Atul Gawande's dual careers in medicine and writing create a virtuous feedback loop. His work as a surgeon at Brigham and Women’s Hospital is his “portal into the real world,” he says, and his work as a staff writer for the New Yorker allows him to both ask and answer questions that real world presents.
In his new book, Being Mortal, the question Gawande explores is why the U.S. health system prioritizes length of life over quality of life for people in their final years. Gawande, 48, joined our On Leadership series to discuss this and the many management challenges that hospitals face in trying to hire, train and restructure for a new type of care. He also shared how he organizes his days in order to squeeze in the work of multiple professions. The conversation has been lightly edited for length and clarity.
Q. How prepared do you think the United States is to handle Ebola?
A. It’s exposed some of the vulnerabilities in our own health system and hospital system. We are not at risk of a major epidemic breaking out here — the ways to contain Ebola are known with standard infection-control practices, which we use in every operating room in the country. But it has exposed the fact that we have two million people who pick up infections in American hospitals every year, mostly because we aren’t following the checklist for infection control.
What we saw in Dallas was that just a couple of simple misses and we let somebody go home, expose people, then got him back. It did not become this infection that is spreading like wildfire, and it won’t here because we have a health-care infrastructure that works. But in West Africa, where the number of sick has overwhelmed the number of hospital beds, they don’t even have gloves and basic supplies. That outbreak is getting worse and continuing to spread fast and what will be key is controlling it there.
Q. Brittany Maynard, a 29-year-old with brain cancer, has announced plans to end her life with physician-assisted suicide. Do we need to be more open to letting patients make choices like this?
A. Brittany Maynard’s case shows the extreme vulnerability that people feel about whether the quality of their life, as they face the end of it, is going to be served in our health-care system or not. Medicine has as its core values survival and safety, and we don’t recognize that people have priorities other than just living longer.
What people in her situation end up being concerned about is that no one is going to honor those priorities. There can be unbearable suffering, and we would be heartless not to be able to provide people options so that they could avoid that suffering. I think they’ve done it safely and effectively in Washington and Oregon. Less than one percent of people who die end up asking for a prescription that would let them end their own life, and only half of those people end up using that prescription. It’s often a comfort just to know the option is there.
Much more important, however, is assisting people with living while they cope with a terminal disease, and that’s what we do terribly. Medicine sacrifices your time and quality of life now for the sake of possible time later, and then we don’t know what to do when that possible time later begins to disappear.
Q. Who are the key actors who could help reshape end-of-life care in this country? Physicians, policy makers, deans of medical schools?
A. We don’t have remotely enough palliative care physicians in the country for the millions of people who die per year. So we have a few key actors that then have to be able to step in. Number one is medical schools and health systems need to start training people right from medical school. Ninety-seven percent never learn geriatric skills.
Second, though, the specialists who do have these skills — the geriatrists, the palliative care doctors, the hospice workers—should not only be responsible for seeing patients, they should be literally paid to assess the quality of the conversations that others in the health system are providing to patients who have these struggles, and then coach them. It actually takes so much skill to have a conversation about the fact that a patient may be dealing with an incurable problem.
The last part is that policy makers need to enable physicians and nurses to take the time to have these conversations. That means financially, too. I make a lot of money when I do that extra operation, and virtually none for taking the time for a series of conversations that may be far more important than the operation I’ll provide. We’ve gotten that wrong.
Q. So if you could put through one policy today, what would it be?
A. I think we’re actually on the path. I don’t think it’s as simple as making a bill that pays people to have these conversations. In many ways, it’s that we need a law that simply requires people to talk with patients about goals and priorities, regardless of whether they’re at the end of life or just chronically ill. This has just got to be part of planning and good care. This is likely to come from the major changes we are making by moving away from fee-for-service payment, paying people for the quantity of care rather than the quality of care.
Q. What does leadership in medicine look like to you?
A. Leadership in medicine has changed enormously. Go back just 20 years and health systems were kind of like real estate companies. They provided space for a doctor to tend to a patient, and some nursing staff, but the doctor’s autonomy was the priority. In a way the doctor was the client, not the patient. That’s changed.
Because we’re all specialists now — even the primary-care doctors only have a piece of the care — the health system has to be responsible for ensuring that we are all working together. That means leadership in medicine is about making functioning teams, and hiring doctors from the very beginning who are willing to be part of those teams.
Q. What other big management challenges do you see hospitals facing?
A. The key thing ends up being managing change, because we’re moving from an industry run by individuals and a fee-for-service kind of structure to organizations responsible for the health of populations. It’s a radical shift, and there’s a huge challenge around making the financing work.
The hospitals right now win by getting more emergency room visits, more admissions, more operations. Yet they know that the future is going to be the opposite. A lot of hospitals feel like they have one foot in the boat and the other foot on the dock. My own hospital, we’re about half and half. We have entire budgets for patients where you can organize to make much of their care outpatient; and the other half is fee-for-service, where somebody is still yelling at me, “You’re not doing enough operations, Atul!” That is the hardest leadership challenge I see for hospital leaders, and it’s part of why I’m not a hospital leader.
Q. Have you found that hospitals tend to be better run by doctors or by professional managers?
A. There’s a huge rise of physician leaders. They are not the only ones who have to lead the system, but I think there has to be a structure of clinical governance. We have to organize around the idea that complex care for, say, cancer patients involves surgery, radiation, social work, all kinds of needs. That shift means you have to elevate clinical leaders into having responsibility for how the whole system works.
It doesn’t mean that the CEO has to be a doctor, but it does mean that clinicians have to take responsibility for not just doing an operation right, but for how everything is organized.
Q. Do you think clinicians often get the right training they need to move into those managerial roles?
A. No. And we don’t know quite what it looks like, right? I spoke at a medical school graduation not long ago, and noticed that about 40 or 50 percent of the students are doing extra degrees — a masters in public health, a masters in public policy, an MBA—out of recognition that they were not getting trained in the skills needed to be effective managers and leaders who can solve the problems that patients have. There’s a whole generation of students who are getting that training now, but not because the medical system’s providing it. They’re going out and getting it themselves.
Q. Between training issues and not having enough students who go into fields like palliative care, how do we get the next generation of health care leaders to reflect the needs we have?
A. Some of the most innovative spaces right now in medicine are the ones that are currently the least paid. But likely, come a decade from now, they’ll be the ones that really make a huge difference. Primary care, geriatrics, palliative care: These are fields where you play a role in ensuring that the entire population does not die with suffering. Those kind of leaders have the chance to make a difference at the individual level and at that broad level, but medical students sometimes go where the money is right now and that’s a mistake.
Also, we make people jump through this gauntlet, as though if you don’t pass organic chemistry in your freshman year in college, you must be a terrible doctor. What the hell are we doing? It’s important to get the science right, but we’ve got some major rethinking to do about how we create that pathway to capture the people who are right for this job.
Q. Do you think individual doctors have a responsibility to drive down patient costs? Or others should wrestle with that and doctors should just be focused on the care?
A. It’s a huge debate. There is often financial toxicity to patients from the treatments we provide them. That is to say that as patients, more and more, have significant co-payments to make, we could end up causing somebody to lose their home or not take their drug.
The usual physician stance on this has been that you don’t worry at all about the cost for a patient. But I think we have to become more educated about what the costs are. And we have to be able to help with the options that people have for the value of their care.
We also have to think hard about not bankrupting the system along the way. My colleagues and I looked at our hernia operations and found that in our division, among our group, the cost of the mesh we use to patch hernias varied from $123 to $15,000. We all had our favorite mesh and we never knew what the difference was in the costs. We all agreed, within an afternoon, to go to the $123 mesh. It really didn’t make a difference. It’s shocking that that is just now starting to be something that we even are aware of.
Q. You wrote a great piece in the New Yorker about getting a coach to be a better surgeon. I’d love to hear more of your thoughts on coaching, and if there are any other techniques you found useful to borrow from other fields that aren’t as common in medicine.
A. We have two very different ways that we think education happens for adult learners. One concept is what I call the Juilliard School of training. You get your 10,000 hours on the violin and then you’re going to learn the rest of the way on your own.
Then there’s the sports version, which says: You’re never going to learn unless you have a coach all along the way. I’m an avid amateur tennis player, and I watched how tennis professionals have coaches even when they’ve reached No. 1. Novak Djokovic has a coach. In medicine, we have the ‘you learn, you get licensed and you’re good to go’ method. Yet I realized when I was in the mid point of my career that I had kind of plateaued. What I wondered was, what would it be like to bring a coach into my operating room?
So I brought one of my colleagues into the operating room to tell me what I was doing well and what I wasn’t doing well. And it was amazing the things I hadn’t recognized. I wasn’t using the lights well. I hadn’t set up the field as well as I could have. There were these little things that he saw that helped me.
I’m now running a laboratory. We have 50 people working in our group, and we were just 11 people two years ago. In the process of that, I realized I needed a coach for the startup itself, and I brought a couple people in whom I talk to weekly about how to cope with the building of a successful team, how to hire well, how to track where we’re going, how to not lose sight of the ultimate goal in the day-to-day ups and downs of a fast-growing team.
Q. What’s a trait that you’ve had to work harder at over the years?
A. The biggest criticism from both my surgical coach and my laboratory coach has been that I wasn’t really effective at listening. One of the things that palliative care doctors really emphasize is that they treat conversations with patients the same way I treat surgical procedures. They really break it down, they really practice at it, they think hard about what happens. And one of their measures is whether the patients do more than half of the talking during the time that you’re in the room.
I realized with my patients that wasn’t true. I was talking 90 percent of the time, and it’s because I wasn’t asking enough questions. Then I carried it over to looking at how I was with my own team, and I was also doing 90 percent of the talking. I’m working at getting it below 50 percent.
Q. What’s a memory from your life that has shaped your thoughts on leadership?
A. When I was in high school in a small town in Ohio, I got to work in a microbiology laboratory. I remember they had me sit in front of petri dishes, counting how many bacteria were growing in one petri dish versus another petri dish to determine if there was any resistance to the antibiotics being used. That discipline of just counting something to see whether there was change or not has really stuck with me. I’m constantly trying to figure out, how do we count stuff that’s really hard to count?
Q. Here’s a question we ask everyone in this interview series. What do you believe?
A. I believe in people’s capacity to solve problems, if we’re willing to admit there are problems. So what I end up believing in is a kind of shared view that both scientists and writers have that really careful observation — being willing to recognize uncomfortable facts or occurrences that violate your previous views, being willing to live with the contradictions of what you really see, and making things more transparent to others — is how you help a lot of people solve problems.
Q. What does writing do for you? And the interplay between practicing medicine and writing?
A. I’ve got this funny life where I get to do surgery, which is always my portal in the real world, and my chance to write is a chance to make sense of what I’m seeing and things that confuse me. Why are costs in health care so high? Why is the way we take care of mortality in medicine so flawed? Why do we itch? Writing has been my way to recognize what I’ve got right and what I’ve got wrong.
The writing lets me get out ahead of a problem, try investigating different ideas, testing the waters on them. And then the science lets me see if it holds up in the real world.
Q. How do you organize your days so that you’re able to do all of this?
A. Not very well. I don’t go for a lot of balance. I partly am a thief of time. I steal time from my family. I write on weekends, especially mornings, and when there’s down time between operations.
I also try to leave about 25 percent of my time unscheduled, so that I can hit priorities that are really important — whether it’s fitting a patient in, dealing with something in our laboratory, or hopefully getting some writing done. Otherwise you just clog it with email and meetings, but nothing that has the long view.
Q. Since you wrote a book called “Being Mortal,” I have to ask what new reflections you have about your own mortality.
A. When life is fragile, either because of your own body and health or because of world events, people’s goals and motivations change enormously. But at the moment, since I’m very healthy and think I’ve got a long time, my priorities are that as long as my brain is working and I’m able to communicate effectively, that will be good enough for me. My wife and I have talked about this, and Kathleen feels quite differently. She said that as long as she looks happy, that is going to be good enough for her.