YouSaid · the spoken record

Atul Gawande

lines on the record: 91
first: 2018-10-02
most recent: 2018-10-02
sittings or episodes: 1
sources: podcast

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“We always have more, in fact, to talk about than we can possibly fit into that meeting. And that process, however, has gotten us to a place where we have lower and lower and lower and lower death rates, faster and faster recovery of people, people doing better and better, and higher and higher expectations of ourselves about what we can pull off.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Legally protected space for us to be open every week about what went wrong and what happened to people, including terrible things. People left permanently disabled because of something that we've done. And it's a kind of ritual where the person presenting stands at the front of the room and says I was responsible for this. My responsibility is not perfection. My responsibility is, however, that we always have to be aiming for it even when we know we're going to fall short. And then the second part. Not only owning it, but also the fact that next week we're going to have another meeting. There's going to be more cases that we will have. We've never come to conference and said, guess what? We have nothing to talk about.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“We just had ours today. Is it today? No, it was yesterday. So this is a conference we have every week, seven o'clock for an hour. And in that meeting, we bring the complications, which is to say the cases that had things go wrong where the patient had a bad outcome and we're specifically bringing up the cases where we're addressing errors and what could we have done differently and how can we learn from it and make things better and then every death is also reviewed there and some of them can be prevented and some can't and part of what's interesting to me is the culture of that there is a space that it's actually a”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Right. But there's all kinds of issues of justice and things that go into it too, because that failure to deliver when you do the wrong thing and somebody dies. Want to hold responsive people responsible, and we should. And at the same time, we have also to grapple with the reality of fallibility, the reality of not everything being in an individual's control, but being a property of a system as well. And that subverts all the ways that our brains generally work.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“How we manage this complexity, the volume of knowledge, our capabilities, and then also how we grapple with and manage the reality of necessary fallibility. It's interesting to me that they actually termed it ineptitude, the failure to deliver, because that word has a judgment applied to it. Like, you know, if an individual or a group of individuals fail to apply the knowledge that exists correctly,”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“The additional reality of necessary fallibility, as they called it, which is we will never have complete knowledge of all of the conditions and states of the world. And we will continue to find we still don't have an understanding of all of the laws that apply to it. So even if we were to come to a complete understanding of all the laws of the universe, we won't be able to understand all of the interconnections and all of the particularities and how they all interconnect. And so we're always making our best prediction and effort to be able to drive that. And so grappling, something about that is deeply human. We have a long way to go being, I think, one of really the first generation where we need an equal amount or sometimes even greater amount of discovery and follow through.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“And there are two aspects of it, as you point out. A substantial amount of it can be solved by being able to understand and address the complexity of making all of these things happen, understanding the variation in how human beings can have these things occur and what we know about how we can manage it. But then there's”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Which is that now we've discovered, for example, in healthcare, we've discovered that there are more than 70,000 ways the human body can fail, 70,000 different diagnoses for our 13 organ systems. We've developed 6,000 drugs, 4,000 medical and surgical procedures, and now we're trying to deploy that capability town by town to everybody alive. Then when you start dissecting, what's the nature of that fallibility, that failure to deliver? Well, first of all, that list I just told you. That's incredible. There's nothing like it. I would argue this is humankind's most ambitious endeavor is to deploy all of these discoveries in the right way, in the right time, in the right place without also bankrupting society. How do we make this happen?”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Or understand them, let alone what to do about them. We didn't understand how society's rose and fell. We didn't understand how economics worked even in the most basic components. And now we're in a place in the 21st century. We haven't answered all the questions, but we have equally now a problem of ignorance and of what they call ineptitude, I prefer to call failure to deliver, a little less judgmental.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Well, so first of all, I want to just call out again Gorvitz and McIntyre. That paper was a 1976 paper for me has been the most influential thing in my career just because it gave me a handlehold for thinking about problems. And you mentioned it as a study, but in fact it was just two philosophers who were thinking about why do we fail at anything we do. The big deal to me about that paper was it pointed out it helped me think about where we were also in history as well. For most of human history, for like 99.99% of it, our world was governed largely by ignorance.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Like you can save lives. And there are areas where you can have leverage and you can also totally screw it up, like screaming at people to start washing hands. Just stop. It doesn't work. We have lots of evidence it doesn't work. Let's move on.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“There are emergent properties. And as soon as you start getting that vocabulary and a sense of expertise and understanding of the complexity and how much smarter some people are about being able to be good at that work versus others, now it's no longer about just slogging it out and dotting I's and crossing T's. It's that if you are If you're intelligent and structured about the way you do things you can get phenomenally better results doing this kind of work. And so as we make that happen, a lot of my writing to some extent is trying to say, hey, figuring out how to get people to wash hands A, it's actually a really interesting problem. And B, we have 2 million people a year who pick up infections mostly because someone didn't wash their hands. It's 100,000 lives lost a year.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Need to be doing, and we've been doing this work as part of my public health work, is unraveling making it almost scientific, what's the nature of the human systems, their interconnections, where the dependencies are, where the bottlenecks are, and how to make that work, and apply ideas to it. What you've called in your blog mental models, there is path dependence.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Well, so I've called it that we've been fantastic at breakthrough innovation and we've had no real understanding of follow-through innovation. And I think it's partly that the follow-through innovation can seem like it's only about nuts and bolts and not about ideas and that it's just about Herculean effort instead of about recognizing that there are ways that you can actually influence and have control, some degree of control with regard to the world around you. So in many ways, how did the breakthrough happen? The breakthrough drug was found because you really began to understand the interconnected complex systems at a cellular level that govern a cancer. Well, all we're doing.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Measured yet that is doing it at the highest levels that would get a five on a five point scale in all of those domains. The average hospital has got poor performance in at least one of them. And we have lots of hospitals that are just ones and twos on all of them because they don't die. businesses go out of business. One of the interesting things is that joining up with her She said manufacturers and retailers Ones just go out of business. In healthcare, they keep on going. And the only thing we have going for us is the schools are even worse on our measurement scores. I want to go back.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“For talent and their ability to achieve your main goals and objectives, do you, number two, do you have measures of whether you are achieving those goals and objectives? Number three, do you have goals and objectives? Do you have targets for what you aim to do that you're measuring against and hiring for? And then fourth, do you standardize operations around do you make a kind of a checklist for the key things that your key targets and where you're trying to accomplish? And we now have seen that there is direct correlation between the more of that you do, the better off patients are, substantially better off patients are and better off in terms of quality. And we also see there isn't a single hospital.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“And so we've started to unravel that. We started to pull those things apart. And it often is really mundane things. One example. We published some data on. Hospitals and the variation between hospitals with a colleague that we partnered with named Raphaela Sudun, who's at Harvard Business School. And we measured across hospitals in the country implementing safe surgery programs and so on. And for many of your listeners, it's like, oh, this is totally just like Business 101. Do you hire”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“But you don't have a single article demonstrating that the leader who makes sure all those things come together is worth multiple percentage points of mortality reduction. And that's really interesting to me that we haven't made that into a tractable, tangible.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Very often, none of us can actually see what the outcome is, and the owner can't see the function of the system. And so then you start finding things like data really matter. So, you know, suddenly you're into all these really unsexy things. You got owners and managers, and you have data. But lives are unlike a single New England journal publication. You can find every week you'll find here is a drug that makes a difference. Here is a specialist technique that can make a difference.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Seeing the system as a system for its function and then for plugging solutions in that can make it work and winning people over to it and adapting it and making it happen. I think the second thing, there's so many things. This is the problem with figuring out even how to write about it because there's so many dimensions to all of this that you start losing the sense of capability like oh man there's so many things I got to do around this but I do think that there are ways that you start to figure out how to pull it together. So the second thing that I was about to say is that when we all have a piece of care or a piece of a problem”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Who's responsible for making sure the supplies arrive? Well, there's a supply clerk. Who's responsible for the nurses knowing what to do? Well, the nurses are responsible for that, but who's responsible for making sure the system that all of those things come together is no owner. creating an owner is one of the key things that you have to have in a system. And suddenly you're into things like governance and responsibility and that's politics. But it's really interesting pulling those very human things apart, realizing nobody owns responsibility for”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Do a process of gather a team, a team of champions, they have to look at this thing that you want to do and ask questions. Will this work as designed in our place and how do we have to change it? And you virtually always have to make changes. And so you need people who own making it happen. That alone is a big thing. How do you If you have an owner to turn to so in surgery, you have owners to turn to. There are managers. There are people who run operating rooms and are chiefs of surgery and so on. We've been running these trials in childbirth though, and that's a completely different story. In large parts of the world, you go and say, who owns responsibility for reducing the death rate of moms and babies in your primary birth center? And it's just a lot of like, I don't know who's responsible for that. I'm just a document.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Of making things work. And then the third level is realizing we have to systematize what we do. And part of it is creating a process solution, a better process that makes it easier to do the right thing than to not do the right thing. And so that can be a checklist or it can be all kinds of things. But then the challenge is implementing that. lot about the components of implementing it. There's a pathway of implementation like doing a Big Bang, as we call it, saying everybody in our hospital is all going to use this checklist tomorrow and we're going to do that in a big bang. Just it's never worked. We've never seen it work at all. Thousands of places are rolled out, never seen it work. Instead, you have to...”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Well, I think that the first level is what we have to unlearn, which is we see what should happen. Doctors should be washing their hands. The operation should be done in this following way. That's better than the other way. We've gathered the evidence. We've shown it to be true. And then we think, well, let's just train it. Let's just teach it. And then you've taught everybody. In fact, that's our dominant way in healthcare that we make things happen. We just train people longer. And then you discover we still suck. And so then we get mad, and then we say, Well, now you must do X, wash your hands, do the operations in the following way, get organized. And we have mandates and requirements and regulations and litigation and so on. And it does make for some better outcomes. Things get slightly better, but Snick's very expensive way.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Right, they're doing it automatically. They feel it's part of what they're doing. Since we published our initial results, it's 2009. We had demonstrated in eight cities a 50% reduction in mortality. I think we're past in that time 100 million of the world's 300 million operations are done with the solution. And we've demonstrated in places like South Carolina, Scotland, and Moldova markedly improved outcomes at large population level. And yet, entire parts of the world, big patches of our own country were just not doing it. It's the standard of care, but we don't do it. So how do you change behavior and the system? And it's not as simple as we should pass a law. And of course, that's the challenge writ large. We're all puzzling over how do we make the complexity of our systems, whether it's Healthcare economics, schools work at scale.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Checklist manifesto was here's a solution that, boy, if you did X, Y, and Z, use this checklist in surgery, and it'll cut you at the death rate 50%. That's a straightforward thing to do. Now, how do I make a system where people are actually doing it when people don't want to do it?”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Not coincidentally turning 50, not coincidentally having a dad who was diagnosed with a brain tumor, not coincidentally having more than a decade of having to talk to people about these kinds of situations and not feeling like I was doing very well. And again, it was recognizing, boy, there's a gap here between what we think should be happening in the ways we deal with mortality and how we understand it and the reality of what we do day to day and digging in there was where I've gone. And so it's just this progressive process. And I feel like now for the last five, six years, it's actually gotten harder to write about in some ways. I'm really trying to wrap my mind around.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“System around me being as important in the outcomes of my patients as me. In fact, in some ways more important, how well the place I work in delivers makes it a huge difference in whether people do well or not. And so that became the next area of session. How do I understand the bell curve, why there's a wide gap between the performance of different people and different places depending on where you go to as a patient. And then by the next stage, I'd found that I could try solutions and borrow them from different places. And checklist manifesto was, you know, so it's like I'm getting to take people along as I'm growing up going through this process and then no surprise, mortality then becomes what you start thinking about. Of course.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“It's evolved in the beginning, it was a lot around how do you cope with the reality of error, complications was partly about the nature of how errors occur. Some of it's because of ignorance and we just don't have the science. Some of it's because of errors and actually failure to do what we ought to know how to do and learning curves and systems and things like that. And some of it is the reality of complexity, meaning that you're always fallible and that you will never be error free. As I then finished my training and went into practice, I became comfortable with the fact that I was doing what I could to keep on climbing the learning curve. But now mystified and struggling with the reality of”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Applying these very basic questions in a space that you have lives on the line and you have a lot of money and you have a lot of complexity. And so it makes it a really interesting kind of and meaningful domain to people, even though I think a lot of the things I'm asking about apply widely.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“About just their performance. It was the team and the organization they built around them. So suddenly this question of what does it mean to be good at what we do? I've been mining that and searching for answers to that all the way along the way. And that has come to include what does it mean to be good when it comes to our costs? What does it mean to be good with care at the end of life? What does it mean to be good at what we do when the science is exploding faster than we can understand it? What does it mean to be good when there's a new piece of data that comes out that says this is the latest, greatest breakthrough drug? But now I've been around long enough to have seen where some of them don't turn out to work in the long run. So is it good to be conservative? Is it good to be take the first thing out of the box? There's so many interesting questions in this space. And I feel like they're very general questions. Medicine is just a place where you're”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“And so there are all kinds of interesting questions about that to me. Here I am at the beginning of my training. And what was evident was there are things happening with technology and computer science and what's that going to mean about what it means for me to be good at what I do in the future. But second is that I'm learning and I'm crap. And how do I have permission to be crap and to learn along the way and how do we even ask permission for such a thing and have a learning curve admit that there's a learning curve, those kinds of things, and then add to it that you have folks who, you know, it's not all about being at Harvard and going to the very best program and being the most pedigreed and the most credentialed, you had these folks who were getting remarkable results and it was not.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Well, in some ways, I think I've been interested in that from the very beginning. So complications was written out of my early New Yorker articles where I was a trainee in surgery. And I was very interested in what does it mean to be good at what we do as a doctor when I'm Still learning, I'm practicing on human beings. One of my very first articles was about a computer that could diagnose heart attacks better than the most experienced doctor could. And a hernia factory in Toronto where the surgeons were, none of them were actually trained as surgeons. One was like a family physician, but they did more hernia operations at lower cost with far better results than any I would ever achieve.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Going beyond kept widening that. And I've just loved that. I've loved adding another space that I could explore. And it was only by happenstance, it was very late that I found I had anything to contribute. And that really wasn't until my 30s when I finally found I could connect the dots between different things I'd been learning about.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“It's more personality. I mean, I think I Grew up Kind of interested in how the world worked. And I had a very Limited vantage point in my town in Ohio growing up. And every opportunity to see my handlehold was through science. My parents were doctors and that gave me a way of seeing and thinking about the world. But then my parents were also people who are deeply involved in the community in trying to deal with the challenges in a community that had a college but was also the poorest county in Ohio. And so my brain worked in such a way that I loved the understanding the ideas at a ideas level and then trying to figure out how you ground it. So I was always looking for ways to understand the world and that meant needing to bridge and look more widely. And so each move, college and then”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Saying and pointing out, wow, we don't live up to what we say we're going to do, it's not usually not for evil reasons, it's usually for really complicated reasons and then unnotting the complexity and just taking time to do that. I find in each line of work, whether it's surgery, our public health research center where we're sitting today, Ariadne Labs, or my writing, I'm just doing the same thing over and over again, actually.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Well, but Doesn't mean I do all of those things well. And B, you know, I like having a lot of irons in the fire. I like being a jack of all trades and finding the edges between things is often where I have something to add. You know, I'm not. If you look at what I contribute in these spaces, it's not genius ideas. Checklist for surgery. It's just taking an idea from one domain and saying, let's bring it over to the other and see if it can work. Or understanding what people's goals are when they face mortality end of life. A lot of them just come from digging in deep enough to understand the gap between what we're aspiring for and the reality of what we're doing and then trying to figure out where the bridge is to narrow that wide gap. And so most of my value just comes from”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Worked actually in politics for a couple years on the Hill and found I didn't want to just work in politics. I kept finding myself gravitating back to medicine where you could have skill. The values were At the core of it for me, that it was about grappling with how science meets humanity in a place where and policy and the world and all the complexities of life in a place where you could really think about the individual in front of you, but also the system as a whole. And I wanted to somehow connect on both levels.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“And then when I got out of Stanford, I went on to do a master's degree in politics and philosophy, economics at Oxford, out of hope that I could maybe do a graduate degree in political theory or something like that. And I just found I wasn't very good at those questions. And a lot of the things that I tried, I just wasn't really made for or cut out for. And I kept coming back to medicine as a place where I was familiar, I was comfortable. It wasn't for the best reasons, right? It was a place that I knew and I could thrive. What I also liked about it was you didn't actually have to decide what you wanted to be when you grew up. So it deferred all kinds of decisions while I figured out everything else along the way. So when I got out of graduate school and decided just stop with a master's degree in philosophy and then I”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“Well, I didn't want to become a doctor. So, you know, I grew up in southeastern Ohio, the kid of two Indian immigrant doctors. And of course, what do they expect? But when will you go to medical school? And so I spent college. I majored in biology, but I also majored in political science, kind of looking for there must be more to the world than just medicine. And I found it. I found it in lots and lots of different places. Some in science, I worked in a lab, some, I tried everything in college. I was in a band. I learned to play guitar. I wrote music reviews for the student newspaper. I joined Amnesty International. I worked on Gary Hart's very short-lived campaign for president as a volunteer.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT
“When we all have a piece of care or a piece of a problem Very often, none of us can actually see what the outcome is, and the owner can't see the function of the system. And so then you start finding things like data really matter.”
2018-10-02 · The Knowledge Project with Shane Parrish · #42 Atul Gawande: The Path to Perpetual Progress · IDENTIFIED FROM THE TRANSCRIPT