Leading as a Surgeon by Day, Writer by Night | Atul Gawande | Voices in Leadership



good afternoon my name is Jessica Flannery and I'm a first year doctor of public health student at Harvard th Chan School of Public Health it is a privilege to introduce dr. Atul Gawande dr. Gawande practices general and endocrine surgery at Brigham and Women's Hospital he is a professor in the Department of Health Policy and management at the Harvard th Chan School of Public Health and in the Department of Surgery at Harvard Medical School dr. Gawande is also the executive director of Ariadna labs a joint center for health systems innovation and the founder and chairman of the life box foundation a non-profit working to reduce surgery deaths globally dr. Gawande Zaka Demick work includes extensively published research on surgery and healthcare since 2007 dr. Gawande has led the World Health Organization's safe surgery saves lives program along with his notable medical and academic accomplishments dr. Gawande is best known for his notable writing he has written four best-selling books and has been a staff writer for The New Yorker magazine since 1998 dr. Gawande recalls that early in his career he struggled with writing however he has since earned two National Magazine Awards and the lowest Thomas Award for writing and science in 2006 dr. Gawande received a MacArthur Foundation fellowship known as a genius grant his work and writings have made significant contributions to the field and public discourse on medical practice ethics and health care dr. Gawande is most recent book being mortal medicine and what matters in the end was published in October of 2014 and quickly rose to the number one New York Times bestseller and remains among the top 10 best-selling non-fiction books the extensively researched book is making phenomenal contributions to the national conversation on end-of-life care in February of 2015 PBS Frontline turned the book into a widely acclaimed documentary dr. Gawande Spath is as full and diverse as his current career he earned his medical degree from Harvard Medical School in 1995 after a brief absence to work as a health care adviser to Bill Clinton he then earned a Master of Public Health degree from Harvard School of Public Health in 1999 before I turn the session over to our moderator today dr. Lucien leap professor of Health Policy please join me in welcoming dr. Atul Gawande to the voices in leadership series at the Harvard th Chan School of Public Health well I want to add my welcome to it's just a delight to have you here I've watched your career for a long time and it's inspired so many people so it's great to have an opportunity to put you on the spot any less that what really makes you tick and we that may be a place to start you've had an interesting trajectory you graduated Stanford you were a Rhodes Scholar at Oxford graduate from Harvard Medical School but I noticed that in that sequence it took you a long time to graduate from Harvard Medical School there were about six or seven years in there so you were doing something else you want to tell us what you were doing and why well so first of all I should confess that Lucien has been a mentor mentor of mine from the moment I came to the school Public Health so it's fun to get to talk with you as a fellow surgeon pediatric surgeon who had gone into public health so it's and I think that pathway is as convoluted as if in your life as it has been in mind I was in medical school after taking five years to even decide I was going to get there I had taken a pathway that where I did two years in politics and philosophy at Oxford I'd hoped that I might become a philosopher and do a PhD in philosophy but I found I couldn't really understand the questions the Philosopher's were asking let alone offer anything in the way of original answers and so I stuck with the masters and then and then I worked in politics for a while so I worked on Al Gore's presidential campaign back in 1988 short-lived campaign people may not remember but it was his admission of having smoked pot at here at Harvard that contributed to his having to walk away from that campaign at the time the world changed by 1992 and I'd started medical school when I was working in politics I'd worked on a health plan with a southern Democrat named Jim Cooper representing Tennessee I had worked for him for about a year and a half and so when I started medical school the plan was that you know this is what I'm going to stick with but health reform became an issue in the 92 election enough that when Bill Clinton ran his head of policy asked if I would join the team as their health policy advisor and social policy advisor so you know I think I was probably number 32 on the list of people they asked by the time at that point I was 26 years old but the job required you to move to Little Rock Arkansas this was during the primaries Clinton was not even in the top two at that time seven Democrats running they were called the Seven Dwarves because bush senior had 70 percent favorability ratings so you know by that I was asked to join and for me it was an amazing opportunity and I believed in Bill Clinton I'd met him during the time when he was governor when we were crafting a health plan that Southern Democrats could sign on to and so I took a leave of absence from medical school it ended up being almost two years because lo and behold we won the primary I had proposed to my now wife at that time and she she had moved up to Boston I said well they got this job offer don't worry we'll lose before we got out of the primary and then we won the primary and go into the general election I said to her well we're supposed to get married two weeks after the election don't worry about working lose it'll work out fine and then just one thing led to another until finally in ended up working in the White House and in the Department of Health and Human Services and then I made the decision after health reform went down the the head of the welfare reform effort was David Ellwood who's now the Dean of the Kennedy School of Government and he had asked if I would join the team to work on welfare reform and I decided I need needed to forge my own set of skills it was a hard decision the group of people I was with you know there was a bunch of us who were young people working on policy and and you know I didn't love the ups and downs of the sharp political elbows people you agree with who would muscle you out of meetings you know playing that that game and I didn't know how I felt about working exclusively my career for politicians so I decided to go back and and complete medical school I'd lost some ground and had to make it up but that's what I came back to do thank you for coming back I think I first met you when you were in the middle of your surgical residency hmm you were spending some time over here working on the medical practice that he follow up but that was the first time I recognized that you had some interest in safety but how did you get an interest in patient safety how did that fit in with this it was you you know I didn't have a particular interest in focus on medical error but I was interested in identifying problems that we could solve and I had started a set of studies that was in with another mentor Troy Brennan who was here at the School of Public Health at the time he was a lawyer doing medical research on malpractice with you and the follow-up study that he's describing was one where we had data from Utah and Colorado across hospitals 15,000 patients and hospitals across the state and I was in charge of looking at the surgical data and what I was interested in is how much of the people who died was because they had complications of care where we just didn't know the answers and the problem is ignorance and we need to overcome that with more scientific research around in the bench lab and how much was because then they just didn't execute that there was knowledge that existed but people died from complications that could have been prevented we found that two-thirds of the surgical deaths were from really error and that they accounted for also two-thirds of the deaths and hospitals in the state so that's when I came started tagging along with you and you were running a program at the Kennedy School of Government there were bringing civic leaders together not just medical leaders but people from politics and a wide variety of fields saying what do we do about this problem that you recognized years before and you got me interested I'll take full credit well we we want to talk about yours I do I want to point out though yes you brought me along as a brand-new student at the School of Public Health everybody else in the room were people with an enormous amount of experience and just getting to be in there that's what made it possible yeah well it was it was certainly a very good investment to say the least we want to talk about your leadership in all three areas that you've excelled in in writing in research and in surgery and and I think writing is the logical place to start because that's where most people are familiar with your work and I must say I'll never forget the first piece of yours in The New Yorker that I read I don't think was your first piece but it was called the learning curve and you described the experience you had in learning how to insert a central line this is putting a big needle in somebody's neck and trying to find the vein and I was reading this your description of it of how frustrating it was and your your you were frightening you or you weren't sure what was going to happen next and I was reading this and saying yes yes that's just the way it is and I realized I was sweating and I said this is somebody who really knows how to write and so let's ask you that question this was you started running from New York or just about the same time you were over here looking at patient safety are they related and more importantly how did you get started writing to New Yorker and how did you learn to write so well I did not have a plan it was not clearly related at all I have always had a a variety of interests I never thought writing would be one of them I had my worst grades and in college were in writing and well there's a take home and and I think I didn't have anything to write about is the most important thing I had nothing to say in surgical residency forged by fire then getting a chance to pull back and think about it in a public health atmosphere where you're thinking about you know how do we solve problems for entire populations it writing was the way that I could stay connected as a surgery resident stay connected to public policy issues without having to be full-time you know like being in politics as a full-time sport you have to be there day and day out you know my wife thought that surgical residency was a was better for her life than being in politics we got two days off in the entire year in an entire year working in that world and so the bottom line for me was that writing started out as just an experiment a friend of mine had started an Internet magazine this was 1996 when it was the netscape browser if any of you remember that so you know you'd literally get if you're lucky hundreds of hits and for me where as a terrible writer that was beautiful I can almost do it in obscurity but I was working with a friend who had been in journalism a long time and he and the people he gathered were fantastic editors and so I wrote a series of what you've now called blogs we called him a column then but I had editing so it was like getting to do 30 gallbladders in a row with a surgeon standing across the table from you I did 30 columns in a row with really great editors telling me this is what you're doing well this is what you're not doing well and boy that argument is really pretty weak and let's see if you can make it better I was forced to revise I never revised anything you know I had to learn how to really revise and so when it was more happenstance than anything it started as really being about public policy issues my first article one of my first articles was about Governor george w bush and the policy he had signed into law in texas allowing criminals to be freed if they agreed to castration if they had been rapists or convicted of child molestation like now what do we think of that policy but it morphed into talking about my own experiences in recognize dealing with errors understanding how you deal with imperfection and medicine and thinking about some of these other kinds of issues and so you know it was the influence of being in this mix of the different things I was working on on the research side living a life of trying to learn how to be a surgeon and thinking about public policy that kind of forged a series of articles in The New Yorker turned out that as the magazine grew it was slate magazine slate went from a few hundred hits to by the time I finished in two years was three hundred thousand hits per article and among those that was reading it was a New York New Yorker editor who offered the chance to try writing for them and I started with small articles in it and it grew over time you once said you revise your first New Yorker article a number of time 22 times I thought it would you know I thought it'd be a couple months of work it was nine months of work going back and back and back and you know but I had to admit it kept getting better so it was painful but the editor would keep throwing me another task and it would keep making the article better it's better so we went that was I think that key difference was I learned I'm an okay writer with a first draft but I learned how to revise to get it to the point that I could be a really a much stronger more vivid writer and make it sound like conversation and that takes a lot of cutting cutting cutting rewriting rewriting rewriting it was James Michener's somebody said you're a great writer he says no I'm a great rewriter but you're in the same Club trying to learn to do that yes now the other two big areas that you've contributed so much in our research and surgery and they came together when the World Health Organization asks you to run a safe safe for surgery project I remember you came in to me and said what do you think about this and I said well WH o is not the easiest place to work with on the other hand big big possibility for making an impact and you decide to do it and and I think would be very interesting for people to understand not only what led you to make that decision but more importantly in terms of the leadership aspect how you were able to corral a group of surgeons of all people from around the world and get them to focus how you came to a conclusion about what to do and and what were the challenges and the leadership challenges in carrying that thing off yeah and for me it was an evolving sense of what was going to be the way that I'd learned to lead I think a lot of my thinking coming out of government and politics and then my initial writing was that where change occurs was really around laws and policy and regulations and trying to move those needles but many of the problems I felt like we saw in making equitable high quality health care that could reach a large number of people was that there are many problems that simply hadn't been solved or accepted or agreed upon even by the profession and so the World Health Organization asked me to take on this project which was to see if we could reduce deaths and surgery globally and I was still in the back of my mind thinking that this might be about policies or things like that we launched into the project it was not funded very well it was a small amount of money to convene a lot of leaders in and around surgery and try to make a kind of set of guidelines about care but what was clear with the team that I assembled as we all wanted to actually see whatever we did make a difference so we're going to go to all this work and if it doesn't if it just sits on a shelf somewhere as a book of guidelines that's that doesn't get anywhere and the more we dug into it more we felt and that the problems were not ones a policy but how to reduce deaths and surgery how to make a feasible pathway that anybody anywhere doing surgery could successfully lower deaths and that was what we decided to tackle there were about 10 major things that you could do to reduce infections in surgery and make sure that you had problems with bleeding brought under control and good communications and all these basic things but it was really meeting people who helped us understand you know what you really got to think about how you make these things become a reality we zeroed in on after we brought in a team from Boeing a leader who was a leader of engineering for Boeing that we recognized you could just make a checklist for surgery and then it was selling it from Boeing but very much yeah that we brought in a safety engineer who helped us understand how they work with professionals and for Boeing it wasn't you know as much regulations regulations create a framework that say they're expected to deliver on safety but then they are that the government does not prescribe what's in a checklist they make the checklist that makes it possible for very professional people you know pilots who are well trained to achieve much better results than they otherwise would and so that became a project that you know we kept following that path and as long as we were staying focused on what produces results what saves lives you could bring the rest of the world along there were definitely you know difficult moments where you definitely where you had people in the profession surgeons leaders in the field saying this is a waste of time it's more paperwork it's a bad idea but we committed to testing it at small scale expanding it to an eighth city trial demonstrating whether it works or does not work but once we began showing and we found a 47% reduction in death across eight cities so once you had done that then it really was okay how do we not commit to following through on delivering it to ever larger scale well it's clearly been one of the most impactful advances in patient safety and the whole history of the movement but I SPECT you're your problems then just began when people started implementing and I just wonder you're you've been around long enough to know that just putting a good idea out doesn't make it happen and so I suspect you were prepared for some pushback and from some criticisms from your colleagues maybe hoping that wouldn't happen but that so what happened when it when your article came out and people began talking about actually putting it in place how did those experiences go huh but in your own Hospital for example well so it was um you know great learning experience on the one hand there were early adopters and there were places just you know you had leaders who grabbed it and ran with it and put it in their hospitals and began publishing that they were getting replicating those results 25% 50% reductions in complications and deaths you had some countries like England that the day after it came out they mandated that it be implemented in the hospitals across the country you had a country like the US where it was still a great deal of uncertainty I don't know that we really need this and even in my own Hospital puzzling over like how we need to adopt this in our hospital but how do you even convince your colleagues to make that happen I mean it took six months to just find a meeting where the surgeons anesthesiologists and nurses all sit down together and make plans around care and that was reflective of where we were we weren't even organizing ourselves as teams and we didn't have a place to make it happen I found the finance meeting that we could hijack because that was the one place you could get them together was in the finance meeting and you know the the Boston often is a place that if it didn't invent it is a late adopter we're necessarily we may be slower to jump on board and so it began really moving in many places and then in Boston that began catching on as people kept demonstrating and replicating the results we also saw plenty of examples where the results not come through in Canada just a couple years ago they published results when Canada mandated that the checklist be used all the hospitals signed off we're absolutely weird we're using the checklist it's the law and we're abiding by the law they measured three months after they had implemented and found no reduction in deaths and our you know as we peered in more closely it's clear there wasn't a real implementation support or rollout and we had to learn what that means so in Scotland they rolled it out they mandated it but they sent they bought teams together to walk through every few months what are you doing to roll this out and they said coaches do site visits to say what are the problems you're running into and let's help you solve them they found it took them three years to create countrywide cultural change to create the adoption but by that point they had lowered their death rates 25 percent enough that they documented 9,000 live saved so it's shown us a great deal about knowing what to do is not the same as knowing how to do it so the first question what do you do to lower surgical deaths now we knew a how use a checklist much as they do in aviation how do you get people to use a checklist was another puzzle and over the years what we found is it's a combination of really needing you can't just pay them or create a regulation that says you have to do it you have to recognize it's a culture change and walk people hand in hand through a hospital process a team process where they can get everybody on board with making a very complex change even though it seems like a simple two minute checklist shouldn't be so complicated so it's really about culture change not not just ticking off the boxes yeah and leadership so you know surgeons are used to the idea that no one tells us what to do about the way we do our operations got the new ship captain ship and I make the rules the idea that there would be a standardized way for any component of the way that we do things the way we communicate the way we plan the way we work together as a team that's what the checklist was really doing was saying we're going to have a scripted way that we discuss what the goals of the operation are how we were going to get it done and that was the culture change to go from Cowboys to pit crews where we would agree we would really be a pit crew for the patient and that I'm finding is true across many problems in public health luckily as we've spread our work into trying to figure out how do you make change for childbirth or how do you make change for people's end-of-life care at the beginning of life and end-of-life has been other projects we've gotten involved in it's been again this idea that there are known ways that you can be more effective and can we make it easy for people to adopt those known ways effectively and if we show that it works then you kind of got to do it and that's and that's a hard place to come to that's a basic lesson for all the things we're trying to do in patient safety one area I want to ask you about is something I think many people in the audience may not be familiar with and that is what I think is one of your most important leadership contribution which was the founding of the Ariadne labs there any labs I will read from the mission statement so I get incorrect and then ask you what's this all about our mission is to create scalable health care solutions that produce better care at the most critical moments in people's lives everywhere and then they go on to stay and I think this is particularly fascinating part it is not enough to research a problem and launch a program at Ariadne labs we go further we ensure that our programs can be effectively adapted and successfully implemented across thousands of healthcare facilities and diverse cultures Wow tell us how that came about and tell us the pitfalls and trying to do such an ambitious project I think it came out of the World Health Organization experience that you could identify ways the system fails you could identify approaches that simplified it through research and discovery and innovation but if all we did was publish an article in 2009 in the New England Journal saying we ran a nice trial and and please everybody adopt this not very much what have happened and we really had to embark on learning the science of how do you evaluate of how you bring something to scale and so that is meant now moving from saying okay can we make this work in a very controlled pretty limited 8 Hospital trial in eight cities just saying you know we created a partnership a year or two after that in the state of South Carolina with all of the hospitals in the state trying to measure what their death rates were and how to bring this capability across the hospital across the state and why some places we're succeeding in other places weren't we had another partnership with the Washington State Hospital Association another one with the country of New Zealand and it was very interesting in Washington State they worked with their insurers and they paid doctors and hospitals to adopt in New Zealand they regulated it and made it a mandate in regulation in law South Carolina being a red state did not want to make it a mandate in law being a state that wasn't as wealthy as Washington State they didn't want to pay for it so we used a social networking approach where we tried sending a team of people just four people around the state to krei partnerships in every hospital with surgeons anesthesiologists and nurses willing to work together to bring it into their hospitals and the striking thing was that simply paying doctors are regulating wasn't nearly as effective as going forward with the social networking approach and those kinds of discoveries led us to want to launch a lab because we could bring those capabilities not to just a sequence of a serial set of projects but we could launch ones in parallel fields in surgery yes where we've expanded the range of things we're doing in the field but then in childbirth how how we can make improvements at the beginning of life and how you could make improvements at the end of life in a palliative care program and there you were you know we were positing the idea that with attracting people across the whole city doing work to make changes to improve health systems and try to bring them to scale we would find people who had common cause and wanting to do it so we launched projects but we also are building the community you know community now that has a couple hundred researchers and people from across the city 45 associate faculty members who are building work in these areas and now creating projects well beyond anything that I'm even necessarily involved with you know people solving everything from how do we reduce these section rates in the country to how do we bring behavioral mental health care that really doesn't get to 75 percent of the population with any kind of appropriate depth how do we get that scaling up and working can technology make a difference those kinds of things it's really impressive and I'm sure it's the wave of the future I think our time for for you and me is up it's time to have questions from the audience and raise your hand and we'll have you ask a tool anything you want yes I have bits and chains thank you for your remarks my question is do you feel that your theory can be adaptable to doctor patient healthcare in terms of one tool or the mattek-sands through country watch mine um so your question is do our ideas have application to people really outside the hospital in the ambulatory setting where it's more one-to-one in clinics rather than having a team like in an operating room or in a child delivery well we're learning that in our child in our end of life work the gap that we're seeing in care for people facing serious illness not even necessarily at the end of life is that as care escalates but produces but but comes up against the limits of people's lives people often end up with care that's completely on the line with their actual goals and wishes but the failure to make their wishes known before they got to the hospital in crisis before they were ending up in surgery before they were in an emergency room in delirious with pain is that you had to make a system that could work upstream in the doctor's office we design and approach which is now deploying at a small scale in the Dana Farber Cancer Institute and in the primary care practices affiliated with the Brigham the hospital I practice at where it is simply saying that when the doctor and the patient sit down they would ask a few key questions that palliative care experts have demonstrated to be really powerful but we don't do those kinds of questions or things like asking people what's your understanding of where you are with your health or your illness at this time do you want to have more information about where things might be going in the future with your disease what are your fears for the future what are your goals and priorities if time were short or your health worsened what are you willing to sacrifice what are you not willing to sacrifice so it's we call it the seven questions approach bringing those questions into the clinic and operationalizing them meant creating a system that tried to make it easy for a doctor to know which of their patients are the highest risk of dying in the next year identifying for those patients for them on their clinic schedule and then giving them reminders you know it's been two visits you haven't had this conversation and they're in danger of heading into a crisis could you do that and we found were able to make it work so far in this still small scale pilot still it's thousands of patients I mean it's not that small scale we have 60% of the primary care patients in medic on Medicare in in the n1 and 80% of the cancer patients and the other you know to reminders we're getting 90% of the patients having a conversation that up till now less than 30% we're having the conversation we're trying to see what the impact is and then figure out how to bring it to more places so I think we're learning how to bring it out of the hospital to smaller teams with less resources but still really important roles and places and care hi I'm Jessica Lange so police officers are like surgeons and pilots in that they have to make split-second decisions under stressful circumstances and errors have deadly consequences I'm wondering if you could envision the safety checklist approach being used to train police officers to reduce wrongful shootings so this is so cool edy Davis the chief of police in what he just stepped down from being chief of police he was chief police through the Marathon bombing he had come to us around creating a homicide checklist so I don't know yet about how you might apply it in wrongful shootings but he applied into homicide investigations and found incredible value Boston had one of the lowest clearance rates for homicide investigations in the country and they followed and mirrored the approach we followed with surgery they gathered a lot of information from how other police departments did it tried to figure out what those police departments thought were their best practices and then they created a checklist for homicide investigators and he said there were things on there like you know in many cities in Boston it's up to the crime scene up to the homicide investigator whether they bring a crime scene investigators see sigh to gather evidence in a really structured way or whether they do it themselves it's up to their discretion in other cities they always have a CSI on scene and they found that one of the reasons why in Boston they had failures was that they didn't gather the evidence appropriately and now you lost your evidence and it made it hard to reach a conviction or a clearance on what actually happened so that's just one of several steps that they identified and they were able to make it go and then they were able to walk through the hard process how do you convince surgeons well how do you convince homicide investigators to not do things their own way whatever way and they just mirrored the way it went and now there's a National Institute of Justice study a randomized trial evaluating whether this is what all cities should do because it's worked phenomenally well in Boston so I think that you know people have brought that approach to successfully reducing the domestic abuse deaths with what police should do and with domestic violence victims and I think in wrongful shooting that taking these approaches that these are probably fundamentally systems failures rather than failures of character of policemen and that taking it seriously as a research and innovation need as a systems need I'm pretty sure would work as well hi my name is IRA lor cobby I'm a geriatrician and I want to thank you so much for your book being mortal and just bringing culture change to the general public my question for you is actually what can we do for nursing homes from a policy level they sort of you know keep getting left out with the SGR repeal now nursing homes still are left out of Medicare's conversation just wondering what your thoughts are on that yeah so that surprised to me as I was writing being mortal my most recent book I thought it was going to be a bad end of life but what it was really about two-thirds of the book ended up being about Aging and care of elder care especially housing care and I realized that there comes a moment in your life when either because of illness or frailty or other conditions you you need help of others you need to depend on them and if you if they're not clear about what your goals are it's a problem the assumption in the medical world is your number one goal is to survive and be and and and be healthy but in fact most people in their lives demonstrate ways in which you know go to your refrigerator and you're making choices all the time about sacrifices that you make around what might be ideal for your health you go into nursing homes and you'll have a medically prescribed very healthy diet and no say over what you get to eat and in many circumstances you know I'd meet an 85 year old Alzheimer's patient who's hoarding cookies hiding them in their room because they're under medically ordered diets that say you can only pureed foods and they were miserable and no one was asking what matters in your life and sometimes they blamed policy the nursing home administrators they'd say well the policies and the way we're measured is are we keeping people safe so you get measured around the number of Falls the result is that you tell people you know you should stay in a wheelchair shouldn't even try to walk because then you fall but people want to try for those moments of Independence and so on so one of the things that I came across was that you know I think there are some policy directions which involve creating measures that really evaluate whether people are in are receiving care where people know what their priorities and and what their priorities are besides just being safe and that they feel that those priorities are respected and if there's conflict there are ways already within the system to allow people to you know have agreements that that you know what I can eat what I want even if it's not safe and and that everybody can come to agreements around those kinds of things and I think making sure that that's clear and easy and can be done is really important the further question about how to have funding and experiments in the ways we deliver care to get it closer to the home in an environments where people feel really in there that they're in control that they're in charge I think is is really important it's sort of still unclear to me you know what are the three or five most important policies that would help people be successful in protecting their autonomy as well as their safety is still a little bit unclear I think we're just waking up to the fact that most places that the elderly end up in its chosen by their children their adult children the adult children are focused as one nursing home administrator said safety is what we want for those we love but autonomy is what we want for ourselves and we they never get asked what are you doing to ensure this person gets what matters most in their life and gets to articulate what matters to them and make that part of care so I feel like we're opening the door now to demand that and then begin having expectations around the policies that it should align with that our policies have focused on safety and that's important here you're talking to two safety researchers but life is bigger than just aiming for safety and we haven't incorporated that into our thinking we've medicalized that whole process and that's been a danger let me pick up on being mortal because although it's Jessica indicated immediately went on the bestseller list and has been number one for half a least half of the time and it's still there and I think we'll be there for another year I don't think I've seen a book in recent memory that has had as much impact as being mortal has had and one of the most impressive things to me is how it has changed the conversation and I've always thought of that as one definition of leadership that is changing the conversation on an important subject and I think that's exactly what you had in mind but I want to ask you about one other aspect and that is you were also giving a clear message to the physician community we've got to change the way we practice and I'm sure you realize that that was going to be fraught and I'm curious to what extent you were concerned about that and whether you've had pushback or problems with the whole idea of physicians changing the way they approach the end-of-life well so my frame and anything that I'm writing is always to ask what should I be doing differently better next week that that you know just would make me more effective in reaching the goals and I felt really incompetent dealing with people who had serious issues of aging and ability or terminal illness they didn't teach you that in medical school yeah and then going around and discovering that you know we as a profession weren't doing some basic things that a few people in very marginalized fields for the most part in our world you know palliative care hospice care nursing home care but they knew stuff that we weren't valuing and that basic set of values were often very simple things like you know recognizing that people have priorities besides just living longer asking them what those priorities are and then incorporating it into your plan care that when you didn't do that it created incredible suffering and that I could try it and do it in my own practice in ways that remarkably changed my own practice and how people felt about my care along the way that was one step but the further step I feel like that was the wake-up call was then my dad got the brain tumor that took his life and accompanying him on physicians office visits he's a surgeon my mother is a doctor and I would go as well and we would feel often completely unable to understand how we can align what they're talking about with what he cared about in the time he had remaining and I think that allowed me to say pretty blunt things about the ways in which we fail because I could watch how there were moments when people did incredible things for him they were completely and aligned with what he needed and pushed him to do things that were the right things to push him but when they didn't understand him it led to really pretty awful care and saying it I didn't I often when I'm writing I'm not thinking enough about how people might react but when I'm revising I start getting worried and then as my editor saying no don't don't tell Matt down say you said it before just say it and and I do always worry when it goes out will people receive it in the way that I'm describing it which is as someone wondering how I might be getting better and what that means about how we all might be better at what we're doing and and the pushback has not been there I feel really lucky than people for the most part with my writing and research have received it with the intention I had in mind I'm sometimes saying hard things even about even for myself to confront the ways that my own practice or my own ways of being in the world are not always the best and and so that that I worry about it maybe that does make me it revised extra carefully for not creating this interpretation and so far I've lucked out that it hasn't come back to bite me I got a note just this you know this kind of note came last week from a cardiologist who does in Michigan who does you know interventional cardiology so you know a gung-ho cowboy just like any other like a surgeon like me and and had someone sent in from a nursing home work where the family was very unhappy with the opinions of two previous cardiologists and had just read the book and just said well let me just ask them what are what are what what it asked them nine year old patient what are your goals what's most important to you and then ask the family and realize they weren't in a line and then got them in line and then concluded that what she really wanted was that the remaining time she had was spent with a better quality of life that she got some better food in her nursing home and had no interest in going through the catheterization and for him that was a revelation and this was a chief of Cardiology and the fact that he wrote that note and sent it along to me it just made my day and made my like that was where I felt like we were connecting we were talking the same language we actually have the same values we just you know had been doing it differently and could you arrive in the same place you got him to ask the right question other questions back hi my name is Angela nee and I'm a master student health policy management program here and you wrote a very provocative piece about the use of coach's personal professional coaches to help top performers to the top of their game not just in music and athletes but also for doctors and I wonder have you seen sort of perceptions around coaches changed since you wrote that piece and found ways to integrate the use of coaches in some of your projects and ongoing work so there's two different answers there one is that I've been disappointed about the about that piece not creating a wave in quite the same way I think there's been a ton of individual interest but people haven't figured out how to operationalize the idea so the core concept was I was contrasting the notion of a kind of the pedagogical model model we have in most of healthcare and in many fields law judges or all kinds of fields teachers that the expectations you get lots of training the beginning you get some experience you get your 10,000 hours and then you're kind of you go out in the world and you're expected to improve yourself for the rest of your career whereas athletes do not believe that you know Rafael Nadal Djokovic number one players in the world have coaches for their entire career because they don't believe they can dissect and improve themselves as well I ended up experimenting with having a coach a former professor of mine I'm at mid-career felt like I wasn't getting any better I was feeling like I was very good I felt like I was where I should be as a surgeon but I experiment with having them come to the operating room and just watching me operate and giving me some feedback and you know afterwards he had 20 different things that he pointed out that I could be doing better and I spent the next year gradually whittling away at doing it and I found my complication drop rates dropped even further and the idea that you need external eyes and ears and that there are ways of getting feedback that allow you to keep climbing as you go through the middle part of your profession and beyond that still hasn't quite caught on in medicine there are places that are now have really introduced coaches for people in their first couple years of practice or for people in the training phase but the idea that you need these at later stages you know most CEOs have coaches they've accepted that but it hasn't come to these other professions it's starting to happen though I just did a you know there's a one group that's spun out of that article was that the Massachusetts judges so there's over 200 judges across the state created a program they call judge to judge based on that article which is awesome and that's where senior people in the on the bench will go and observe other coaches other judges as they handle their juries as they interact and give them feedback let them see themselves in ways that they don't they even use videotape in that program and it's fascinating so you know you have people are members of the Supreme Judicial Council our Supreme Court in the state who are going through this program and accepting that kind of approach so I think we're we're not quite there now in our program in our laboratory Ariadne labs we use coaching very regularly that it's the most important tool we think for reaching scale it's often coaching leaders in places trying to implement difficult programs whether it's a checklist and surgery or end-of-life project or in northern India program that is trying to reduce deaths and childbirth and we're teaching nurses to coach nurses doctors to coach doctors and and and trying to make it work so I'm Emily George and I know most of your books have been in the healthcare field and I was just wondering if you had ideas outside of healthcare if you had all the time in the world what you would write about well first of all she's not a plant but she works at area add Neela has a coach working so she's part of a team of just two people who are coaching 520 ambulatory surgery centers around the country to adopt effectively the safe surgery work we've done in outpatient surgery clinics that don't have all the advantages of hospitals and so really interesting great work they're doing what would I write about if it was outside of medicine you know I don't really know I to me I get this little window on the world and I can use medicine to illuminate almost anything because you see human beings coming in and it's everything from how do we what kind of career do you have to what is suffering and what do people go through or how does the brain work you know I feel like there's very little the world I can't capture politics global globalism you know various kinds of phenomena so I love that it gives me the full range and I'd feel really an expert in most other fields but I'm my one place I grew up a tennis player playing competitive tennis and and I don't do it so much anymore but I feel like it's a world that I have a little window into and I could imagine trying something around something like that or maybe around writing but there's so many people who fill pages with writing about sports and writing about writing that I feel like I get this unique vantage point through the eyes of both trying to practice surgery try to do Public Health trying to lead a smaller organization that that I've a list this long and I'm never going to get through it in my lifetime so I probably won't be writing my tennis piece yes hi I'm Mel I'm an mph student um I was wondering obviously you left a kind of burgeoning career in politics at a fairly early stage in terms of personal impact using your career and I appreciate this might be quite hard to give an accurate off but you feel that you've had more impact in public health or you may have had or being able to have more impact in politics if you'd carried on and develop that career well I think it's partly it's trying to be a little bit honest with yourself about what you're good at and also what you have tolerance for so I love trying out ideas that are kind of a little bit on the edge and I'm impatient often as my team will tell me with trying to bring everybody along and and so entering politics is all around being able to try to persuade really a very broad swath of people to come along I love working with the early adopters who want to drive something forward and then use a poll I come with me come with me what's let's let's do this and I also was very impatient with the with the irrationality of politics the ways in which you are trying to get lots of people who fundamentally disagreed on values or were really arguing about something else and it was just power and being effective in dealing with people whose primary aim is power I was not that great at it and and I didn't love it so Bill Clinton working for him you could see he loved an enemy he loved the battle he loved somebody who was really going after him and he could it energized him and where it depressed me and maybe I'll change over time as I get more confidence in being able to take that on but dealing with a world that is going to attack you from every pause you know I had little glimpses of it so for example when I wrote an article about McAllen Texas being the most expensive the most expensive counties for healthcare in America you know some of the attacks that came were around you know insinuating that I'm a Muslim who is raising heads connections to terrorists and was really trying to trying to harm people in this county in Texas and it was floated you know first of all then how do you respond like well it's not bad if I'm a Muslim I don't happen to be but how so how do you even answer that and then you're getting caught in that whole thing and then you're just buying into the whole line of argument it was you know the kind of stuff I hate rather than fired up like okay we got a battle we're on so I think I was I've been about as effective as I could be considering my personality and what I hope is that over time I learned to be effective you know when I first worked in government I ended up really resigning and stepping down out of frustration with the power politics and just you know if we just did it rationally we'd be all okay to you know finding some of that when working with the whu-oh and just being able to relax enough to let the politics happen let the ups and downs and get some patience with it not enough that I could enjoy some of the power plays that can go on but maybe in another 10 years I'll get better at that and so I feel like that's a real area that I'd like to learn how to deal with more effectively the tool sadly our time is coming to an end so we asked you in the last couple minutes if you could sum up what you what you would like to have the audience take away from this and particularly in terms of leadership well one thing I would say which we didn't talk much about but struck me when another friend of ours in patient safety Bob Walker and I had a conversation about this and and what he pointed out was that it's very different trying to figure out how you lead when you're under 40 and then how you lead when you're over 40 and his basic rule and I like this rule because I think I followed it intuitively was say yes to everything when you're under 40 and then start saying no to pretty much everything after you're 40 but that you get this tremendous experience from just trying things out and saying yes to almost everything you never quite get the priorities right and you don't get the balance right and all of those kinds of things you burn the candle it all ends but that was what gave me tremendous on I just said yes to everything and I ended up working a little rock and I ended up writing for The New Yorker and doing all these kinds of things and now I'm trying to figure out how do you you know be sane and balance it and and achieve the things that you can achieve and that comes from a different kind of leadership which I'm trying to learn how to express at this later stage somehow I think you'll figure it out thank you so much

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