I’m back. After the takeover editions, I’m answering Jessica DaMassa about Atul Gawande as the CEO of the ABC new venture, the demise of Caresync, Ooda Health and its demand for a female VC, and whole bunch more blather! — Matthew Holt
Atul Gawande is the preeminent physician-writer of this generation. His new book, Being Mortal, is a runaway bestseller, as have been his three prior books, Complications, Better, and The Checklist Manifesto.
One of the joys of my recent sabbatical in Boston was the opportunity to spend some time with Atul, getting to see what an inspirational leader and superb mentor he is, along with being a warm and menschy human being. In my continued series of interviews I conducted for The Digital Doctor, my forthcoming book on health IT, here are excerpts from my conversation with Atul Gawande on July 28, 2014 in Boston.
I began by asking him about his innovation incubator, Ariadne Labs, and how he decides which issues to focus on.
Gawande: Yeah, I’m in the innovation space, but in a funny way. Our goal is to create the most basic systems required for people to get marked improvements in the results of care. We’re working in surgery, childbirth, and end-of-life care.
The very first place we’ve gone is to non-technology innovations. Such as, what are the 19 critical things that have to happen when the patient comes in an operating room and goes under anesthesia? When the incision is made? Before the incision is made? Before the patient leaves the room? It’s like that early phase of the aviation world, when it was just a basic set of checklists.
In all of the cases, the most fundamental, most valuable, most critical innovations have nothing to do with technology. They have to do with asking some very simple, very basic questions that we never ask. Asking people who are near the end of life what their goals are. Or making sure that clinicians wash their hands.Continue reading…
“I learned about a lot of things in medical school, but mortality wasn’t one of them.” So begins Being Mortal, Atul Gawande’s fourth and most ambitious book.
All of Gawande’s prior books – Complications, Better, and The Checklist Manifesto – were beautifully crafted, lyrical, and fascinating, and all were bestsellers that helped cement his reputation as the preeminent physician-writer of our time. Each blended Gawande’s personal experience as a practicing surgeon with his prodigious skills as an author and journalist. They took readers behind the curtain of the hospital and the operating room, revealing much about some very important matters, like medical training, quality improvement, patient safety, and health policy.
But they were only partly revealing of Gawande himself. He told us what we needed to know about his thoughts and biases in order to make his points, but no more. Being Mortal is Gawande’s most personal book, and as such it reaches a level of poignancy that surpasses the others. Mind you, it’s not an easy read, it’s a bit dull in the early going before it hits its stride, and it has an attitude: Gawande’s indictment of modern medicine’s approach to aging and dying is pointed and withering. But, even more than his other books, this one matters deeply.
Let’s see a show of hands. Who among us, doctor, nurse, patient, family member, wants to give or get health care inspired by a factory—Cheesecake or any other?
I didn’t think so.
True confession: I have never actually eaten at a Cheesecake Factory (hereinafter referred to as the Factory). My wife, Mary, and I did enter one once. We were returning from a summer driving vacation. Dinnertime arrived, and we found ourselves at a mall walking into a busy Factory.
It seemed popular. The wait was long—really long. We got our light-up-wait-for-your-table device. We perused the menu. There was a lot there. Portions seemed gigantic. We looked at each other and, almost without speaking, walked back to the hostess, returned our waiting device and left.
You got me—I cannot say 100 percent that I wouldn’t love Factory food. We were so close that one time!
A young woman in our small New Jersey town recently opened a new restaurant here. We tried it the other night. She and her business partner tended us and all the other patrons with such attention and care. We waited some, true, but she seated us near the bar while we waited—brought over pieces of cheese (no light-up device) for us to enjoy. The menu was ample and varied—not enormous. It’s also true that two items on the menu—including my first choice—were no longer available that evening. The chef however crafted the dishes that we did select with flare and pride. Dinner was a delicious, wonderful, relaxing experience—made better because of the human touch.
It’s probably not fair to contrast my one near-Factory dining experience with this other. Big chain restaurants have clearly figured out a way to provide a consistent meal for millions of satisfied customers. But the Factory way is not for everyone. People, I think, crave customized, attention-to-detail service experiences—in their dining choices. And—I’ll go out on a limb—in their health care too.
Medical errors happen every day. Few make the headlines, but when they do, almost everyone who chimes in to comment offers the same type of solution for avoiding them. Three of the most common are guidelines, decision support and checklists.
From my vantage point as a primary care physician I agree that checklists, in particular, can enhance clinical accuracy, but some of the lists I have to work with in today’s healthcare environment are more likely to bog me down and distract me than focus my attention on the essentials. I call them choke lists.
Re-reading “The Checklist Manifesto” by Atul Gawande, published in 2010, the year before my clinic implemented their first EMR, I am reminded of how much has changed since then.
How I work and where my attention is drawn has changed because of the minutia of Meaningful Use, Patient Centered Medical Home, Accountable Care and all the other new philosophies and forces that define primary health care.
Last week, a study in the New England Journal of Medicine called into question the effectiveness of surgical checklists for preventing harm.
Atul Gawande—one of the original researchers demonstrating the effectiveness of such checklists and author of a book on the subject—quickly wrote a rebuttal on the The Incidental Economist.
He writes, “I wish the Ontario study were better,” and I join him in that assessment, but want to take it a step further.
Gawande first criticizes the study for being underpowered. I had a hard time swallowing this argument given they looked at over 200,000 cases from 100 hospitals. I had to do the math. A quick calculation shows that given the rates of death in their sample, they only had about 40% power .
Then I became curious about Gawande’s original study. They achieved better than 80% power with just over 7,500 cases. How is this possible?!?
The most important thing I keep in mind when I think about statistical significance—other than the importance of clinical significance —is that not only does it depend on the sample size, but also the baseline prevalence and the magnitude of the difference you are looking for. In Gawande’s original study, the baseline prevalence of death was 1.5%.
This is substantially higher than the 0.7% in the Ontario study. When your baseline prevalence approaches the extremes (i.e.—0% or 50%) you have to pump up the sample size to achieve statistical significance.
So, Gawande’s study achieved adequate power because their baseline rate was higher and the difference they found was bigger. The Ontario study would have needed a little over twice as many cases to achieve 80% power.
This raises an important question: why didn’t the Ontario study look at more cases?
If you follow digital health, Rachel King’s recent Wall Street Journal piece on Stanford physician Abraham Verghese should be required reading, as it succinctly captures the way compassionate, informed physicians wrestle with emerging technologies — especially the electronic medical record.
For starters, Verghese understands its appeal: “The electronic medical record is a wonderful thing, in general, a huge improvement on finding paper charts and finding the old records and trying to put them all together.”
At the same, he accurately captures the problem: “The downside is that we’re spending too much time on the electronic medical record and not enough at the bedside.”
This tension is not unique to digital health, and reflects a more general struggle between technologists who emphasize the efficient communication of discrete data, and others (humanists? Luddites?) who worry that in the reduction of complexity to data, something vital may be lost.
Technologists, it seems, tend to view activities like reading and medicine as fundamentally data transactions. So it makes sense to receive reading information electronically on your Kindle — what could be more efficient?
In a well-publicized and well-written article in the New Yorker, Atul Gawande (one of my doctor writing heroes) talks about his visit to the popular restaurant, The Cheesecake Factory, and how that visit got him thinking about the sad state of health care.
The chain serves more than eighty million people per year. I pictured semi-frozen bags of beet salad shipped from Mexico, buckets of precooked pasta and production-line hummus, fish from a box. And yet nothing smacked of mass production. My beets were crisp and fresh, the hummus creamy, the salmon like butter in my mouth. No doubt everything we ordered was sweeter, fattier, and bigger than it had to be. But the Cheesecake Factory knows its customers. The whole table was happy (with the possible exception of Ethan, aged sixteen, who picked the onions out of his Hawaiian pizza).
I wondered how they pulled it off. I asked one of the Cheesecake Factory line cooks how much of the food was premade. He told me that everything’s pretty much made from scratch—except the cheesecake, which actually is from a cheesecake factory, in Calabasas, California.
I’d come from the hospital that day. In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how. Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.
While the nation has been focused on the recent Supreme Court ruling on the Affordable Care Act, innovations in hospitals and physician practices far from Capitol Hill have been triggering an historic transformation of our health care system. Propelled by a mix of urgency and vision, innovators at hospitals, physician groups and companies are remaking American health care by demonstrating that more effective and affordable care is achievable quite apart from statutory changes in Washington.
These organizations are working to achieve the Triple Aim: improve the health of the population; enhance the patient experience of care (including quality, access, and reliability); and reduce, or at least control, the per capita cost of care. This approach, developed by the Institute for Healthcare Improvement, is a sharp break with the traditional focus on single encounters with patients within the strict walls of health care delivery, typically addressing only the most immediate problems.
In the current issue of The New Yorker, surgeon Atul Gawande provocatively suggests that medicine needs to become more like The Cheesecake Factory – more standardized, better quality control, with a touch of room for slight customization and innovation.
The basic premise, of course, isn’t new, and seems closely aligned with what I’ve heard articulated from a range of policy experts (such as Arnold Milstein) and management experts (such as Clayton Christensen, specifically in his book The Innovator’s Prescription).
The core of the argument is this: the traditional idea that your doctor is an expert who knows what’s best for you is likely wrong, and is both dangerous and costly. Instead, for most conditions, there are a clear set of guidelines, perhaps even algorithms, that should guide care, and by not following these pathways, patients are subjected to what amounts to arbitrary, whimsical care that in many cases is unnecessary and sometimes even harmful – and often with the best of intentions.
According to this view, the goal of medicine should be to standardize where possible, to the point where something like 90% of all care can be managed by algorithms – ideally, according to many, not requiring a physician’s involvement at all (most care would be administered by lower-cost providers). A small number of physicians still would be required for the difficult cases – and to develop new algorithms.