0:11

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?
0:36
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.
0:58
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.
1:43
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.
2:52
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 subtyped 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.
4:04
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.
4:46
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.
5:33
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.
6:11
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.
6:50
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, selfsufficiency 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.
7:22
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.
8:26
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.
9:17
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.
10:15
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.
10:59
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.
11:32
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.
12:00

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.
12:47
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.
13:26
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.
14:19
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.
15:11
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.
16:01
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.
16:28
(Applause)
16:34
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.
17:31
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.
18:08
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.
18:53
Thank you.
18:55
(Applause)