't see a lot of it helping the decision making.

I guess it is a very important question that you've asked, and it's partly thinking through all the kind of processes that we deliver in something like medicine. I start off the book discussing the really mundane thing of just hand washing, right? Here's something that we ought to do consistently over and over again. 2 million people walk out of hospitals in the United States with an infection they didn't come to the hospital with. 90,000 will die from that infection. They're leaving that hospital through the wrong door. And the reasons why is not because people are lazy. The nurse ends up having to care for and wash their hands 150 to 200 times a day by most estimates. If you're taking care of four to six patients, just the number of times in and out of room someone drops something, you go to pick it up, you got to then wash your hands afterwards. And we just aren't doing it. We might achieve 7, 70, or 80% of the time that we're doing it. And then I went to a hospital in Pittsburgh where they actually got rid of. It's the one place in the country it's gotten rid of staph infections now, for 18 months, something we didn't think was really possible. And they did it with a combination of things. One was the information technology to let surveillance be possible. When you come into that hospital, they stick a little swab up your nose and they take a culture. And then they need to make sure that that culture, which will give them an answer in about 24 hours, ends up alerting everybody whether this person has a resistant bug that could pass to other patients. And they have to have that person isolated. So they need the surveillance to be able to notice that. And also then to look overall at their rates and watch them go down, they need kind of a statistical control chart, a way of following this along. The second thing was it was a very mundane human thing. At first, they tried bringing experts in to tell everybody how, this is what you got to do and this is what you got. That didn't work. They then had someone come in who didn't offer any solutions. Instead, they asked each team to sit down and tell them how to get rid of infections. And they knew the answers. They already knew what to do. They said, you know, you put your dispensers for these alcohol gels over here. My patient's over there. Let's move these dispensers over here. The gloves and gowns run out at 3 o'. Clock. Why do they do that? Half of my patient calls are, because the patient needs a dressing or needs this drug. Why can't we have it in the room so that I don't have to wash every time I walk in, walk out? And they engineered it down to get rid of it. It was looking at themselves as a kind of process. We don't teach this in medicine. We don't think through it on a larger level. We are at a point where mostly what we need is to simplify the first level of professional development. In going from just being a mere artisan who just does what you do without really paying attention to it, and then going to the next level, is looking at your results and then simplifying things, making them reliable enough that you can follow through and do it 100% of the time, or 99.9% of the time. The second level, when you want to go to another level, if you actually reach the point where you're doing it 99% of the time, but you want to do it 99.9% of the time, it takes more than just catching, than being diligent on your own. You need technology. When we wanted to lower our likelihood of leaving a sponge or an instrument inside people. We recognize that about this only occurs about one in a thousand operations where you have abdominal surgery. It's a crazy kind of error, right? What kind of idiot leaves a 13 inch retractor in people? Well, it turns out that what happens is you count everything at the beginning of an operation and then the end of an operation. It's about 250 to 300 instruments and sponges. If you ask people to count over and over 300 things and get the count right at the beginning and then do it at the end, it has a failure rate. It's about a 1 in 1,000. It's actually even more than that. It's maybe a 1 in 100 failure rate. So we have two nurses do it twice so they catch each other's failures. But even then it has a failure rate. Now if you want to get that even lower, we have conscientious people and we've looked at the studies and over and over again they've done the counts, they got it wrong and something got left in someone. The only way we can do that now is technology. And so we've started testing with radio frequency ID tags inside sponges or even just a simple one penny, a sponge barcode with a barcode scanner like you have in the supermarket to scan things and scan out at the end. So there is the opportunity for innovation and thinking about how we fail on a day to day basis in medicine. And I actually would argue in a lot of things that we do in the world that could let us engineer these problems down. Yes, right here. If the microphone. Oh, I'll follow the microphone. Sorry. Okay, whoever got it, I'm right here. Okay.

I have a 4 year old son with complex congenital heart defects and he's had five surgeries. We just got home from in the hospital just a couple weeks ago. He spent 20 weeks in the hospital over the last year.

Oh my goodness.

Spent a lot of time around folks like you. And also as an engineer by background, I naturally want to see the world as a giant scatter plot. But suddenly now I see one giant point on a graph. And what I found is interesting is the doctors that we feel that we've had the best connection with seem to also see the world both as a giant scatter plot, but also individual points. And the ones that we feel there's a misconnection have been the ones where we don't feel like they see that one point on the graph that's so important to us. And I guess I'm curious to hear from you. How do you, how do you get doctors to see both the whole, the aggregate, what, what's happening in the world of medicine on the whole, which is incredibly important to each individual case, but also to realize that, you know, when you're in this room, when you're talking to us, nothing else matters except this, this one patient, this one child.

It's a great question. And you're going through, I think, a really hard experience because one of the things, my son also has a congenital heart defect. And I remember, as much as I know about medicine, sitting there and being very aware of the minor ways in which we fail, being left sitting in a waiting room for three hours and no one knows what's going on. Or my son had a bleed after his heart surgery and had to be taken back to the OR and wondering exactly why did that happen? This attribute of being able to see the scatter plot and the point is really important and it's one that we haven't grasped yet. We're used to teaching about medicine as a one on one phenomenon, but the great effective surgeons, doctors and others can see the pattern of what happens over time so that they can reduce the likelihood that they're going to have a bad outcome. That is that they recognize their failures and are able to engineer it down. They see their lives in a way, as engineers. You all have met that doctor. And they don't have a human connection sometimes. And that's the ambition, is to have that ability to think about how we do as a whole, but then do our work with individuality and humaneness. And many of the people who are very individual may not have the confidence, the best results at the largest level. But I do think they go hand in hand. When you meet someone who is incapable of communicating to you exactly why things are happening the way they happen, who can't acknowledge mistakes, mistakes, Those are the people that I'm nervous about when I'm training residents or medical students and that I'm less likely to trust. And if I were a patient, I'd be less likely to trust. So you're asking a more productive question though. How do we bring that kind of knowledge together? And the answer is, one of the admonitions I have in the book is that we need to measure. It's not something we understand much about in medicine. Most of us go through our practices in our lives never asking ourselves even one thing about how we are performing on a quantitative way. So one of the things I say at the end is just, it doesn't matter what you count. Just start counting something. Count how often you see your patient within an hour of their appointment time, and you'll discover how shockingly often you're failing to do even that simple thing. Or even better, count how many complications you have and whether you have fewer in the last six months than you have in the next six months. Or it could be any number of things. One of the geniuses of Warwick was that he could have been asked to count 100 different things, 50 different things. He zeroed in on one key measure, the lung function of his patients that he wanted to make sure was something he would follow for his entire career. And the knack is to pick something worthwhile measuring, interesting enough for you to stick with, and then actually to do it, to take the time to do it. In the battle for Fallujah in April And November of 2004, there were 1100 soldiers wounded. One of my colleagues from my hospital, a resident I trained with, was one of the surgeons in Fallujah, and he described doing something that he never did in his career in civilian medicine, and that was to record immediately after every injury exactly what happened. It was incredibly time consuming. 1100 wounded came in. They had 48 hours straight. They would go without sleep, go to sleep for two hours and wait up again and have another 12 hours on. But then they would take the time, regardless, to sit down and peck away at a little computer that would say what the wounds were, whether the people survived, how they were doing, and it would be sent back to Washington where people could look at the results. It's public every week. This is how we know how many people have lived or died. Go down to any one of these hospitals and ask them if they know how to. How many lived and died that week? We don't have any idea. So I'd say the short answer for you is that we have to get used to measuring ourselves. It's simpler than we think. It's scarier than we think as well, because we all discover things about ourselves that are sometimes hard to acknowledge. Like, I have to wonder where I really stand on the bell curve for how I do as a surgeon. Not sure sometimes I necessarily want to.

Know.

Who else has the microphone. Ma'. Am. There you go.

Hi. Thanks very much for coming. I wanted to ask you a question, partly because I'm a physician as well as someone who plays here as a.

You're a Google physician.

I'm a physician who works at Google, although I don't see patients here. And I've also spent some of my young career as a teacher of medicine. And, you know, I think that Dr. Warrick, perhaps when he went to medical school and residency, he learned some of his key attributes from his teachers. But I suspect that most of us who trained more recently don't have that opportunity. And those are things that I think are just about him and things that perhaps his parents taught him. And I wonder what your reflections are on what we can do to medical training to try to squeeze more of us into the right side of the correct side of the bell curve.

It's a great question. There are two undervalued strengths in our particular profession. One is leadership ability. We don't value and understand. We've never made it a major object of study, how leadership saves lives. And we all kind of, when we think about it, realize that the person who manages to run a hospital can be someone who makes that place grind down into the dirt and never make anything work well and become a place that you just wouldn't want to put your foot in. Or they can turn them into stellar institutions, and those people save lives in a way that we've never acknowledged. But one of the things Warren Warrick did, the way he learned, he was asked to do a study as a young pulmonologist of a guy up in Cleveland who was claiming to have patients who were living to 21 years of age when the rest of the world had death well before the age of six. And they more or less wanted him to expose him to be a fraud. And what they found was that Leroy Matthews at Rainbow Babies in Cleveland was indeed saving kids and having them live into their teenage years and age 21 and so on. And he learned his diligence and that creativity from watching Leroy Matthews do his work. Leroy Matthews then moved on. He no longer is the head of Rainbow Babies and Rainbow Babies is not in the top 5% anymore. That's Leah leadership. It's that creative capability. The second thing is that idea of. And so when we teach, I think one of the things we have to understand in this world now is that it's not enough to be a good diagnostician and a good technician and an empathetic human being. It also, you have to be able to see the scatter plot. You have to be able to do some measuring of yourself and then target ways, learn how to target ways to change results and actually make it happen. And that's a skill that has to be taught, I think, in medical training. The other aspect is whether we can teach about leadership and the fact that we work in Teams now. We are not individuals only doing this work. Most of us hate the administrative work of sitting on committees figuring out how to make an institution grind a lot. I work in a hospital with 10,000 employees and it feels like you are a white coated cog in the machine. And making a difference often just seems impossible. When you can't get the radiologist on the phone, when your patient complains that they were supposed to have been discharged by 12 noon and it's 5 o' clock and no one has given them her prescriptions. Understanding how to use leadership to be able to solve problems and think quantitatively about how we do are the two important skills we'll need for the future. Great.

So knowing that the normal distribution is a powerful force in the universe, I'm curious if you think that it is possible or even desirable to push from a bell curve to that more shark's tail curve curve or really what we should continually strive for is moving of the mean.

There are ways to change the bell curve and our strategies have to be very conscious of that. So one of the ways you lift the bottom of the bell curve is you recognize what the problems are that are holding people down at the bottom end. The hospitals at the bottom of the bell curve are predominantly hospitals seeing the poor and the uninsured. And we have to do something about our insurance part problems in the country. They're heavily hospitals where black patients in the United States are concentrated. And there's a real problem of racial disparities that we haven't attacked in that similar way. So there are some things we do to bring that bottom end up. The other thing though is transparency. You can change the shape of the curve by letting everybody know where they stand on the curve. And you know, people are afraid of that because they're worried that their patients will leave them. The interesting thing is that when there have been publicity about how the curve is really shaped, patients don't end up using that information nearly as much as they could. And the markets, the patient loads don't change, but the curve changes because you suddenly know where the best people are, you begin to learn from them. I would love to know in my field in cancer surgery who the best best really are. And go see them, follow them for their results. I know who has the best reputation. I've gone to see them. Sometimes they're great. Sometimes you really wonder where they got their reputation. And so you will never. One of the things I'd point out is you're never going to get rid of the bell curve at times you might be able to raise the median and that's among the most important things you do. I think you can narrow the gap, especially by bringing up the bottom end and doing things about ordinary, clear problems that we have. But there are going to be a few Warwicks out there, leaders who have enormous creativity and ability to change that are going to be the leaders constantly pulling everybody else upward. And so, yes, our main goal, I think, is to move the median ever upward. And for each of us as individuals, though, most of us are going to be average and we have to live with the at some level and that's hard for the public to accept. The most important thing is the public wants to know that we are not settling for average, that we are aiming always to raise our bar. Well, it's great to be here at Google. It's delightful to hear from people with different varieties of backgrounds and get ideas from you, so thank you. Doctor Gwande has kindly offered to sign.

Books up at the front.