I have a seven-minute drive to work. Sounds like a brutal commute, I know. It gets worse. I drive past two golf courses, a multitude of palm trees and skirt by the intracostal before I arrive at the hospital.
It’s a tough ride. To cope with the challenge, I used to spend that time listening to one or two songs on the way in and would often call a family member on the way home. Seven-minute calls are about as much as I can handle. It really only takes my mom two minutes to make me feel guilty. “When am I going to see the grandkids?”
I say this because over the last year, I’ve now become addicted to podcasts. Which means I lost my seven minutes of morning wake-up music, and my mom really lays on that guilt because I don’t call anymore. Also, the seven minutes now seem too short.
With two seven-minute rides a day during my seven days on service, in a week, I can easily listen to three thirty-minute podcasts. There are some good ones, my favorites touching on medicine or science, or the Gladwell series throwing in some history with great storytelling. (See this recent one on safety, Toyota and human error).
My current must hear is the latest Radiolab, Playing God, with Sherri Fink, which delves deep into her book Five Days at Memorial, regarding the aftermath of Katrina at one New Orleans Hospital and how we think about triage.
For this post, I wanted to summarize a 90-minute interview Ezra Klein did with Atul Gawande. Klein, formerly of the Washington Post, now editor of Vox, has terrific conversations with some big names. He recently interviewed Moby, of 1990s electronica fame. They lament big cities losing the cultural milieu that can spur on big, new ideas. As large urban areas price out many, including starving artists, the loss of that cultural innovation is inevitable. Moby recalls an environment that was spartan and challenging, but perfect for that time in his life, sparking his creativity – an environment that’s hard to duplicate, but he notes as a secret to his success.
Other recent interviews on Klein’s podcast, include Malcolm Gladwell, Bill Gates, Hillary Clinton and most recently, the wide-ranging interview with Atul Gawande.
Gawande, author of Being Mortal, and the Checklist Manifesto, discusses topics from what helped kick start his career in writing, where he was before medicine and his friendship with the lead singer of Weezer, borne out of Checklist Manifesto.
Klein gushes over Gawande immediately, clearly excited about the interview. “You are the person I most wanted to interview.” Klein starts off with a great question, a nice conversation starter for anyone: “What’s the most interesting thing you’ve been doing lately?”
Gawande discusses his work with Ariadne Labs, a company he formed to research ways to improve the health care system. The company is a culmination of his work as surgeon, writer and researcher. As he writes about medicine, policy and quality from a physician perspective, the work helps flesh out large ideas that he then scales for research.
Klein was fascinated about this, though his process of work is similar to any academic clinician- researcher. Taking bench to bedside, or bedside to bench, innovating, and writing to spread ideas.
Gawande’s latest project was inspired by the Being Mortal thesis: how to improve care at the end of life. He took two groups of physicians and trained half in improving discussions at the end of life. They would learn how to ask questions such as:
- What are your fears and worries for the future?
- What are your goals if time is short?
- What are you willing to go through and not willing to go through for the sake of more life?
- What’s the minimum quality of life you would find acceptable?
Three years into the work, they’ve found that patients who saw physicians trained in this model had 50% less anxiety about their care, and these conversations occurred up to five months before patients died – not simply days before the end. Survival was the same in both groups, but the experiment group of patients had less depression and anxiety. Currently, it’s being implemented in 40 systems across the country and within care teams around the world.
ON POLITICS AND POLICY
Gawande’s parents are both physicians, hence he pushed back on medicine in his early career. He worked for the Gary Hart campaign as an “envelope stuffer” and for Al Gore in the late 80s. In 1992, he was a healthcare and social policy advisor for Clinton. Working for Gore, he was given an assignment to figure out desalinization of water because “Gore knew there would be a water problem in twenty years.” Gawande notes this as one of Gore’s flaws: an in-the-weeds, detail-oriented guy. Gawande couldn’t figure out why that was important for a campaign.
He “didn’t want his future controlled by the fate of physicians,” so he took fate into his own hands and went to medical school. He also felt he couldn’t play the political game. When asked if he ever thought about running for office, Gawande replied, “I am from a rural town in Ohio. I couldn’t get a date in high school; how was I going to run for office?”
Even though politics wasn’t in the cards, he loved policy and how “ideas moved.”
Somerset Maugham, another physician-writer, wrote, “I do not know a better training for a writer than to spend some years in the medical profession.”
Gawande echoes this sentiment: “There isn’t anything that doesn’t happen across the course of the human lifespan that isn’t reflected in some way in what we do in medicine.”
His first job writing was with Slate. It was started in 1996 by a colleague of his, Jacob Weisberg, who couldn’t get “real journalists,” so he asked friends to write. One of his earliest pieces was in response to George Bush, then governor of Texas, ordering voluntary chemical castration for sex offenders. Did it really work? What was the history, the ethics behind the proposal?
As ideas for stories arise, he constantly scratches down items that are “confusing or interesting or both. Usually both.”
When he worked for the New Yorker, he had a budget for the first time and really enjoyed the research aspect of his writing. The “discovery and the editing” become his favorite parts of writing, and that initial draft became the most challenging aspect. Initial drafts are written in long hand, to avoid the distraction a computer affords, with the attendant compulsion to edit. Summarizing Joan Didion, he notes that “writing nonfiction is like sculpture, turning the clay into a work of art. Taking this lump of facts and sculpting.”
Gawande: “There is no mistake too dumb for us to make; we make them all the time.”
He summarizes his work as largely based on the cross section of failure and suffering. The quality work informed by work he discovered in his early philosophy days, research on failure. A study from the 1970s describes failure resulting from either ineptitude or incompetence. As a society, we were historically filled with incompetence; we just didn’t know the answers. Now we have the answers, and the balance of failure has tilted towards ineptitude. We continue to try to solve this by blaming the individual when the complex system we work in is often the source of failure – a reminder of why the work in quality improvement and systems redesign remains so important. In that environment, we still struggle how to create a just culture that fosters an environment for improvement and not finger pointing. Gawande points out that this is an area continually underinvested. We strive for new drugs and new technologies, but if we spent time researching current systems and improving the delivery of care, we would begin to solve the problem of ineptitude.
He discusses the notion that the expectation of perfection is challenging, and perhaps a vice in both medicine and politics. Infallibility in humans doesn’t exist, and it is a problem. We need to be “unforgiving about whether we are getting better but forgiving about individuals.”
ON MEDICAID EXPANSION
Access to healthcare is an important aspect of improving quality across the county. Gawande has written widely on this topic, from stories about the Affordable Care Act, Medicare and the challenges of delivering care to the patients that account for some of the highest costs, the Hot Spotters.
In Klein and Gawande’s discussion about the Affordable Care Act, they review the results of the Oregon Experiment. Oregon expanded Medicaid to a limited number of its residents and compared results of expansion to a group that didn’t receive Medicaid. Access to care improved, as did improvements in mental health and reduction in financial strain; however, standard measures of quality for diabetes and blood pressure care didn’t improve. Depending on your viewpoint, this was viewed as favoring expansion or lack of benefit of access to healthcare. Access to healthcare is clearly important. The results from Oregon were possibly too short a timetable – about 2 years of work – or underpowered for success, or other unseen effect.
Gawande’s conclusion is not that we don’t need access, but that “systems don’t work; that’s why we still do this work.” Our healthcare system continues to fail us. It “massively underperforms” We need to improve our system, while we continue to find ways to improve access.
After the interview, Gawande was headed to a Weezer concert. The lead singer of Weezer, Rivers Cuomo, reached out to him after reading Checklist Manifesto. Cuomo incorporated checklists into his writing, which helped spur his last two albums. His checklist for songwriting brought him back to his roots, reminding him to go through steps he used for his early albums. He listened to old songs, capturing unique guitar riffs. Per Gawande, he had an “insane number of steps.” Cuomo talked about this process on a song explorer podcast.
Gawande: “Spend more than half the time listening; it would be a better conversation.”
“Listen better” was the best advice he received, and he noticed he was doing the opposite in several avenues. While reviewing transcripts of research interviews, he found he was doing most of the talking. In particular, with patients, he noticed he was talking 95% of the time. As a physician, he frequently gathered a quick history, then spent most of the time offering up his thoughts, doling out plans, but not listening or asking enough questions. He now goes into conversations consciously aware of the questions he wants to ask, whether in the patient room, in life, in interviews. “Even in social life, I come with questions. Practicing being human.”
ON FAVORITE AUTHORS
Gawande notes his inspirations to be three great physician writers: Conan Doyle, Sachs, and Verghese. He reaps the detective work of Holmes, the vast ideas of Sachs and the weaving of stories by Verghese. He credits Verghese for instilling the sense that he could write, integrating stories, with the drama of ideas and creating works that inspire.
This was a lengthy interview, with many ideas you might already know or heard Gawande speak or write about. There are many ways to catch up on one of our most important physician voices today. Read his books, visit his website, or catch these great talks from Gawande on the BBC’s Reith lectures series.
This is a brief summary of some of the conversation, and I hope it helps if you don’t have a chance to listen to the full podcast. I recommend you do try to listen.
Work starts in seven minutes – have to get in the car.
Jordan is a hospitalist at Morton Plant Hospitalists in Clearwater, Florida. He currently chairs SHM’s Quality and Patient Safety Committee. In addition, he’s been active in several SHM mentoring programs, most recently with Project BOOST and Glycemic Control. He went to medical school at University of South Florida, in Tampa, and completed his residency at Emory University.
He recognizes the challenges of working in a hospital that lines the intracostal waterways of a spring break mecca. Requests that if you want to be selected as a mentored site, you will have a similar location with palm trees and coastline nearby. He tries to find time to sit on the beach with his family to escape the hospital’s miasma. While there, he looks forward to reading about the history of hospitals/medicine, and how it relates to quality (Anti-UpToDate reading material). But inevitably will get a five year old dumping sand on him, and then has to explain why she is buried up to her neck.