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Gawande on Cowboys and Pit Crews

 |  By Philip Betbeze  
   July 19, 2011

Philip Betbeze is attending the American Hospital Association Leadership Summit in San Diego, where Atul Gawande, MD, spoke Monday.

It's hard to underestimate the pull of an Atul Gawande presentation in healthcare these days. The surgeon, writer and teacher has, over a very short amount of time, become a champion for the difficult work of cutting costs and improving quality—not necessarily in that order—in healthcare. That's why I was not surprised at the packed house when he spoke at the 2011 American Hospital Association Leadership Summit in San Diego Monday.

Gawande's message: We are in a battle for the soul of healthcare. Though he didn't say it in so many words, we're probably in a battle for the soul of the American Dream, and whether people realize it or not, that battle will likely be won or lost on whether we, as a nation, are successful in driving down costs and improving quality in healthcare. After all, much of the partisan battle going on in Congress right now over the national debt ceiling has its roots in the unsustainably high costs of healthcare.

"We cannot afford to have healthcare devour our economy," he said.


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Gawande spent a lot of time talking about using checklists in the operating room, which is not surprising, given that his 2009 book, The Checklist Manifesto, deals with the same subject.

In this struggle, he says, it is fortunate that people who have the most expensive care don't necessarily receive the best care. If that weren't true, our only solution to cutting healthcare costs would be rationing.

"This is playing out in the political realm, and it makes it difficult to have a successful conversation about it. It descends into a yelling match," Gawande said. "There's not even agreement about the source of the problems. Is it government, for-profit medicine? I don't think these are the factors. Regulations and insurance hassles make our jobs more difficult. But they are not the root of the problem, they're the symptom."

Man's most ambitious endeavor is how to provide optimal capability without wasting resources. We have 13,600 diagnoses on how the human body can fail, we have 6,000 drugs and 4,000 possible medical and surgical procedures. While other industries have succeeded in driving down costs and improving quality, no single industry has to deliver on that many service lines, let alone do it every single time, he said.


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In fact, healthcare has become so complex, that no single physician can hope to do it alone. Part of the problem with healthcare costs and complexity is that we've built our system on the belief that the physician is the ultimate arbiter and that he or she should have autonomy.

"Five percent of the population accounts for 50% of healthcare costs. That's no surprise. They're sick," he said. "We've built our system on a structure that was built 50 years ago. This has forced us into a very difficult situation."

Gawande argues that the system should be built instead on the analogy of race team pit crews, which must function as a team, not as cowboys, who make all their own decisions. Part of this teamwork ethic can be applied in surgical checklists, a safety innovation borrowed from other industries based on the fact that no single person can keep track of all the processes that must be employed to provide optimum care.

Although hospitals have introduced technology to cut down on mortality, the death rate from surgery has remained high. About 150,000 deaths a year are attributed to surgical complications, but about half are avoidable, Gawande says.

Part of the frustration stems from the fact that although checklists in surgical situations have been proven to reduce complications and costs, hospitals, health systems and physicians, with many notable exceptions, continue to resist them.

"I spend half my time as a surgeon building checklists," he says. "Many industries that grapple with high risk and high failure depend on them, like skyscraper construction or airlines." Boeing, whose top safety engineer is helping on this project, says a good checklist undergoes as many as 50 revisions before it is incorporated into practice.


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But the results are undeniable.

"Through use of this successful two-minute checklist, patients had a 47% lower death rate and complications dropped by one third," he says. "VHA has tried it across 74 hospitals; results show an 80% drop in mortality."

So why is adoption so slow?

"If we had a drug that could cut complications by this much, everyone would implement it, we would have ads all over TV, and lots of people would become rich from it. But it's free, and ironically, that's part of the problem," he said. "Contained in checklists are values very different from what we have in many cases. It requires humility, discipline,  and teamwork."

Teamwork, by and large, is hardly ingrained in healthcare, an autocratic system if there ever was one.

And the system is costly. "Healthcare costs are the fundamental issue of our generation," he said. Gawande used a historical analogy to illustrate the seriousness of the problem.  

In the 1900's, it was food. Forty percent of income was spent on food and 50% of the population depended on agriculture for employment. Governments rose and fell over this issue. It was responsible for tens of millions of deaths. The market couldn't solve it. Food was largely produced by tenants and sharecroppers. It didn't pay to invest in mechanization.

Food shortage was one of the reasons Communism developed. It failed too. The incentives were all wrong. But through a combination of government and private solutions, the food problem was largely solved in the developed world. It was solved by providing farmers with knowledge and power. It used comparative effectiveness and financed incentives. The government funded agricultural extension services, the National Weather Service, and other programs. Financial incentives helped develop a nation of farmers who owned their land. In one generation, outlays for food went from 40% of income to 20% and only 20% of employment depended on farms.

The most difficult skill in this transition attempt is leadership, Gawande contends. "The hardest thing to do is lead institutions -- to make those necessary changes.

One of you will be the first institution, to lower healthcare costs. It hasn't happened yet."

In closing, he offered a personal anecdote to illustrate the seriousness of the problem:

"My son was having trouble at school, and I was upset that he was stuck in a class of 30 where he was getting lost. So I approached the school superintendant after a school board meeting and asked what he was doing to lower class size. He said, 'do you know what I spend most of my time doing? Figuring out how to fight rising healthcare costs.'"

"Oh, I said. The system had a cap on taxes and so had to take from other areas to pay for healthcare. I operated on one of the teachers there for lymphoma. She's doing well, but I realized she and I were one of the reasons costs were going up so fast for the school system. The choice should not be whether my son gets enough time or whether that teacher gets great lymphoma care.

"Our job is to find that answer."

 

Philip Betbeze is the senior leadership editor at HealthLeaders.

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