How to pronounce "rationing"

I got my start

in writing and research

as a surgical trainee,

as someone who was a long ways away

from becoming any kind of an expert at anything.

So the natural question you ask then at that point

is, how do I get good at what I'm trying to do?

And it became a question of,

how do we all get good

at what we're trying to do?

It's hard enough to learn to get the skills,

try to learn all the material you have to absorb

at any task you're taking on.

I had to think about how I sew and how I cut,

but then also how I pick the right person

to come to an operating room.

And then in the midst of all this

came this new context

for thinking about what it meant to be good.

In the last few years

we realized we were in the deepest crisis

of medicine's existence

due to something you don't normally think about

when you're a doctor

concerned with how you do good for people,

which is the cost

of health care.

There's not a country in the world

that now is not asking

whether we can afford what doctors do.

The political fight that we've developed

has become one around

whether it's the government that's the problem

or is it insurance companies that are the problem.

And the answer is yes and no;

it's deeper than all of that.

The cause of our troubles

is actually the complexity that science has given us.

And in order to understand this,

I'm going to take you back a couple of generations.

I want to take you back

to a time when Lewis Thomas was writing in his book, "The Youngest Science."

Lewis Thomas was a physician-writer,

one of my favorite writers.

And he wrote this book to explain, among other things,

what it was like to be a medical intern

at the Boston City Hospital

in the pre-penicillin year

of 1937.

It was a time when medicine was cheap

and very ineffective.

If you were in a hospital, he said,

it was going to do you good

only because it offered you

some warmth, some food, shelter,

and maybe the caring attention

of a nurse.

Doctors and medicine

made no difference at all.

That didn't seem to prevent the doctors

from being frantically busy in their days,

as he explained.

What they were trying to do

was figure out whether you might have one of the diagnoses

for which they could do something.

And there were a few.

You might have a lobar pneumonia, for example,

and they could give you an antiserum,

an injection of rabid antibodies

to the bacterium streptococcus,

if the intern sub-typed it correctly.

If you had an acute congestive heart failure,

they could bleed a pint of blood from you

by opening up an arm vein,

giving you a crude leaf preparation of digitalis

and then giving you oxygen by tent.

If you had early signs of paralysis

and you were really good at asking personal questions,

you might figure out

that this paralysis someone has is from syphilis,

in which case you could give this nice concoction

of mercury and arsenic --

as long as you didn't overdose them and kill them.

Beyond these sorts of things,

a medical doctor didn't have a lot that they could do.

This was when the core structure of medicine

was created --

what it meant to be good at what we did

and how we wanted to build medicine to be.

It was at a time

when what was known you could know,

you could hold it all in your head, and you could do it all.

If you had a prescription pad,

if you had a nurse,

if you had a hospital

that would give you a place to convalesce, maybe some basic tools,

you really could do it all.

You set the fracture, you drew the blood,

you spun the blood,

looked at it under the microscope,

you plated the culture, you injected the antiserum.

This was a life as a craftsman.

As a result, we built it around

a culture and set of values

that said what you were good at

was being daring,

at being courageous,

at being independent and self-sufficient.

Autonomy was our highest value.

Go a couple generations forward

to where we are, though,

and it looks like a completely different world.

We have now found treatments

for nearly all of the tens of thousands of conditions

that a human being can have.

We can't cure it all.

We can't guarantee that everybody will live a long and healthy life.

But we can make it possible

for most.

But what does it take?

Well, we've now discovered

4,000 medical and surgical procedures.

We've discovered 6,000 drugs

that I'm now licensed to prescribe.

And we're trying to deploy this capability,

town by town,

to every person alive --

in our own country,

let alone around the world.

And we've reached the point where we've realized,

as doctors,

we can't know it all.

We can't do it all

by ourselves.

There was a study where they looked

at how many clinicians it took to take care of you

if you came into a hospital,

as it changed over time.

And in the year 1970,

it took just over two full-time equivalents of clinicians.

That is to say,

it took basically the nursing time

and then just a little bit of time for a doctor

who more or less checked in on you

once a day.

By the end of the 20th century,

it had become more than 15 clinicians

for the same typical hospital patient --

specialists, physical therapists,

the nurses.

We're all specialists now,

even the primary care physicians.

Everyone just has

a piece of the care.

But holding onto that structure we built

around the daring, independence,

self-sufficiency

of each of those people

has become a disaster.

We have trained, hired and rewarded people

to be cowboys.

But it's pit crews that we need,

pit crews for patients.

There's evidence all around us:

40 percent of our coronary artery disease patients

in our communities

receive incomplete or inappropriate care.

60 percent

of our asthma, stroke patients

receive incomplete or inappropriate care.

Two million people come into hospitals

and pick up an infection

they didn't have

because someone failed to follow

the basic practices of hygiene.

Our experience

as people who get sick,

need help from other people,

is that we have amazing clinicians

that we can turn to --

hardworking, incredibly well-trained and very smart --

that we have access to incredible technologies

that give us great hope,

but little sense

that it consistently all comes together for you

from start to finish

in a successful way.

There's another sign

that we need pit crews,

and that's the unmanageable cost

of our care.

Now we in medicine, I think,

are baffled by this question of cost.

We want to say, "This is just the way it is.

This is just what medicine requires."

When you go from a world

where you treated arthritis with aspirin,

that mostly didn't do the job,

to one where, if it gets bad enough,

we can do a hip replacement, a knee replacement

that gives you years, maybe decades,

without disability,

a dramatic change,

well is it any surprise

that that $40,000 hip replacement

replacing the 10-cent aspirin

is more expensive?

It's just the way it is.

But I think we're ignoring certain facts

that tell us something about what we can do.

As we've looked at the data

about the results that have come

as the complexity has increased,

we found

that the most expensive care

is not necessarily the best care.

And vice versa,

the best care

often turns out to be the least expensive --

has fewer complications,

the people get more efficient at what they do.

And what that means

is there's hope.

Because [if] to have the best results,

you really needed the most expensive care

in the country, or in the world,

well then we really would be talking about rationing

who we're going to cut off from Medicare.

That would be really our only choice.

But when we look at the positive deviants --

the ones who are getting the best results

at the lowest costs --

we find the ones that look the most like systems

are the most successful.

That is to say, they found ways

to get all of the different pieces,

all of the different components,

to come together into a whole.

Having great components is not enough,

and yet we've been obsessed in medicine with components.

We want the best drugs, the best technologies,

the best specialists,

but we don't think too much

about how it all comes together.

It's a terrible design strategy actually.

There's a famous thought experiment

that touches exactly on this

that said, what if you built a car

from the very best car parts?

Well it would lead you to put in Porsche brakes,

a Ferrari engine,

a Volvo body, a BMW chassis.

And you put it all together and what do you get?

A very expensive pile of junk that does not go anywhere.

And that is what medicine can feel like sometimes.

It's not a system.

Now a system, however,

when things start to come together,

you realize it has certain skills

for acting and looking that way.

Skill number one

is the ability to recognize success

and the ability to recognize failure.

When you are a specialist,

you can't see the end result very well.

You have to become really interested in data,

unsexy as that sounds.

One of my colleagues is a surgeon in Cedar Rapids, Iowa,

and he got interested in the question of,

well how many CT scans did they do

for their community in Cedar Rapids?

He got interested in this

because there had been government reports,

newspaper reports, journal articles

saying that there had been too many CT scans done.

He didn't see it in his own patients.

And so he asked the question, "How many did we do?"

and he wanted to get the data.

It took him three months.

No one had asked this question in his community before.

And what he found was that,

for the 300,000 people in their community,

in the previous year

they had done 52,000 CT scans.

They had found a problem.

Which brings us to skill number two a system has.

Skill one, find where your failures are.

Skill two is devise solutions.

I got interested in this

when the World Health Organization came to my team

asking if we could help with a project

to reduce deaths in surgery.

The volume of surgery had spread

around the world,

but the safety of surgery

had not.

Now our usual tactics for tackling problems like these

are to do more training,

give people more specialization

or bring in more technology.

Well in surgery, you couldn't have people who are more specialized

and you couldn't have people who are better trained.

And yet we see unconscionable levels

of death, disability

that could be avoided.

And so we looked at what other high-risk industries do.

We looked at skyscraper construction,

we looked at the aviation world,

and we found

that they have technology, they have training,

and then they have one other thing:

They have checklists.

I did not expect

to be spending a significant part

of my time as a Harvard surgeon

worrying about checklists.

And yet, what we found

were that these were tools

to help make experts better.

We got the lead safety engineer for Boeing to help us.

Could we design a checklist for surgery?

Not for the lowest people on the totem pole,

but for the folks

who were all the way around the chain,

the entire team including the surgeons.

And what they taught us

was that designing a checklist

to help people handle complexity

actually involves more difficulty than I had understood.

You have to think about things

like pause points.

You need to identify the moments in a process

when you can actually catch a problem before it's a danger

and do something about it.

You have to identify

that this is a before-takeoff checklist.

And then you need to focus on the killer items.

An aviation checklist,

like this one for a single-engine plane,

isn't a recipe for how to fly a plane,

it's a reminder of the key things

that get forgotten or missed

if they're not checked.

So we did this.

We created a 19-item two-minute checklist

for surgical teams.

We had the pause points

immediately before anesthesia is given,

immediately before the knife hits the skin,

immediately before the patient leaves the room.

And we had a mix of dumb stuff on there --

making sure an antibiotic is given in the right time frame

because that cuts the infection rate by half --

and then interesting stuff,

because you can't make a recipe for something as complicated as surgery.

Instead, you can make a recipe

for how to have a team that's prepared for the unexpected.

And we had items like making sure everyone in the room

had introduced themselves by name at the start of the day,

because you get half a dozen people or more

who are sometimes coming together as a team

for the very first time that day that you're coming in.

We implemented this checklist

in eight hospitals around the world,

deliberately in places from rural Tanzania

to the University of Washington in Seattle.

We found that after they adopted it

the complication rates fell

35 percent.

It fell in every hospital it went into.

The death rates fell

47 percent.

This was bigger than a drug.

(Applause)

And that brings us

to skill number three,

the ability to implement this,

to get colleagues across the entire chain

to actually do these things.

And it's been slow to spread.

This is not yet our norm in surgery --

let alone making checklists

to go onto childbirth and other areas.

There's a deep resistance

because using these tools

forces us to confront

that we're not a system,

forces us to behave with a different set of values.

Just using a checklist

requires you to embrace different values from the ones we've had,

like humility,

discipline,

teamwork.

This is the opposite of what we were built on:

independence, self-sufficiency,

autonomy.

I met an actual cowboy, by the way.

I asked him, what was it like

to actually herd a thousand cattle

across hundreds of miles?

How did you do that?

And he said, "We have the cowboys stationed at distinct places all around."

They communicate electronically constantly,

and they have protocols and checklists

for how they handle everything --

(Laughter)

-- from bad weather

to emergencies or inoculations for the cattle.

Even the cowboys are pit crews now.

And it seemed like time

that we become that way ourselves.

Making systems work

is the great task of my generation

of physicians and scientists.

But I would go further and say

that making systems work,

whether in health care, education,

climate change,

making a pathway out of poverty,

is the great task of our generation as a whole.

In every field, knowledge has exploded,

but it has brought complexity,

it has brought specialization.

And we've come to a place where we have no choice

but to recognize,

as individualistic as we want to be,

complexity requires

group success.

We all need to be pit crews now.

Thank you.

(Applause)