Author Atul Gawande

Just got done reading a remarkable book about “getting things right” by surgeon Atul Gawande. It’s called “The Checklist Manifesto” and it methodically proves that the best way to solve complex problems is often the simplest.

He shows how checklists reduce errors, improve communication, and positively shift power within teams trying to fly a plane,  perform surgery and create a top-flight meal at a Boston bistro.

How do you use checklists, in your work, or in your life?  Join our conversation, Monday morning at 9am ET.

"Oh, Beeyill..."

I like you. Do you like me? Here are Gratuitous World’s favorite people of 2009.  

10. Anna Paquin: Until my Old Lady sat me down to watch HBO’s True Blood, I scoffed at the recent interest in Vampire-related media. After all, I thought we went through that phase in the 90s. Not to mention the 1890s. Paquin’s character is a refreshing female lead, not afraid to stand up for her convictions, or take her top off. Titties!  

9. Dr. Atul Gawande: Gawande’s New Yorker article, The Cost Conundrum, was the best piece I read on America’s broken health care system. While avoiding much of the finger-pointing that makes up the current “debate,” Dr. Gawande’s article addresses many fundamental behaviors in need of correction, including those of doctors, patients, hospitals and insurance companies. While offering no “magic bullets,” he does offer concrete examples of systems such as the Mayo Clinic and Grand Junction, Colorado, where good care and coverage are provided, while costs remain low. Great article.  

a lot going on here?

8. Phish: I was skeptical when one of my favorite bands announced their return after a 5-year absence. Anyone who saw their disastrous final ‘04 effort at Coventry knows what I’m talking about. However, a little time off and some sobriety have done the men well. They’re having fun on stage and the audience is returning the favor. Following the band’s tours provided me with much enjoyment over the year. And yes, I did rank the “jam band” Phish between a widely renowned doctor and a Supreme Court Justice.  Please feel free to bring the ridicule.

7. Justice Sonja Sotomayor:  In 2009, I discovered “empathy” was a naughty, naughty word.  And of course we found out “judicial activism” now means any decision in disagreement with Conservative dogma.  We also discovered your sex and ethnic background are really important, unless of course you’re an old white man.  On a related note, if you graduate at the top of your class at 2 Ivy League Institutions, and you’re not a white male, it’s obviously the result of affirmative action.  

While Sotomayor has yet to surprise with her votes on the bench or author any transcendent opinions, she’s on this list for handling her confirmation with class. She had more federal judicial experience than any nominee for the Court in the last 100 years. She was more than qualified, yet had to let bigots like Sen. Jeff Sessions drag her through the mud for weeks.  While I understand the nature of confirmation hearings, I don’t think I’ve seen so many (untrue + unneccessary) personal attacks levied at a SC candidate in my lifetime. That includes you, Justice Thomas.  

Sotomayor handled the entire circus with grace and class – especially for a hot-blooded Latina!  

6. David Rohde: Unless Dick Cheney wants to talk out of his ass about something, America’s mainstream media hasn’t paid much attention to our actual conflicts in Iraq and Afghanistan for about 6 years. That’s one reason Rhode’s 5-part NYT series “Held By The Taliban” is so powerful. Rohde spent almost a year in captivity, and this series provides amazing (and much-needed) insight into our enemies, their culture, and the daunting challenges presented to our troops and the region’s civilians. Please read it.  

5. Dr. George Tiller (deceased): ”In 1993, George Tiller was shot in both arms. He did not let this stop him from returning to work and helping women caught in the most difficult of circumstances. He continued in his work despite daily harassment. He continued in his work despite being labeled a “baby killer” no less than 28 times by Bill O’Reilly. He continued despite lies told about him by O’Reilly and others. He continued until an anti-abortion activist entered the church where he was attending worship, and shot George Tiller through the eye at close range.”  

4. David Eggers: Screenplays for Where the Wild Things Are and Away We Go are both laudable, but his book Zeitoun was the true highlight of Eggers’ prolific year.  

3. Stephen T. Colbert:  Stephen did nothing specific, except maintain the most intelligent, creative, and humorous show on television. Suck it, Charlie Rose.  

2. The Ricketts’ Family + Rocky Wirtz: While the Ricketts family has yet to do much, listening to the new Chicago Cubs’ owners talk about their vision for the franchise makes me smile. For decades, the Tribune and Wrigley corporations ran this franchise into the ground. They continue to be a laughingstock, but I sense a bright future ahead – right after they unload Soriano’s contract in 4 years.  

While it’s never easy to lose a father, it was readily apparent what Rocky Wirtz needed to do in order to bring fans back to the Chicago Blackhawks. He first needed his father (“Dollar” Bill) to die so he could take over the team. He then needed to put the games back on tv. Genious! Finally, add the best young team in the NHL and hockey is back in Chicago for the first time since Larmer, Chelios, and Roenick made it happen in the early 90s. Fantastic!

1. The Iranian Opposition: Every year in countries we don’t care about, courageous people put their lives on the line to protest injustice and attempt to effect needed change. Obviously, in places like Myanmar and Sudan, struggles against oppressive regimes are ongoing. Kudos to those who keep fighting.   

While we clearly pay a lot of attention to Iran for different reasons, the continued opposition to the election fraud, violence, and overall oppression is truly amazing. While these disillusioned masses don’t represent the entire country, the images have been poignant and their ongoing fight against a misguided and corrupt regime is truly inspirational. 

Hopefully, this is one occasion where America can sit back and watch this unfold organically.  So to those with a warped interpretation of “American exceptionalism” and a selective memory of history(1953) – people like Mike Pence and Joe Lieberman - please shut the fuck up on the matter. Good luck in 2010.  

_____________________________________________________________________________

Thanks to Paul for his assistance.  This decade should be better. Let’s rock out 2009.  

If there are any definites in this very indefinite and chaotic era, here is one:  change is constant, and to get to what works successfully tomorrow requires a lot of innovation and experimentation and collaboration to make it to that successful tomorrow.

Atul Gawande

Recently, Atul Gawande — surgeon/professor of surgery at Harvard Medical School/international expert and leader on surgical processes/journalist for the New Yorker/MacArthur Fellow (the “Genius Grant”) – wrote about the Senate health care bill that just passed.  Many have complained that it really only offers pilot programs to try out in hopes of fixing the problems.  This is what he writes:

Where we crave sweeping transformation, however, all the current bill offers is those pilot programs, a battery of small-scale experiments. The strategy seems hopelessly inadequate to solve a problem of this magnitude. And yet—here’s the interesting thing—history suggests otherwise.

In the article, he speaks glowingly and factually about the great success story of the government provided “extension agents,” who work tirelessly to help our farmers increase their productivity.  Their work is a textbook example of innovation and experimentation and collaboration.  They try all sorts of new ideas, in many pilot programs, and they are always calling each other asking for advice on what will solve their specific local challenges.

The article tells the history of this long-running and ongoing and successful government program (officially the U.S.D.A. Cooperative Extension Service).  The first agent was called an “Agricultural Explorer.”  How’s that for a title!  Gawande includes this provocative paragraph:

Cynicism about government can seem ingrained in the American character. It was, ironically, in a speech to the Future Farmers of America that President Ronald Reagan said, “The ten most dangerous words in the English language are ‘Hi, I’m from the government, and I’m here to help.’ ” Well, Lewandowski (a current extension agent based in Athens, Ohio) is from the government, and he’s here to help. And small farms in Athens County are surviving because of him. What he does involves continual improvisation and education; problems keep changing, and better methods of managing them keep emerging—as in medicine. (emphasis added).

Though the article is about the health care crisis, and the encouraging lessons to be learned from the government extension agents, the formula is clear, and provides quite a successful business model:  innovation + experimentation + collaboration can lead to a successful tomorrow.

(Check out Gawande’s web site to read some of his earlier articles.  He is a terrific writer).

Wednesday, January 13, 2010 8 pm
Atul Gawande–The Checklist Manifesto: How to Get Things Right

The New Yorker staff writer Atul Gawande is the author of Better: A Surgeon’s Notes on Performance and Complications, a humane and passionate reminder that doctors are people, too. A MacArthur Fellow, a general surgeon in Boston, and an assistant professor at Harvard, Gawande’s latest work finds a remedy for grievous medical errors in the humblest and simplest of techniques: the checklist. Gawande takes us from Austria, where an emergency checklist saved a drowning victim, to Michigan, where a cleanliness checklist in intensive care units virtually eliminated a type of deadly infection.

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New York Times columnist David Brooks is one of my favorites. Each year he gives out what he calls Sydney Awards for the most important essays of the year. You can read his column with the awards by clicking here.

Brooks awards for essays on the health care “system” are as follows:

Atul Gawande for his essay, “The Cost Conundrum” published in the New Yorker in June. Most likely everyone looking in on this blog has read Gawande’s essay, it’s worth reading again.

Next was David Goldhill’s, ”How the American Healthcare System Killed my Father” published in September in the Atlantic. In this essay, Goldhill looks at the health care “system” from the point of view of an outsider, without the biases that those of us working in the industry bring to work with us every day.

Finally, Brook’s honor’s Jonathan Rauch’s essay, “If Air Travel Worked Like Health Care” published during September in the National Journal. I complain about commercial air travel all the time, but I shudder to think about what it would be like if run like the health care industry.

There are lessons to be learned in each of these essays. The thing that strikes me about each is the consistent underlying premise that the “system” is badly broken. The second is the apparent divergent points of view around what needs to be done to bring about a real system.

All three essays are well worth your time.

Some of the statements coming from politicians and pundits about health reform are so stone ignorant you wonder if they ever in their lives got sick or saw a doctor. The word ‘choice’ gets flung around a lot.

Sometimes it’s claimed that we should all have medical savings accounts. We can save faster by skipping the preventive care. Then when we have a stroke we’ll pull out the phone book and consult the online doctor ratings and shop around for the best deal. That’s empowering.

Another out-of-context concept is ‘more is better’. Kiersten wrote about a classic NYT article by Dr. Atul Gawande contrasting two Texas towns. They were much alike except for the quality of medical care, which was better and cheaper, with fewer tests and healthier people in the town that reformed its system. You’ll hear Dr.Gawande’s study quoted a lot in the debate.

Last month the right wing had hysterics about a task force recommendation that routine mammograms could start at a later age. They missed the word, ‘routine’ and grabbed this as an example of mad scientists forcing us to ration health care, even though the government has not acted on the recommendation.

“Simmer down”, I wanted to say. Studies like this look at populations of tens and hundreds of thousands. We have to have evidence to justify routine screening. Otherwise why not start mammograms at age 16? Someone would make a buck off it, and there are rare cases of breast cancer in very young women. Why shouldn’t they be scared all the time too?

Mammograms are a form of x-ray, and x-ray exposure raises the risk of cancer. X-rays are totally justified if there is a benefit, but old people like me notice that they are used less routinely and with shorter exposures than when we were young.

And any woman who’s been through a scare when an abnormal mammogram requires more tests and waiting knows that it’s not a no-risk proposition. The emotional toll is huge. Hecate, a breast cancer survivor, gives a nuanced and beautifully honest account of her ‘routine follow-up’. She strongly favors screening mammograms and knows what she’s talking about. It’s a very individual decision.

A few years ago private companies were offering a full-body CT Scan for people who wanted to pay cash to be checked out. It was a totally boneheaded idea. Now evidence shows that the radiation in a CT scan is a cancer risk, which is unsurprising. I’ll bet there were a lot of people who went through multiple tests and anxiety when their CT scan showed some spot that turned out to be nothing. There was no evidence that scanning healthy people was beneficial, and no map for what to do with the abnormalities that were bound to show up.

Michael Jackson had all the medical care a millionaire could buy, with doctors on call day and night. He got whatever he wanted from them, but they didn’t make him well. He seems to have lived in a nightmare of pain and anxiety, until his hired doctor gave one too many doses.

Brittany Murphy, it appears, died from too many prescription drugs. Rahul K. Parikh, M.D. in Salon.com has some insight into the fragmentation and lack of information in our current system that allows a troubled person to doctor shop for drugs.

I worry about some of my patients, the ones who have trouble sorting out the chaos of our present system. They can’t always see the same doctor in the office they go to. Test results disappear. They take pills but don’t always know why or what the effects are. I work very hard to teach patients and organize their information. That’s my job.

But it shouldn’t be this hard. Privatization makes competitors of what should be a team. I like computers, but they will not do any good if there are not humans with humane intentions to use them right.

And the key word in the mammogram panic–routine. If you have a reason to get a mammogram at age forty, tell your doctor. That was also in the task force recommendation. Unfortunately there are few of us who can’t name some risk factor. I think doctors will generally err on the side of testing.

But perhaps younger women shouldn’t have a slip handed to them once a year for a routine screen. Time will tell. That’s epidemiology, the study of large groups over time.

Speaking of large groups, it looks like the H1N1 flu will be mild. It’s a relief, but let’s look at it as a test. Our public health system at best got a ‘C’ for response.

Thinking individually fails in health care. We fail to get good care if we randomly demand every test they invent. We’ll fail to stay safe if we don’t make immunization available to all. The consumer model doesn’t work. Consume chocolate, but don’t treat medical care like a product. It’s a science, an art and a relationship and life is precious.

UPDATE: Dr. Parikh really got flamed in the comments section of Salon. I think we are paying too high a price in wasted money and lives for the present system, but privacy concerns are valid. Paranoia strikes deep. Centralized medical records will be the ‘death panel’ talking point of 2010, and a reasonable discussion of how to protect privacy while ensuring that your doctor knows what she needs to know will be hard to find.

Alain Enthoven provides the thoughtful analysis of Atul Gawande’s latest writing in the New Yorker I was looking for. When I wrote about Gawande’s article earlier I had expressed my own doubts.  Enthoven provides a much more in-depth critique of Gawande’s argument, essentially calling it wishful thinking.  I couldn’t agree more with Enthoven.  Powerful forces exist within the medical industrial complex and these forces make a lot of money under the current system, so they are not going to sit and do nothing as they lose billions of dollars.  My heart wants to believe that Gawande is right, but the available evidence suggest otherwise.  I’m beginning to agree more and more with Jay Parkinson that radical reform is necessary and that such reform will come from individual innovation sparking a revolution in the delivery system.

And the form of the reform is taking shape. It’s a major issue in the U.S. and an insanely hot button topic in politics, made even more in modern politics after the defeat of Hillarycare in Clinton’s first term. I’ve stayed largely on the sidelines on heath care reform and have mostly sought as unbiased as possible ideas and opinions. I did think it was a strategic mistake for the GOP to effectively take itself out of the serious sausage-making of the bills and just throwing random poop at the walls to see what resonated as a decent attack line.

I’ve finally read one piece that makes me feel quite a bit better about the legislation that will hit Obama’s desk sometime in the near future, “Testing, Testing” by Atul Gawande in the December 14, 2009, issue of the New Yorker. Gawande is a M.D. and a regular New Yorker contributor and has written on the challenges of receiving and practicing medical care in the current climate. This article is measured, doesn’t really take any of the partisan sides other than to acknowledge something has to be done to change the status quo, and lays out a vision where the current legislation could start an ongoing process of continued improvement in heath care and its administration.

Whichever side of the reform debate you stand on, this article should be a priority read for a glimpse into what could be with the current legislation. It’s not going appease anyone who opposes the bill on either extreme, but it should make anyone who reads the article feel a bit better about the future of medicine in the United States.

In the article Gawande lays out parallels between the agriculture reform efforts of the twentieth century and the current effort at health care reform.

From the link, here’s the concluding graf:

Getting our medical communities, town by town, to improve care and control costs isn’t a task that we’ve asked government to take on before. But we have no choice. At this point, we can’t afford any illusions: the system won’t fix itself, and there’s no piece of legislation that will have all the answers, either. The task will require dedicated and talented people in government agencies and in communities who recognize that the country’s future depends on their sidestepping the ideological battles, encouraging local change, and following the results. But if we’re willing to accept an arduous, messy, and continuous process we can come to grips with a problem even of this immensity. We’ve done it before.

I love Atul Gawande’s writings on health care.  He has a rare talent for describing technical details of health care, insurance and finances in terms that most people can understand.   His recent article in the New Yorker discussed the current health reform bills’ approach to curbing costs, using the agricultural industry as a potential model.

One of his basic points is similar to one I have made before.  He describes two kinds of problems: “those which are amenable to a technical solution and those which are not.  Universal health care coverage belongs to the first category . . . Problems of the second kind [referring to rising health care costs], by contrast, are never solved, exactly; they are managed.” I would frame it somewhat differently.  The two basic kinds of problems are those which are amenable to a government solution, and those which are best addressed using decentralized market forces.

There are two serious shortcomings in our current health care system: lack of access to health care and insurance coverage for many low-income people, and the rising costs of health care.  While private market forces do have the potential to address cost issues –”efficiency” in the jargon of economists – they don’t do very well at handling issues of “equity”.  Specifically, private markets can’t do the following very well in the health care system:

• Provide access to insurance or health care to low-income or very ill people
• Ensure that reliable standardized information is available to consumers
• Maintain the appropriate balance of power between providers and consumers

This means there is an important role for government:

• Ensuring that coverage or care is available to low income and very sick people
• Providing information is reliable and available
• Maintaining healthy markets.

In the latter role, it is appropriate for government to establish the rules for the structure of the market in order to create:

• Real choice
• Healthy competition
• Incentives for improving value (quality/cost)

Government can also play a role in providing financing for innovations (i.e., start-up funding for pilots).  After this point, however, it’s probably better for government to get out of the way and let the market do what it can do best – drive improved value for consumers.

So far, so good.  I basically agree with Gawande’s observation that different problems should be addressed by different means.  But is Gawande correct in using the developments of the agricultural industry as a model for what might occur in health care?  While there are a lot of parallels (e.g., fragmented and inefficient production, resistance to change), I am concerned that there are some important differences between agriculture and health care.  I won’t offer a critique of the outcomes of U.S. agriculture (lower prices, yes, but also the growth of corporate farming at the expense of family farms and small town economies, as well as serious concerns about food safety); I want to focus on two other issues about the relevance of the agriculture model to health care.

First, the economic incentives in agriculture seem much more direct and consistent with consumer welfare.  If the farmer can find more efficient ways to produce crops, it will result in higher net income.  Lower production costs also allow the farmer to reduce prices, gain market share and increase revenue.  Other farmers then have a strong financial incentive to adopt better production methods; otherwise they will lose market share, revenues and profits.  This healthy competition results in lower prices and improved value for consumers.

In the health care world, however, the financial incentives for improving efficiency are much weaker.  The knowledge about how to be more efficient is available, but the adoption of these methods is very limited.  Simply introducing the health care equivalent of USDA extension agents and financing a lot of pilot projects are unlikely to change this.  The incentives are weak for a variety of well-known reasons: health insurance, which shields most consumers from the real costs of health care; federal tax policy, which excludes employer-sponsored health benefits from personal income taxes; the ability for insurers to use risk management strategies to avoid high-risk enrollees; the ability for providers to use payer-mix strategies to avoid low-reimbursement patients; the well-entrenched use of fee-for-service payments that reward volume instead of outcomes, etc.  Unless we make structural changes to address these issues, the financial incentives will not be aligned in a way that will cause the health care industry to embrace more efficient production methods.

The second potential problem is the difference in relative market power of buyers and sellers.  In agriculture, the sellers (farmers) are much weaker than the buyers (consumers and middlemen), which forces the farmers to compete aggressively on price and quality.  In health care, however, the sellers (physicians, hospitals, drug manufacturers) are more powerful than buyers.  There are several reasons for this: providers have professional knowledge and expertise that consumers rely upon, and many areas have a high concentration or even monopolies of providers.  Even if the provider payment incentives were aligned with consumer interests, health care providers would probably still be able to charge relatively high prices.

How do the current Senate and House bills line up with the issues raised by Gawande and my analysis?  The underlying philosophy of the legislation is consistent with the two-sector approach described above: government helps low-income people to get access to health care and sets the rules for the health care market, while private sector providers and insurers compete to offer the best value to consumers.  The bills also begin to address the issue of financial incentives, by encouraging alternatives to fee-for-service, eliminating the use of risk skimming by insurers, and taxing high cost health plans.  Not surprisingly, the bills do not directly address the market power issue, although the proposed strengthening of the Medicare payment commission would be a small step toward curbing costs.

Will all of this work?  We don’t really know, but at least the bills are built on a framework that has some chance of success.  We do know, however, that the current system is cruel in human terms and unsustainable in economic terms, and we have to try something.  We will have more work to do to get this right.

Kabuki: President Obama talked tough to the bankers today, but don’t be misled: If he 1) knew what he was doing and 2) were serious about it, a lot of the executives he’s talking to would have been jobless by now and the U.S. taxpayer would be substantially better off.

Heck of a job, Bushie: The Bush administration’s birth-control policies helped fuel a population boom in Africa, which also means a poverty boom. Nice.

Tony Blair: We were gonna remove Saddam, and if he didn’t have WMDs, then we’d come up with some other reason. No, that’s actually pretty much what he said. If we don’t put these people in prison, our grandchildren are going to be calling us “good Germans.”

Rumsfeld, 10 military officials skate on torture liability: The Supreme Court declined today to hear an appeal of an appeals-court ruling that former Defense Secretary Donald Rumsfeld and 10 military officials are immune from civil claims of torture filed by four now-released Guantanamo prisoners from Britain. Even the normally reliable SCOTUSBlog hasn’t elaborated on this ruling, so I’m not sure what it means, but any time the word “immunity” appears close to Rumsfeld’s name, my gorge rises. (So, yeah, in case you’re wondering, I’ve spent the last five years throwing up in my mouth a little bit.)

“The bill is a hodgepodge. And it should be.”: Physician/journalist Atul Gawande, author of this groundbreaking article on why medical costs are rising so fast, says there’s actually a century-old historical precedent for measures in the health-care reform bill to improve efficiency, and a successful precedent at that: agriculture. It’s an unexpectedly optimistic piece. Check it out.

Burn in hell, Joe Lieberman: Ezra Klein says it best: “At this point, Lieberman seems primarily motivated by torturing liberals. That is to say, he seems willing to cause the deaths of hundreds of thousands of people in order to settle an old electoral score.”

“You have toyed with me for the last time!”: Fully a third of Democratic voters say they’ll be less likely to turn out in 2010 if Congress doesn’t pass a public option. Also, 81% say Joe Lieberman should be punished if he filibusters health-care reform. I think Lieberman should be punished in any event, just for being an ass.

Not so fast with that cover-up, there, mate: Also related to the Iraq invasion, six top physicians in Britain have launched legal action to have the purported suicide of government bioweapons expert Dr. David Kelly re-investigated. Kelly died in 2003, supposedly a suicide, just days after he was exposed as the source of a news report that a dossier of evidence regarding Iraq’s WMD program had been “sexed up” to justify invading Iraq. The physicians credibly claim that the investigation was, in technical terms, screwed six ways to Sunday.

Not so fast, the sequel: The Russian Supreme Court has overturned the acquittals of four suspects in the 2006 slaying of journalist Anna Politkovskaya. All four were accused of being accomplices. The actual triggerman, who evidence in the trial said was paid $2 million, is believed to be still at large. (Earlier.)

What’s going on in southern Russia? In August, 20 people died in a suicide bombing, described in Russian news reports as the latest in a series of attacks in the republic of Ingushetia. Then early today in that same area, a large bomb on an above-ground natural-gas pipeline was defused. Insights, anyone?

Ho-ho-home: Authors Stephen and Tabitha King are paying $12,999* so that 150 members of the Maine National Guard, currently in training in Indiana before shipping out to Afghanistan in January, can come home for the holidays. Glad they’re getting to go home. Wish they didn’t have to go overseas.

*Because he thought $13,000 was an unlucky number. One of King’s personal assistants kicked in the remaining buck.

NextGen is a technology-enabled transformation of the Nation’s air transportation system. NextGen must achieve higher levels of system performance to meet our Nation’s demand for aviation services.  Technology is a key enabler for higher performance, and therefore, we often think of NextGen in terms of big modernization programs designed to deliver that performance: ADS-B, Datacom, and SWIM, for example.  But what often gets lost in the focus on those big programs is that transformation is about change—change to the way we deliver services; change to roles and responsibilities; change to policies and procedures—that is fundamental to translating high-performance technologies into a high-performance system.

We too often think that if we can just find the right message on the benefit of these new technologies everyone will line up behind them and support their implementation.  But change is a human-focused process that must broadly involve the people and organizational cultures at the heart of aviation: pilots, controllers, dispatchers, and other emerging operators (think UAS, for example) as well as the planners, researchers, and developers that support them.  As John Kotter, one of the nation’s leading experts on change management puts it, “People change what they do less because they are given analysis that shifts their thinking than because they are shown a truth that influences their feelings.”  Therefore, perhaps the most critical part of the NextGen transformation is the process that enables us to show truth and influence feelings.  We must engage the intellect, creativity, and passion of aviation’s cultures.  And I would contend that means a substantial and sustained focus on prototyping, experimentation, and demonstration involving the people required to operate the system.

In a very interesting analogy to that very point, in a recent article in The New Yorker entitled, “Testing, Testing,”  Dr. Atul Gawande recounts the transformation of farming at the turn of the 20^th century, and draws analogies to the transformation that is required to achieve health care reform.  To cut to the punch line, through an extensive and continuous series of pilot programs and demonstrations involving working farms and the capture and communication of best practices through U.S.D.A. Extension Services, the U.S. went from a crisis in food production to agricultural abundance.  This process created “a feedback loop of experiment and learning and encouragement.”  The “simple but critical rule” for change was this: “What a man hears he may doubt, what he sees he may possibly doubt, but what he does himself he cannot doubt.”  That quote, from 1903, is completely in line with John Kotter’s quote from 2002!

Dr. Gawande goes on to conclude that “there are, in human affairs, two kinds of problems: those which are amenable to a technical solution and those which are not.”  The approach to the first type of problem is to pick a solution and charge forward.  However, “problems of the second kind, by contrast, are never solved, exactly, they are managed.”  Dr. Gawande argues that health care has both types of problems.  For example, achieving universal coverage is a problem of the first kind – pick an approach, implement, and adjust.  However, health care reform is of the second kind – it is extraordinarily complex and requires the kind of extensive and continuous experimentation that enabled the transformation of agriculture.

Aviation, too, has problems of both kinds.  The modernization of systems tend to be problems of the first kind, and the transition to new and different policies and ways of delivering service is of the second kind.  Now, to be clear, health care is not agriculture and aviation is certainly not health care.  But there are common threads in the transformation of these complex systems—among them the need for continuous and extensive experimentation; the need to be inclusive of the people and cultures that comprise the systems; the need for feedback and learning; and, the need for flexibility to change plans and directions as required.

So, let’s make sure we keep both modernization and transformation in our sights—together they will get us to the NextGen system that our Nation needs.

Bob Pearce
JPDO Deputy Director

What we read while looking for a more suitable sponsor…

• Has this climate controversy been blown out of proportion? But then what will Al Gore and Sarah Palin have to argue about?

• With a few exceptions, we’ve more or less stayed neutral on this health care disaster. Well,  Atul Gawande thinks the new bill could end up saving money. Wait, what?

• While behavioral economics has its problems, it also leads to some fascinating insights, particularly with regards to eating out at restaurants. Check out this interesting analysis of a restaurant menu.

• It has been empirically verified: Close games are more enjoyable than blowouts (well, depending on how you define enjoyable).

• It has been empirically verified: Some people choose not to own cats. Which, depending on your perspective, seems to verify this article’s thesis.

• We almost always recommend something from it, but consider reading this week’s NY Times Magazine cover to cover: It’s the 9th Annual Year in Ideas Issue and it features an interview with eminent University of Chicago Philosopher Martha Nussbaum.

• When we read Russian lit–and you know we do–we do our best to procure the translation by the husband and wife team of Richard Pevear and Larissa Volokhonsky. The Millions recently did an interview with the pair about their methods, philosophies, and future projects.

Full piece here.

Gawande likens the state of health care to farming at the beginning of this century and what’s happened since.   Individual doctors, patients and communities must make their own decisions, and work constantly to innovate, share knowledge, and solve the problems they have, alongside government officials (but not top-down mandates).

“At this point, we can’t afford any illusions: the system won’t fix itself, and there’s no piece of legislation that will have all the answers, either. The task will require dedicated and talented people in government agencies and in communities who recognize that the country’s future depends on their sidestepping the ideological battles, encouraging local change, and following the results. But if we’re willing to accept an arduous, messy, and continuous process we can come to grips with a problem even of this immensity. We’ve done it before.”

Like NOAA maybe?  It’s a fine line to walk and maybe we can do it.

Anyways, a libertarian friend makes the argument that while this would be nice if it worked, it’s simply more of the same:  extending health-care to is akin to extending home-ownership to all (Fannie Mae and Freddie Mac)…or college education to all.  That’s too much egalitarianism, and look for the political and social consequences.

I don’t think she’s winning the argument right now…

Also On This Site:  From Clive Crook: Is Health Care Reform On Track?…From The New Yorker: Atul Gawande On Health Care-”The Cost Conundrum”

Also: From KeithHenessey.Com: ‘The House-Passed Bill’s Effects On Health Insurance Coverage’

Atul Gawande has an interesting article in the New Yorker about the current reform bills circulating through Congress.  Like everything else Gawande has written, this piece is insightful, concise, and inspiring.  He draws a parallel between American agricultural reform during the early part of the 20th century and the current debate over health care.  Given I am not well-versed in agricultural reform in the US (I did see a PBS special on it once), I’m not exactly certain of the appropriateness of this analogy.  What Gawande does accomplish in this piece (and why you should read it) is a sense of hope in our collective ingenuity to actually accomplish effective health care reform.  He believes this goal will be achieved through provisions in the current Senate reform bill for dozens of pilot programs to test new payment structures and delivery systems.  Although Gawande makes a strong, eloquent argument, I am only partially convinced.  How will these pilot programs generate substantial change?  How long will it take for these programs to demonstrate substantive value and then how much longer would it take to scale up their lessons?  I actually like the idea of pilot programs, but they need to have scale to make an impact.  As I have argued many times before, different approaches should be tried at the state level (like Massachusetts) and then scaled up when appropriate.  Such larger programs offer two distinct advantages: (1) their relative scale means evidence of effectiveness (or ineffectiveness) will be generated more quickly and (2) scaling such programs to multiple states or  the national level will take less time and effort since the original scale is more proximate to the end goal.  But read Gawande’s article, it really is quite good (despite my skepticism).

Atul Gawande seems to have done quite well for himself. Not only that, but he has done a great deal for others in the process, especially patients. The Harvard Associate Professor, writer and general surgeon desparately wants doctors to be better at their jobs, which is the focus of his book, the aptly titled Better, published in 2007. It’s all about getting better at being doctors.

Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.

I know how often I witness  doctors who fail to do simple things like washing their hands. This is nothing new. The author explores how hard it has been throughout history to get doctors to comply with simple, obvious guidelines for infection control etc. Gawande then moves on to deal with a variety of other issues from the ethics and practicalities of intimate examinations, doctors involved in legal executions and how lucrative private practise affects clinical practice.

Gawande is all too aware of the limits of medicine, and of the potential for doing more harm than good in our attempts to push the boundaries of modern care. One of the chapters which intrigued me most dealt with how more people are living longer than ever, but with more disease than ever too. Now people are living long enough to get cancer where in the past they would have died of something else first. Gawande explores this phenomenon among horrifically wounded soldiers in Iraq and Afghanistan. He asks searching questions, not least what sort of quality of life these “saved” soldiers will have if they are kept alive with no arms and only one leg. I don’t think it’s our place to judge how someone else views their quality of life, but it does make for a thought-provoking read.

Gawande acknowledges his own failings as much as he points them out in others. Better is a good exploration of a world where mistakes happen all the time, yet where the consequences can be disastrous. Looking forward to getting my hands on his latest book Complications, out soon.

On a recent visit to DC, I made a brief foray into Kramerbooks, where I had the good fortune to stumble across Complications: A Surgeon’s Notes on an Imperfect Science. This book, by Atul Gawande, provides an eye-opening look at what goes on behind the scenes. Medicine is messy, he argues, filled with unknowns and human error.

Because of Atul’s book, I now know that there are an estimated 17 million to 21 million Americans that are afraid of Friday the 13th. Apparently there is a word for this condition: paraskevidekatriaphobia. Who knew? Thanks, Atul. And happy Friday the 13th.

Highly recommended article from David Leonhardt, Econonics correspondent at the NYT.

Since I’ve resigned myself that something like one of the two bills in Congress is going to pass, I hope it does something related to costs, like at least keep the “cadillac” tax in place to stop the maddening growth of tax-subsidized employer-based health care.

He seems optimistic about the Senate bill. I’m not, but it is better than the bill that just passed the House.

I’ve just finished reading Better: A Surgeon’s Notes on Performance by Atul Gawande.  Here I learned of a name for a concept I only vaguely intuited when I wrote A New Version of the Golden Rule:  positive deviance.  (Had I known this at the time, I might have called it Be A Positive Deviant.)  In the book, Gawande briefly describes how Jerry Sternin used this concept during his work with Save The Children to reduce child malnutrition in Vietnamese villages by 65 to 85% in six months (described in more detail here, by David Dorsey in Fast Company magazine).  Gawande then goes on to show how amplifying positive deviance was used to improve workers’ diligence in hand washing at a hospital, resulting in a drop in MRSA infection rate from nine percent of patients to zero.  This stunning success followed years of trying many different things to get people to wash their hands, all of which resulted in no lasting improvement at all.  What all those unsuccessful things had in common is that the changes originated from outside the hospital worker community.

When a community has a problem, people often seem to think that the solution lies “out there” somewhere, and they go looking for someone who can give them the answer to their problem.  However, even if this is true, it pretty much never works, because people simply do not listen to anyone from outside their community telling them how their community should do things.  The immediate reaction tends to be, “but you don’t know how things really are here – what you’re saying may have worked somewhere else but it’s too hard for us because we have this, this and that to contend with.”  In the case of the hospital handwashing problem, this was true even when it was people who worked for the same hospital who were offering solutions – because ”improving handwashing rates” was all their job was.  They weren’t part of the “community” of doctors and nurses whose hands needed to get washed.  Nothing stuck… until they found some people who did wash their hands, asked them how they managed to accomplish that, and had them share those strategies with the rest of their own doctor-and-nurse community. 

In very basic terms, the idea of amplifying positive deviance is to find someone from within the community (however that community is defined by the members of that community themselves), who is successful already, figure out what they’re doing differently, and publicize the fact that it works.  In Vietnam, it was mothers who added sweet potato greens and tiny crabs and shrimp they caught in the rice paddies to their childrens’ rice and fed them several small meals a day, rather than one or two larger ones, whose children were the best nourished.  These practices flew in the face of the local culture’s conventional wisdom.  When outsiders tried to get them to change these practices, prior to Jerry Sternin’s visit, it never worked.  But it is almost impossible to argue with direct evidence, and this is what positive deviance relies on. 

So.  Why am I blogging about it here?  The answer to that is more questions:  What communities are you a member of?  What do you do differently that could serve as a positive example to the rest of your community?  What do others do that you can learn from?  These are valuable questions to develop a constant awareness of, and answer again and again throughout our lives.  We all have circles of influence, and no matter how small your circle may seem to you, you can bring about tremendous positive change if you use that influence.  The people you influence in your circle are themselves members of other circles as well, which they can then have a positive impact on.  When you pull the end of a chain, every link moves.  Where do you want your chain to go?

Click to learn about the Positive Deviance Initiative.

“The nuns in attendance reminded me of a phone conversation I had with my father after the autopsy of the young motorcyclist.  Over the course of the conversation, he asked how my time at the hospital was going.  I recounted to him, without going into much detail, that the process of autopsy is quite difficult to watch.

“‘Is it just that the body is being treated so brutally?’ he asked.  I paused for a moment to consider the question, then decided that it wasn’t actually that at all.  The process is brutal, I told him, but the upsetting part of the autopsy is not the way the body is handled, but rather that such handling makes no difference whatsoever.  What one cannot quite comprehend, in the end, is that no matter what is done to the body, it has absolutely no effect on the person who once inhabited it.  The horror is not what is present and cut apart but what has so completely and irreversibly gone.”

–Body of Work by Christine Montross, Penguin, 2007.

There was recently a very spooky “Fresh Air” interview with Dr. Atul Gawande, dealing with how we draw the line between life and death.  He describes new uncertainties that physicians have about the clarity of “brain death,” and what the brain can recover from.  You only have to sit through one medical examination of someone you love to connect with the eerieness of how the body is not the person, and how freeing and terrifying that is.

The interview is at:

http://www.npr.org/templates/story/story.php?storyId=113681104

“Evil.  I am cast upon a horrible desolate island, void of all hope of recovery.  I am singled out and separated as it were, from all the world, to be miserable.

“Good.  But I am alive, and not drowned, as all my ship’s company was.  But I am singled out, too, from all the ship’s crew to be spared from death; and He that miraculously saved me from death can deliver me from this condition.

“Evil.  I am divided from mankind, a solitaire, one banished from human society. I have not clothes to cover me.  I am without any defence or means to resist any violence of man or beast.  I have no soul to speak to, or relieve me.

“Good.  But I am not starved, and perishing on a barren place, affording no sustenance.  But I am in a hot climate, where, if I had clothes, I could hardly wear them.  But I am cast on an island where I see no wild beasts to hurt me, as I saw on the coast of Africa; and what if I had been shipwrecked there?  But God wonderfully sent the ship in near enough to the shore, that I have gotten out so many necessary things as will either supply my wants, or enable me to supply myself even as long as I live.”

–Robinson Crusoe by Daniel Defoe, first published 1719.

The vision of a man alone on an island, struggling with himself and methodically building a system of nourishment and protection, is deep in our Western consciousness.  I was making Robinson Crusoe style good/evil lists and charting out matters pretend and practical from a very young age.

There is a lot of crazy racist, patriarchal, colonialist nonsense in the book, but its confessional, sweet spirit still shone through to me.  It’s a great adventure, and Crusoe seemed like a really honest guy to me.  I frequently feel like I am trapped on an island and don’t know what to do with myself.  And I often make good/evil lists without even noticing what I am doing, like so many western thinkers.

“Surgeons are control freaks. With a scalpel in your hand you feel unstoppable. There’s no fear, there’s no pain. You’re ten feet tall and bulletproof. And then you leave the OR. And all that perfection, all that beautiful control, just falls to crap.” -Meredeth Grey

I come from a family of medical professionals. My Grandmother was a nurse, my biological Grandfather was a surgeon, my Nonno was family practitioner,  my step grandmother was a nurse, my great-aunt was the head of nursing for Kaiser hospital Oakland, my aunt is nurse, and the list goes on. I have second cousins, step- aunts and uncles, and other distant relatives who have titles far too difficult to figure out all in the medical field. Seriously. I am surrounded by medical professionals. Despite medicine being the family business, I have never been corralled into becoming a doctor, nurse, podiatrist, psychiatrist, whatever. In an alternate universe, however, where having a family wasn’t high on my priority list, and I didn’t have so many other things I wanted to pursue, I would totally become a general surgeon- no questions asked.

I have a profound interest in medicine (it’s clearly in my blood and with all of the family members passing down “the medical gene,” I would guess that it flows through my veins as abundantly as red blood cells), though it hasn’t always been that way. Without the family prodding, I had to discover the fascination on my own. I used to watch House (before the plot became more about the character’s drama than about the medical drama) and am a Grey’s Anatomy addict- seriously. For years, my interest lay dormant, fulfilled by my weekly dose of medical dramas.  This past summer however, while browsing through the hundreds of books lining the walls of my parent’s office, I came across one called Complications: A Surgeon’s Notes on an Imperfect Science by Atul Gawande. A small novel, about 250 pages packed full of case studies, and surgery explanations (I know how to insert a direct line into a patients chest- the hard part is getting the IV around the clavicle bone and into the main artery without puncturing the artery all the way through. Apparently, it’s a lot harder than it sounds).  Every page captivated me and I got through the book quickly, readily picking up the sequil- Better: A Surgeons Notes on Performance.

Apprenhensively, I went to my various grandparents to explore what it was like to be doctor or a nurse. Cautiously, I asked questions because I wasn’t sure where they would stand on the idea of their beloved granddaughter considering becoming a surgeon. My Nonno seemed impartial, simply doling out facts and antic dotes while my Grandma discouraged the idea immediately. Ultimately it didn’t matter what either of them  said, I have no interest in continuing my schooling for another 7 years with 7 more years as an intern before I become a resident- even then it’s a lot of work.

So I live vicariously through surgeon’s memoirs and Grey’s Anatomy. I imagine myself a general surgeon or diagnostician (If I was to, I would specialize in one of those).  The tiny problem with being an amateur medophile is that I now am an amateur hypochondriac. I use they word “hypochondriac,” but I mean more that through my research I have become well-informed and I am intrinsically a worrier. However, I do not wake up in the morning with a pain in my arm (probably from sleeping on it funny) and immediately suspect that I have a spinal cord tumor. It’s more along the lines of that for a couple of days I’m feeling foggy, have cluster headaches, a sore throat and a crick in my neck (from sleeping on it funny) and call my parents to make sure I don’t have meningococcal meningitis. Or I get a huge gash on my leg from running into the rusty stairs in the back of my building and watch it, wash it and whipe it very carefully to insure I don’t contract necrotizing fasciitis, but everyone else is worried about tetanus.

The world of medicine inspires me and interests me, but it’s not the world FOR me. I don’t think I could ever actually insert a central line in the real world or watch people die every day. We all have impracticale, unattainable fantasies, mine is to be Meredith Grey.

Here’s a question:  do you have a checklist?  It sounds so simple, but it is so profound in its simplicity.  We forget what to do.  And because we forget what to do, we don’t get it (all) done.  We need a checklist.

The idea is vigorously championed by Atul Gawande, Surgeon, Rhodes Scholar, Macarthur fellow, (the Genius Grant) medical writer extraordinaire, and Harvard Professor.  In his article in the New Yorker, The Checklist, Gawande describes in detail the many places and procedures that have gone from dismal failures to amazing successes just by following a checklist.  Here’s a paragraph describing the cardiac unit at a hospital surrounded by the Alps, where people come in “from cardiac arrest after hypothermia and suffocation:

Speed was the chief difficulty. Success required having an array of equipment and people at the ready—helicopter-rescue personnel, trauma surgeons, an experienced cardiac anesthesiologist and surgeon, bioengineering support staff, operating and critical-care nurses, intensivists. Too often, someone or something was missing. So he and a couple of colleagues made and distributed a checklist.”

The checklist meant that people literally were able to live – people with similar injuries that killed the many that came before.  And the reason was clear – the emergency workers were too busy to remember everything they needed to do.  They needed a usable, tangible reminder:  a checklist.

Recently at the New Yorker Festival, Gawande (he writes for the New Yorker) spoke of this, and reminded everyone that the hero of the year, Chesley Sullenberger, is a true believer and a faithful follower of the checklist approach.  (Read the post Captain of the Checklist).  Here’s the key excerpt:

To illustrate, (Gawande) discussed the way in which the media had rapidly mythologized the pilot Chesley Sullenberger, the pilot who landed a commercial plane in the Hudson River. “There became questions of who exactly was the hero here,” Gawande said. “Sully kept saying, ‘I want to correct the record. This was a crew effort.’ ”
In saving the plane, Sullenberger and his co-pilot showed daring, but they also methodically went down a list to ascertain their options, and chose the next step until they landed safely. “They adhered to their rigid discipline—they went through their series of checks.”

Did you catch that brilliant simplicity?

• went down a list
• chose the next step

I think that all of the time management insight on the planet boils down to this three step process:

1)  plan the next thing well (so that you always know the next thing to do)
2)  put it on the list
3)  and then do the next thing on the list.

Then — repeat the process…

Atul Gawande

I enjoy reading non-fiction, mostly around HCI issues, but occasionally in other areas. One such book was Better: A Surgeon’s Notes on Performance, by Atul Gawande. From the book jacket: “The struggle to perform well is universal: each of us faces fatigue, limited resources, and imperfect abilities in whatever we do. [Sound familiar?] But nowhere is this drive to do better more important than in medicine, where lives may be on the line with any decision.” Gawande describes three core requirements for success in medicine:

1. Diligence — attention to detail.
2. To do right — despite moral obstacles.
3. Ingenuity — arising “from deliberate, even obsessive, reflection on failure and a constant searching for new solutions.”

Medicine is a profession that involves risk and responsibility; and so does human-computer interaction design. As we consider Gawande’s core requirements for medicine, what are the parallels in hci/d?

We are half way through the semester; we are at an important turning point as we engage in the CHI 2010 International Design Competition problem: will we dig deep within ourselves to find our excellence, or will we simply do what’s necessary to complete the task?

Maya Lin’s design document is quoted here:

Walking through this park-like area, the memorial appears as a rift in the earth, a long, polished, black stone wall, emerging from and receding into the earth. Approaching the memorial, the ground slopes gently downward and the low walls emerging on either side, growing out of the earth, extend and converge at a point below and ahead. Walking into this grassy site contained by the walls of the memorial we can barely make out the carved names upon the memorial’s walls. These names, seemingly infinite in number, convey the sense of overwhelming numbers, while unifying these individuals into a whole.

The memorial is composed not as an unchanging monument, but as a moving composition to be understood as we move into and out of it. The passage itself is gradual; the descent to the origin slow, but it is at the origin that the memorial is to be fully understood. At the intersection of these walls, on the right side, is carved the date of the first death. It is followed by the names of those who died in the war, in chronological order. These names continue on this wall appearing to recede into the earth at the wall’s end. The names resume on the left wall as the wall emerges from the earth, continuing back to the origin where the date of the last death is carved at the bottom of this wall. Thus the war’s beginning and end meet; the war is ‘complete,’ coming full- circle, yet broken by the earth that bounds the angle’s open side, and continued within the earth itself. As we turn to leave, we see these walls stretching into the distance, directing us to the Washington Monument, to the left, and the Lincoln Memorial, to the right, thus bringing the Vietnam Memorial into an historical context. We the living are brought to a concrete realization of these deaths.

Brought to a sharp awareness of such a loss, it is up to each individual to resolve or come to terms with this loss. For death, is in the end a personal and private matter, and the area contained with this memorial is a quiet place, meant for personal reflection and private reckoning. The black granite walls, each two hundred feet long, and ten feet below ground at their lowest point (gradually ascending toward ground level) effectively act as a sound barrier, yet are of such a height and length so as not to appear threatening or enclosing. The actual area is wide and shallow, allowing for a sense of privacy, and the sunlight from the memorial’s southern exposure along with the grassy park surrounding and within its walls, contribute to the serenity of the area. Thus this memorial is for those who have died, and for us to remember them.

The memorial’s origin is located approximately at the center of the site; its legs each extending two hundred feet towards the Washington Monument and the Lincoln Memorial. The walls, contained on one side by the earth, are ten feet below ground at their point of origin, gradually lessening in height, until they finally recede totally into the earth, at their ends. The walls are to be made of a hard, polished black granite, with the names to be carved in a simple Trojan letter. The memorial’s construction involves recontouring the area within the wall’s boundaries, so as to provide for an easily accessible descent, but as much of the site as possible should be left untouched. The area should remain as a park, for all to enjoy.

[For Maya Lin's complete submission, see: http://upload.wikimedia.org/wikipedia/commons/f/fb/MayaLinsubmission.jpg]