Atul Gawande Quotes

These are folks that keep people out of hospitals, out of emergency rooms, out of nursing homes. And not only that, they help people achieve more fulfilling lives.

I think the extreme complexity of medicine has become more than an individual clinician can handle. But not more than teams of clinicians can handle.

With a DO-CONFIRM checklist, he said, team members perform their jobs from memory and experience, often separately. But then they stop. They pause to run the checklist and confirm that everything that was supposed to be done was done. With a READ-DO checklist, on the other hand, people carry out the tasks as they check them off
it's more like a recipe.

You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist. With a DO-CONFIRM checklist, he said, team members perform their jobs from memory and experience, often separately. But then they stop. They pause to run the checklist and confirm that everything that was supposed to be done was done. With a READ-DO checklist, on the other hand, people carry out the tasks as they check them off - it's more like a recipe. So for any new checklist created from scratch, you have to pick the type that makes the most sense for the situation.

Living is a kind of skill.

My third answer for becoming a positive deviant: Count something. Regardless of what one ultimately does in medicine - or outside medicine, for that matter - one should be a scientist in the world....If you count something you find interesting, you will learn something interesting.

When, as the researchers put it, "life's fragility is primed," people's goals and motives in their everyday lives shift completely. It's perspective, not age, that matters most. Tolstoy

Practice is funny that way. For days and days, you make out only the fragments of what to do. And then one day you've got the thing whole. Conscious learning becomes unconscious knowledge, and you cannot say precisely how.

George Orwell is a pinnacle writer, for his combination of moral insight and literary writing.

There was a succession of roommates, never chosen with her input and all with cognitive impairments. Some were quiet. One kept her up at night. She felt incarcerated, like she was in prison for being old. The

A year on, Eleanor remained haunted by what happened to her. She still had no idea where the bacteria came from. Perhaps the foot soak and pedicure she had gotten at a small hair-and-nail shop the day before that wedding.

What is needed, however, isn't just that people working together be nice to each other. It is discipline.
Discipline is hard
harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can't even keep from snacking between meals. We are not built for discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.

Human interaction is the key force in overcoming resistance and speeding change.

Introduction I learned about a lot of things in medical school, but mortality wasn't one of them. Although I was given a dry, leathery corpse to dissect in my first term, that was solely a way to learn about human anatomy. Our textbooks had almost nothing on aging or frailty or dying. How the process unfolds, how people experience the end of their lives, and how it affects those around them seemed beside the point. The way we saw it, and the way our professors saw it, the purpose of medical schooling was to teach how to save lives, not how to tend to their demise. The one time I remember discussing mortality was during an hour we spent on The Death of Ivan Ilyich, Tolstoy's classic novella.

Arriving at an acceptance of one's mortality is a process, not an epiphany.

The hardest question for anyone who takes responsibility for what he or she does is, What if I turn out to be average?

The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don't want a general who fights to the point of total annihilation. You don't want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn't, someone who understood that the damage is greatest if all you do is fight to the bitter end.

We want autonomy for ourselves and safety for those we love. That remains the main problem and paradox for the frail. Many of the things that we want for those we care about are things that we would adamantly oppose for ourselves because they would infringe upon our sense of self.

Over time I learned that there are two very different satisfactions that you can have in your life. One is the satisfaction of becoming skilled at something. It almost doesn't matter what the terrain is. There is a deep, soul-feeding resonance in mastery itself, whether in teaching, writing a complicated software program, coaching a baseball team, or marshalling a group of people to start a new business ...

For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by the significant moments, the ones where something happens. Measurements of people's minute-by-minute

If I became just a brain in a jar - as long as I can communicate back and forth with people, that would be okay with me.

The vast majority of doctors really do try to take the money out of their minds. But to provide the best possible care requires using resources in a way that keeps you viable but improves the quality of care.

When I saw him three months later, he was still despondent. "I feel as if a part of my body is missing. I feel as if I have been dismembered," he told me. His voice cracked and his eyes were rimmed red. He had one great solace, however: that she hadn't suffered, that she'd got to spend her last few weeks in peace at home in the warmth of their long love, instead of up on a nursing floor, a lost and disoriented patient. *

Oliver Sacks remains my hero to this day. He was one of the first medical writers I read. The other was Lewis Thomas, who is no longer alive but is just heroic to me.

As people's capacities wane, whether through age or ill health, making their lives better often requires curbing our purely medical imperatives - resisting the urge to fiddle and fix and control.

Few societies have come to grips with the new demography. We cling to the notion of retirement at sixty-five - a reasonable notion when those over sixty-five were a tiny percentage of the population but increasingly untenable as they approach 20 percent. People are putting aside less in savings for old age now than they have at any time since the Great Depression. More than half of the very old now live without a spouse and we have fewer children than ever before, yet we give virtually no thought to how we will live out our later years alone.

I was willing to be rejected. That's what allows you to be a good salesperson. You have to be willing to be rejected.

You know, there's this phase of people's lives in which they can't really cope on their own, and we ought to find a way to make it manageable.

That's how a doctor earns money, she told me. It's a war with insurance, every step of the way.

There are, in human affairs, 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: you can pick one of several possible solutions, pass a bill, and (allowing for some tinkering around the edges) it will happen.

There have now been many studies of elite performers - international violinists, chess grand masters, professional ice-skaters, mathematicians, and so forth - and the biggest difference researchers find between them and lesser performers is the cumulative amount of deliberate practice they've had. Indeed, the most important talent may be the talent for practice itself.

We are not omniscient or all-powerful. Even enhanced by technology, our physical and mental powers are limited.

Training in most fields is longer and more intense than ever. People spend years of sixty-, seventy-, eighty-hour weeks building their base of knowledge and experience before going out into practice on their own - whether they are doctors or professors or lawyers or engineers. They have sought to perfect themselves. It is not clear how we could produce substantially more expertise than we already have. Yet our failures remain frequent. They persist despite remarkable individual ability. *

The core predicament of medicine - the thing that makes being a patient so wrenching, being a doctor so difficult, and being a part of society that pays the bills they run up so vexing - is uncertainty. With all that we know nowadays about people and diseases and how to diagnose and treat them, it can be hard to see this, hard to grasp how deeply uncertainty runs. As a doctor, you come to find, however, that the struggle in caring for people is more often with what you do not know than what you do. Medicine's ground state is uncertainty. And wisdom - for both the patients and doctors - is defined by how one copes with it.

Death is the enemy. But the enemy has superior forces. Eventually, it wins. And in a war that you cannot win, you don't want a general who fights to the point of total annihilation. You don't want Custer. You want Robert E. Lee, someone who knows how to fight for territory that can be won and how to surrender it when it can't, someone who understands that the damage is greatest if all you do is battle to the bitter end.

One American in seven has no coverage, and one in three younger than sixty-five will lose coverage at some point in the next two years. These are people who aren't poor or old enough to qualify for government programs but whose jobs aren't good enough to provide benefits either.

The job of any doctor, Bludau later told me, is to support quality of life, by which he meant two things: as much freedom from the ravages of disease as possible and the retention of enough function for active engagement in the world. Most doctors treat disease and figure that the rest will take care of itself.

Ingenuity is often misunderstood. It is not a matter of superior intelligence but of character. It demands more than anything a willingness to recognize failure, to not paper over the cracks, and to change. It arises from deliberate, even obsessive, reflection on failure and a constant searching for new solutions.

An audience is a community. The published word is a declaration of membership in that community and also of a willingness to contribute something meaningful to it.
So choose your audience. Write something.

They provided assisted living, but no one seemed to think it was their job to actually assist him with living

Expertise is the mantra of modern medicine. In the early twentieth century, you needed only a high school diploma and a one-year medical degree to practice medicine. By the century's end, all doctors had to have a college degree, a four-year medical degree, and an additional three to seven years of residency training in an individual field of practice - pediatrics, surgery, neurology, or the like. In recent years, though, even this level of preparation has not been enough for the new complexity of medicine.

At least two kinds of courage are required in aging and sickness. The first is the courage to confront the reality of mortality- the courage to seek out the truth of what is to be feared and what is to be hoped. But even more daunting is the second kind of courage - the courage to act on the truth we find.

they have priorities beyond merely being safe and living longer; that the chance to shape one's story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone's lives. Inevitably,

Percent of medical students take no course in geriatrics,

No, the more familiar and widely dangerous issue is a kind of silent disengagement, the consequence of specialized technicians sticking narrowly to their domains. "That's not my problem" is possibly the worst thing people can think, whether they are starting an operation, taxiing an airplane full of passengers down a runway, or building a thousand-foot-tall skyscraper.

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.

Those of us in medicine don't help, for we often regard the patient on the downhill as uninteresting unless he or she has a discrete problem we can fix.

If we took away the ability to put defibrillators in people in their last years, people would be shouting in the streets.

Our health-care morass is like the problems of global warming and the national debt - the kind of vast policy failure that is far easier to get into than to get out of. Americans say that they want leaders who will take on these problems.

But the dismal finances of geriatrics are only a symptom of a deeper reality: people have not insisted on a change in priorities.

So for any new checklist created from scratch, you have to pick the type that makes the most sense for the situation.
The checklist cannot be lengthy. A rule of thumb some use is to keep it to between five and nine items, which is the limit of working memory.

You want to ensure people can do it right 99 percent of time. When we have to fire one of our surgical trainees, it is never because they don't have the physical skills but because they don't have the moral skills - to practise and admit failure.

This is the reality of intensive care: at any point, we are as apt to harm as we are to heal.

The important question isn't how to keep bad physicians from harming patient; it's how to keep good physicians from harming patients. Medical malpractice suits are a remarkably ineffective remedy.
(In reference to a Harvard Medical Practice Study) ... fewer than 2 percent of the patients who had received substandard care ever filed suit. Conversely, only a small minority among patients who did sue had in fact been victims of negligent care. And a patient's likelihood of winning a suit depended primarily on how poor his or her outcome was, regardless of whether that outcome was caused by disease or unavoidable risks of care. The deeper problem with medical malpractice is that by demonizing errors they prevent doctors from acknowledging & discussing them publicly. The tort system makes adversaries of patient & physician, and pushes each other to offer a heavily slanted version of events.

She was doing impressively well, he said. She was mentally sharp and physically strong. The danger for her was losing what she had. The single most serious threat she faced was not the lung nodule or the back pain. It was falling. Each year, about 350,000 Americans fall and break a hip. Of those, 40 percent end up in a nursing home, and 20 percent are never able to walk again. The three primary risk factors for falling are poor balance, taking more than four prescription medications, and muscle weakness. Elderly people without these risk factors have a 12 percent chance of falling in a year. Those with all three risk factors have almost a 100 percent chance.

Living is a kind of skill. The calm and wisdom of old age are achieved over time.

Before taxiing out to the runway, we paused again for five more checks: whether anti-icing was necessary and completed, the autobrakes were set, the flight controls were checked, the ground equipment was cleared, and no warning lights were on. The three checklists

assisted living isn't really built for the sake of older people so much as for the sake of their children.

The M & M sees avoiding error as largely a matter of will - of staying sufficiently informed and alert to anticipate the myriad ways that things can go wrong and then trying to head off each potential problem before it happens. It isn't damnable that an error occurs, but there is some shame to it. In fact, the M & M's ethos can seem paradoxical. On the one hand, it reinforces the very American idea that error is intolerable. On the other hand, the very existence of the M & M, its place on the weekly schedule, amounts to an acknowledgement that mistakes are an inevitable part of medicine.

Courage, Laches responds, "is a certain endurance of the soul.

Pain is a symphony - a complex response that includes not just a distinct sensation but also motor activity, a change in emotion, a focusing of attention, a brand-new memory.

So Pabrai added the following checkpoint to his list: when analysing a company, stop and confirm that you've asked yourself whether the revenues might be overstated or understated due to boom or bust conditions.

In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression. Spending one's final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or "It's O.K." or "I'm sorry" or "I love you."

People have concerns besides simply prolonging their lives. Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The hard question we face, then, is not how we can afford this system's expense. It is how we can build a health-care system that will actually help dying patients achieve what's most important to them

Under conditions of complexity, not only are checklists a help, they are required for success.

In one of her most influential studies, she and her team tracked the emotional experiences of nearly two hundred people over years of their lives. The subjects spanned a broad range of backgrounds and ages. (They were from eighteen to ninety-four years old when they entered the study.) At the beginning of the study and then every five years, the subjects were given a beeper to carry around twenty-four hours a day for one week. They were randomly paged thirty-five times over the course of that week and asked to choose from a list all the emotions they were experiencing at that exact moment.
If Maslow's hierarchy was right, then the narrowing of life runs against people's greatest sources of fulfillment and you would expect people to grow unhappier as they age. But Carstensen's research found exactly the opposite. The results were unequivocal. Far from growing unhappier, people reported more positive emotions as they aged. They became less prone to anxiety, depression, and anger. They experienced trials, to be sure, and more moments of poignancy - that is, of positive and negative emotion mixed together. But overall, they found living to be a more emotionally satisfying and stable experience as time passed, even as old age narrowed the lives they led.
The findings raised a further question. If we shift as we age toward appreciating everyday pleasures and relationships rather than toward achieving, having, and getting, and if we find this more fulfilling, then why do w

Medical professionals concentrate on repair of health, not sustenance of the soul. Yet

Obstetrics went about improving the same way Toyota and General Electric went about improving: on the fly, but always paying attention to the results and trying to better them. And

The writing I love has something memorable in it - an image, a smell. It's the connection between the moment and the whole concept, weaving the micro together with the macro so that it has a hold on people - that's writing.

When someone has come to you for your expertise and your expertise has failed, what do you have left? You have only your character to fall back upon - and

We want progress in medicine to be clear and unequivocal, but of course it rarely is. Every new treatment has gaping unknowns - for both patients and society - and it can be hard to decide what do do about them.

In one study, old people assigned to a geriatrics team stayed independent for far longer, and were admitted to the hospital less.

But the fact that, by 2012, one in thirty-five Dutch people sought assisted suicide at their death is not a measure of success. It is a measure of failure. Our ultimate goal, after all, is not a good death but a good life to the very end. The Dutch have been slower than others to develop palliative care programs that might provide for it. One reason, perhaps, is that their system of assisted death may have reinforced beliefs that reducing suffering and improving lives through other means is not feasible when one becomes debilitated or seriously ill.

Block has a list of questions that she aims to cover with sick patients in the time before decisions have to be made: What do they understand their prognosis to be, what are their concerns about what lies ahead, what kinds of trade-offs are they willing to make, how do they want to spend their time if their health worsens, who do they want to make decisions if they can't? A decade

A young doctor is not so young nowadays; you typically don't start in independent practice until your midthirties. We

Our ultimate goal, after all, is not a good death but a good life to the very end.

Michael Jordan always had to wear University of North Carolina boxer shorts under his Chicago Bulls uniform.

We're always trotting out some story of a ninety-seven-year-old who runs marathons, as if such cases were not miracles of biological luck but reasonable expectations for all. Then, when our bodies fail to live up to this fantasy, we feel as if we somehow have something to apologize for.

human beings fail the way all complex systems fail: randomly and gradually.

The purpose of medical schooling was to teach how to save lives, not how to tend to their demise.

The investigators at Johns Hopkins and elsewhere had also observed that when nurses were given a chance to say their names and mention concerns at the beginning of a case, they were more likely to note problems and offer solutions. The researchers called it an "activation phenomenon." Giving people a chance to say something at the start seemed to activate their sense of participation and responsibility and their willingness to speak up. These

When our time is limited and we are uncertain about how best to serve our priorities, we are forced to deal with the fact that both the experiencing self and the remembering self matter. We do not want to endure long pain and short pleasure. Yet certain pleasures can make enduring suffering worthwhile. The peaks are important, and so is the ending.

For all but our most recent history, death was a common, ever-present possibility. It didn't matter whether you were five or fifty. Every day was a roll of the dice.

As different as Emily Dickinson's parents' life in America seems from that of Sitaram Gawande's in India, both relied on systems that shared the advantage of easily resolving the question of care for the elderly. There was no need to save up for a spot in a nursing home or arrange for meals-on-wheels. It was understood that parents would just keep living in their home, assisted by one or more of the children they'd raised. In contemporary societies, by contrast, old age and infirmity have gone from being a shared, multigenerational responsibility to a more or less private state - something experienced largely alone or with the aid of doctors and institutions. How did this happen? How did we go from Sitaram Gawande's life to Alice Hobson's?

Along the way. Whenever serious sickness or injury strikes and your body or mind breaks down, the vital questions are the same: What is your understanding of the situation and its potential outcomes? What are your fears and what are your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding? The field of palliative

Are doctors who make mistakes villains? No, because then we all are.

In every industrialized nation, the movement to reform health care has begun with stories about cruelty.

And in stories, endings matter.

Most people are squeamish about saying how much they earn, but in medicine the situation seems especially fraught. Doctors aren't supposed to be in it for the money, and the more concerned a doctor seems to be about making money the more suspicious people become about the care being provided.

We yearn for frictionless, technological solutions. But people talking to people is still the way norms and standards change.

Even our brains shrink: at the age of thirty, the brain is a three-pound organ that barely fits inside the skull; by our seventies, gray-matter loss leaves almost an inch of spare room.

In fact, he argued, human beings need loyalty. It does not necessarily produce happiness, and can even be painful, but we all require devotion to something more than ourselves for our lives to be endurable. Without it, we have only our desires to guide us, and they are fleeting, capricious, and insatiable. They provide, ultimately, only torment.

Thinking about averting plane crashes in 1935, or stopping infections of central lines in 2003, or rescuing drowning victims today, I realized that the key problem in each instance was essentially a simple one, despite the number of contributing factors.

It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals. And

In other words, people who had substantive discussions with their doctor about their end-of-life preferences were far more likely to die at peace and in control of their situation and to spare their family anguish. A

Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers. I wrote this book in

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination.

Our ideas of what our priorities are shift as we come face-to-face with some of the struggles.

All involve risk, uncertainty, and complexity - and therefore steps that are worth committing to a checklist and testing in routine care. Good checklists could become as important as doctors and nurses as good stethoscopes (which, unlike checklist, have never been proved to make a difference in patient care). The hard question - still unanswered - is whether medical culture can seize the opportunity.

In the past, surviving into old age was uncommon, and those who did survive served a special purpose as guardians of tradition, knowledge, and history.

During the Second World War, for example, Lieutenant Colonel Henry K. Beecher conducted a classic study of men with serious battlefield injuries. In the Cartesian view, the degree of injury ought to determine the degree of pain, rather like a dial controlling volume. Yet 58 percent of the men - men with compound fractures, gunshot wounds, torn limbs - reported only slight pain or no pain at all. Just 27 percent of the men felt enough pain to request pain medication, although such wounds routinely require narcotics in civilians. Clearly, something that was going on in their minds - Beecher thought they were overjoyed to have escaped alive from the battlefield - counteracted the signals sent by their injuries. Pain was becoming recognized as far more complex than a one-way transmission from injury to "ouch.