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tv   A Surgeons Notes on Performance  CSPAN  November 3, 2013 6:00pm-7:01pm EST

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and all 16 major league teams were in the north. more production drew blacks north to the bleachers. as takeout makes clear in his splendid book, baseball's great experiment, jackie rabin and his legacy, robinson was a biblical and normal miracle. he probably was not even the best player in the negro leaks, but the best all-night athlete in american history. ..
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>> 154-game season and the intense concentration involved in hitting a rocketing round ball with a round bat. and when in the field, tensing in anticipation on at least 120 pitches every game. robinson had to excel at the most difficult game under the most difficult of conditions. with the attention of black america focused on his every at bat, he succeeded in in spite of excrew chaiting -- excruciating tension. he became the perfect model for black americans and for white americans too. his style of play was everything that blacks were then rarely allowed to be; confident, aggressive, dashing, aristocratic.
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in a 1947 game with the archrival giants with the score tied and one out, robinson doubled. when he tagged and went to third on a flyout, a giant official complained that's bush league stuff. with two occupants he's just -- outs he's just as valuable on second as he is on third. what's he going to do now, steal home, i suppose? on the next pitch, he stole home. [laughter] some called him uppity. more called him exciting. in 1946 a war-weary nation welcomed the ball players home by setting a new major league attendance record. in 1947, thanks to robinson, the record was smashed. most a called him admirable. by the end of 1947, a poll ranked him the second most admired american man behind bing crosby. [laughter] he certainly was a bargain. his 1947 salary was the major league minimum, there are 5,000.
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less than alex rodriguez makes today, press than one-sixth of what alex makes in one at bat. three dodgers protested robinson's presence. ricky got rid of them. when in june 1947 bill veck, owner of the indians, made larry doby the first black in the american league, he took doby into the clubhouse. three players refused to shake his hand. veck traded them. and remember the grace of joe gordon, the indians' infielder? doby struck out swinging wildly on three pitches. gordon, the next batter who normally hit that particular pitcher, fanned on three pitches probably deliberately, then went and sat next to doby in the dugout. it is arguable that doby more than robinson spurred the search for black players. robinson was an athletic
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prodigy. doby represented a larger class of merely finish merely -- talented alt athletes. all teams were not integrated until 1956, but september 1948, robinson had exercised an american's most sacred first amendment right, arguing with an umpire so vehemently, he was thrown out of the game. [laughter] a rival gashed him badly, stepping on his calf. the spiking seemed deliberate. robinson neither left the game, nor retaliated then. but a but years later when robinson was settled at second base, the man who spiked him came sliding in. robinson tagged him high and hard, removing a few of his teeth. [laughter] call that an emancipation problem la nation. --
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proclamation. [laughter] i've used up my time, i thank you for coming. thank you very much. [applause] >> you can watch these and other booktv programs in their entirety on our web site, 2013 marks booktv's 15th anniversary. it debuted on september 12, 1998. in april of 2007, surgeon atul gawande discussed the challenges that confront his profession. he explored the malpractice system, doctors' earnings, field surgery in iraq, doctors' participation in lethal injections and the influence of money on the medical system. this hourlong program is next on booktv. ms. . [applause] >> thank you all for coming, and
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thank you for including me in your day. and thank you, also, for c-span's interest in having be the part of everybody else's day as well. what i wanted to talk about is the reason i've written this new book, give you a little flavor of it with a couple readings, but also try to give you the arc of where some of my writing has come. partly this is a new book that is very much like "complications" in that it is another book of stories from medicine. but it is trying to do a different task. i wrote "complications" when i was a trainee in surgery. i'd never written anything before i came into surgery, but i began to puzzle over as a resident something that we all puzzle over in medicine which is why is medicine imperfectsome and -- imperfect? and then if medicine is imperfect and we are fallible, what does it mean to be competent at something like this? well, now that was five years
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ago, and aye come out -- i've come out the other end and a couple years ago joined the faculty as a surgeon. i'm a general surgeon. and the puzzle has shifted a little bit. i came out feeling reasonably competent, that is, i at least was comfortable that if i didn't know something, that maybe the rest of my colleagues didn't either, and i wasn't a complete moron. but the harder question became what is the difference between those who are merely competent at what they do in ped sin and -- medicine and those who are really great at what they do? because it is a where, of course, all of us want to try to aspire to be. and medicine is fascinating in the answers here partly because, of course, as all -- in terms of it as an important human activity, it's important because we have lives on the line. but there's another aspect in which it is fascinating, and
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that is that that failure is really easy in medicine. and if failure is really easy, then how do we actually become really good at what we do? well, in the stories along the way i found that the answer is not that the people at the top of the curve are smarter than everybody else. i didn't find that they were geniuses. i found, instead, something quite different. that the people who are really great at what they do in medicine have a capacity to recognize their fallibility, to see it in others and to see the fallibility of the systems around them that they have to work in. and then they have found ways to try to overcome that fallibility. they don't always overcome it, but they find ways to try to do just a little bit better. well, what we come to recognize
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as we watch medicine and are on the inside of it is something that we have a ard time acknowledging sometimes -- a hard time acknowledging sometimes which is that there is a real bell curve in medicine. there is a distance between the people who are at the bottom of the curve and those who are at the top, and it's a wide difference -- distance. is and also that we're not mostly all grouped around that very best outcome despite all of our training and all the years that we spend in schooling. instead, most of us are grouped right there in the middle, sort of mediocre middle x. there are a few, a handful that tend to be at the very top whether we're talking about institutions or we're talking about individuals. i'll give you a couple of examples. one example is one of the first operations that i learned to do. i wrote about it a little bit as i was learning to do it during
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"complications." and it's a repair of a hernia. it's a condition that all of you know, but for people who may not know, it is a problem where the abdominal wall becomes weak. it's almost like there's a tear in the it. i've described it as if you had a tear in a couch cushion, and the stuffing is coming out. and the classic repairs for this kind of thing is a, putting a patch on it or just sewing it together. and i described in "complications" visiting a place, a clinic this -- in canada and there are a few places like that around the country where they have less than a one in a thousand chance that after your operation you'll have a hernia come back. what is the national average, though, more success with hernia repair? the national average is that it's about 5% of patients who will have their hernia come back. and then if you look at the whole bell curve, you see that there are sures that have --
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surgeons that have a 10, 15 or 20% likelihood that a hernia will come back. there is a bell curve. another example is the wild west of medicine, in vitro fertilization. there are hundreds of invitro fertilization centers now across the country, and in in vitro fertilization, you'll see that the likelihood of success after a woman goes -- well, a couple go for to try to get pregnant, the likelihood of success with in veto fertilization resulting in a successful pregnancy is about 5% to 75% depending on what institution you go to. and the average is 45%. it's a bell curve. i could give you lots of examples like this across all different walks of medicine, and what you see is the same pattern, a wide difference between the top and the bottom
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and the shape of the curve where most of us are grouped in the middle. but the one that really fascinated me the most was cystic fibrosis. and that's because cystic fibrosis care works the way we want all of medicine to work. so, you know, for hernia repair, for example, the ones who are grouped toward the top seem to be the ones who have the most experience. but in cystic fibrosis care, this is a condition that children inherit. it's genetic, leads to the clogging up of the lungs, difficulty with digestion of foods, and it is a fatal condition. the average survival for a child born with cystic fibrosis is 33 years. cystic fibrosis patients work the way i said we kind of want all of medicine to work, and that's because we have concentrated the care in 117 centers across the country.
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these are all high-volume, high-experience centers. these are all centers that have a commitment to ultra-specialty care. not only that it be pediatric pull nonologists taking care of these kids, but pull nonologists with special expertise in ncf. they all participate in clinical trials, and they all use detailed guidelines, more detailed than we use in the rest of medicine. and so with all of that, you would think they all would get pretty similar results, but that is not what you find. instead, there is a bell curve. the average survival for cystic fibrosis in the country is 33 years, but at that center it's 47 years. so why is there a difference in performance? what could explain this? so i went to a hospital in the middle of the grouping to try to find out. and that was the university of cincinnati's program in their
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children's hospital there. and that turned out to be a place that was just below the halfway mark on the bell curve for care of children and their lung function with cf. and i went there nosing around kind of looking for problems, bad care, things not working right. and that's not what i found at all. this was a fantastic hospital. the university of cincinnati children's hospital is a hospital with a national reputation. it's the place where sabin discovered the oral polio vaccine, invented it, the vaccine that we now depend on for eradication of polio in the world. in cystic fibrosis, turns out some of our country's top experts are at the university of cincinnati. the author of the chapter on cf in "the bible of pediatrics" is
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the director of the program there. they wrote some of the guidelines that our country depends on for good care of the children. and yet there they were right in the middle. so i thought, well, okay, you have, you know, all the marquee stars, but what really happens underneath? when the patients actually arrive? and so i spent time in clinic there, and i saw conscientious, attentive care, as good care as i could hope for for my child. the doctors were, knew tear patients extremely -- their patients extremely well. the patients were devoted to them, and the care was as careful as you could hope for. and yet there they were in the middle. so then the puzzle is, well with, maybe they're doing something differently at the top. maybe they have a secret drug nobody else knows about. [laughter] and so i went to the center that
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happened to lie on the top of the curve, the university of minnesota program at minneapolis run by a guy named dr. warren warric. and he'd been there for more than 30 years running that program, and i found that they didn't have any secret drug. in fact, they were using the same treatments that were in use at cincinnati and everywhere else. they followed the same guidelines, and yet they had different results. well, maybe the kids there had a different gene, you know, a less damaging gene. there are various forms of the gene that causes cystic fibrosis, but it turned out that they didn't. the kids were as likely to have the worst mutation as elsewhere. the kids in minnesota, maybe they had a little bit more insurance or were from richer families. well, it does turn out that on the bell curve about a quarter of that variability has to do with social income and dem graphics and genetics. but only a quarter.
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75% of the variability wasn't accounted for. so i went around with the doctor at the clinic trying to see was there really anything different being done here? how was it that year after year they had stayed on top of the curve? and what i found was extraordinarily different care. and yet i couldn't quite just describe it. all i can do is show you a little bit about what it was like to be in clinic there. just in the case of one patient. so in the clinic one afternoon, i joined the doctor as he saw a 17-year-old high school senior named jenelle who had been diagnosed with cf at the age of 6 and had been under his care ever since. she had come for her routine three month checkup, she wore dyed black hair to her shoulder blades, black avril la screen eye liner, four earrings in each
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ear, two more in an eyebrow and a stud in her tongue. warric was 76 years old, tall, stooped and frumpy looking. with a well-worn tweed jacket, liver spots dotting his skin, wispy gray hair. by all appearances a doddering mid century academic. he stood in front of jenelle for a moment, hands on his hips looking her over, and then he said, so, jenelle, what have you been doing to make us the best cf program in the country? it's not easy, you know, she said. they bantered. she was doing fine. school was going well. warric pulled out her latest lung function measurements. there had been a slight dip. three months earlier jenelle had been at 109% of normal. she was actually doing better than the average child without cf. now, she was at around 90%.
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that was still pretty good, and i knew from looking through the files at cincinnati that some ups and downs in the numbers are to be expected. but this was not the way warric saw the results. he knitted his eyebrows. why did they go down, he asked. jenelle shrugged. any cough lately? no. colds? no. fevers? no. was she sure she'd been taking her treatments regularly? yes, of course. every day? yes. did she ever miss treatments? sure, everyone does once in a while. how often is once in a while? and then slowly warric got a different story out of her. in the past few months, it turned out, she'd barely been taking her treatments at all. he pressed on. why aren't you taking your treatments? he appeared neither surprised, nor angry. he seemed genuinely curious, as
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if he'd never run across this interesting situation before. [laughter] i don't know, she said. and he kept pushing. what keeps you from doing your treatments? i don't know. up here, and now he was pointing at his own head. what's going on? i -- don't -- know. [laughter] he paused for a moment, and then he turned to me, deciding to take a new tack, and he said the thing about patients with cf is that they're good scientists. they always experiment. we have to help them interpret what they experience as they experiment. so they stop doing treatments and what happens? they don't get sick. therefore, they conclude doctor warric is nuts. [laughter] but let's look at the numbers. he said all this to me, still
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ignoring jenelle. he went to a little blackboard he had on the wall. it appeared to be well used. a person's daily risk of getting a bad lung illness with cf is 0.5%. he wrote the number down. swre knell rolled her eyes. she began tapping her foot. the daily risk of getting a bad lung illness with cf plus treatment is 0.05%. and he wrote that number down. so when you experiment, you're looking at the difference between a 99.5% chance of staying well and a 99.95% chance of staying well. seems hardly any difference, right? on any given day, you have basically a 100% chance of being well. but, he paused now and took a step towards me, it's a big difference. he chalked out the calculations. sum it up over a year, and it is the difference between an 83% chance of making it through the
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year without getting sick and ending up in the hospital and only a 16% chance. and now he turned back to jenelle. how do you stay well all your life? how do you become a geriatric patient? her foot finally stopped tapping. i can't promise you anything, i can only tell you the odds. now, in this short speech i realized was the core of warric's world view. he believed that excellence came from seeing on a daily basis the difference between being 99.5% successful and being 99.95% successful. many things human beings do are like that. catching flyballs, manufacturing microchips, delivering overnight packages. medicine's only distinction is that lives are lost in those
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slim margins. and so he went to work on finding that margin for jenelle. he eventually figured out that she had a new boyfriend. she had a new job, too, and was working nights after school. the boyfriend had his own apartment, ask she was either there or -- and she was either there or at a friend's house most of the time, so she rarely made it home to take her treatments. new rules at school required her to go to the nurse for each dose of medicine during the day, so she skipped going. it's such a pain, she said. he learned there were some medicines she took and some she didn't, one was the only thing she felt actually made a difference. she took her vitamins too. why your vitamins? because they're cool. the rest she ignored. warric proposed a deal. jenelle would go home for a breathing treatment every day right after school and get her best friend to hold her to it. she'd also keep key medications in her bag or her pocket at
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school and take them on her own. the nurse won't let me, he said. don't tell her. [laughter] and thereby deftly turned taking care of herself into an act of rebellion. so far jenelle was okay with this. but there was one other thing, he said, she'd have to come to the hospital for a few days of therapy to recover the lost ground. she stared at him. today? yes, today. how about tomorrow? we failed, re knell. -- jenelle. it's important to acknowledge when we've failed, and with that she began to cry. what warren warric was doing was very different. and one of the things i tried to
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understand along the way in this book is what, what is different about what you see in moments like that? one of the attributes is diligence. it's attention to detail. it's in the way he saw the little barriers that were making his own treatments for her fail. and seeing how something as simple as slipping a few medicines into her pocket and having her take them in defiance of the school could actually succeed. and if you thought that was diligence, you should see what it was like when i traveled along with a world health organization doctor to southern india as he responded to an outbreak of polio there. there was just one case that appeared after they thought they had eradicated it, and he needed to make sure that 4.2 million people were vaccinated inside 48 hours in a 50,000-square-mile
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area. in a place where the infrastructure for health had broken down. and he did it. it required having plans and being able to recognize where the fatal flaws that could make the whole operation fail and then zero in on finding ways to address each of those details. you know, we often hear sometimes in the business world, other places you don't need to sweat the details. but in medicine we all know you have to sweat the details. so what does it mean to be really good at that? i began to see it in people like the doctor who i'd followed in that campaign in southern india. and he succeeded, by the way, in getting more than 90% of the children there vaccinated. anything below 90% in that vaccination would have been a
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failure, but he did it. a second thing that you see, i saw it with both of those cases -- polio, dr. warric -- was a kind of surveillance. remember one of the first questions he zeroed in on when he saw jenelle was what was her lung function. he had it charted out in the graphs. he follows it religiously for every child. it's a simple measurement of what a number is for how well or poorly their lungs are functioning. and he had picked something that he could track for long enough that he could ask, are we doing better this year than we did last year? and is this individual doing better or worse? the, there are other places where you see this. i've been fascinated by the fact that the military had for 50 years a roughly 25% chance that a soldier wounded in the
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battlefield would die of their battle wounds. and if this war -- in this war the military has succeeded if lowering the likelihood that a soldier injured in iraq or afghanistan will die from a battlefield wound to less than 10%. despite roadside bombs, sniper attacks, everything else. and part of the reason for their success, a huge part of the reason i end up showing, i think, is that they know how many are wounded, know how many lived or died and are transparent about it. you can know how someone had done who was wounded on the battlefield three or four days ago just by going to the department of defense web site where that information gets posted. we don't know whether how many surgery patients live or die in civilian hospitals and anything like that level of transparency, but it's allowed them to ask hard questions like where are our failures? they learned, for example, that
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soldiers were coming in with heart and lung and abdominal wounds that they shouldn't have had, because they should have had their kevlar. and they realized the soldiers weren't wearing their kevlar. they were coming in without their kevlar on. and so they held commanders responsible for making sure that their troops wore the kevlar. didn't matter if it was 110 degrees outside and they complained about the weight of these 18-pound vests that could protect their lungs and heart and abdominal organs. they noticed, for example, that the transport time from the battlefield to an operating table was too long for people to survive. and so they ended up doing something that is a, was a system that they'd had in place going back to world war ii but hadn't used very much which was sort of battlefield surgery tents. it meant that they had to
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actually far from increasing the amount of technology they had, they had to strip away technology. they had orthopedic surgeons having to operate on the battlefield with no x-ray equipment. they searched for fractures by feel. but it allowed them to save the soldiers and watch their numbers come down. as they tracked how well survival went. you can contrast that, by the way, with the picture of the military care after the soldiers returned and were saved, because we've all heard about the scandals at walter reed. watched there? what happened there? you saw failure six months, a year later in large part because they weren't asking the same questions. there wasn't the tracking to see one year later how many are doing well and how many are not doing well. and where are the flaws in the system. and so when the flaws were exposed, you saw the classic
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response. you saw defensiveness, anger, finger pointing. instead of what you see which is an openness about how they go about trying to save the soldiers on the battlefield. besides attention to detail and a way of counting, looking for what the results really are and trying to understand how it goes better and how it goes worse, they also had the capacity in minnesota if that cf program and in other places to do right despite the obstacles. that visit i described to you with jenelle was a 20 minute visit. they're under as much pressure as everybody else is from the insurance companies, pediatric insurance in particular compensates woefully. this is a center that has to struggle with remaining profitable in order the keep their doors open.
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and there's perversities in their ability to do what they need to do around that insane insurance system we have to work in. but hay did it. they did it. we live in an insurance system that rewards you for things that often don't have anything to do with doing better. i describe in a chapter in there what it was like to get paid for the first time as a doctor and to try to figure out how i make more, how i make less and how i make more had nothing to do with whether i took good care of patients. it had to do with whether i found ways to keep the uninsured from coming in to see me or even more, what kind of expert i was at fighting with insurers. well, success in this kind of work requires being able to do right in spite of obstacles or
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incentives to do wrong. or to at least ignore the best way to go. and i saw that in people like dr. warric. the other thing i saw in him, another attribute, was he had a kind of bedside ingenuity that really is part of the reason that i love medicine. he solves problems in all kinds of ways, small and large. and so you saw the ingenuity he had for figuring out how to get jenelle to take her medicines, he also has to cope with the reality that he's not the only doctor in his clinic taking care of these patients, and if he wanted everybody in his clinic to be doing as well, he somehow had to have them all on the same page. and so he does an unusual thing that we don't see very much in medicine, he sits all eight of the pediatricians down every week who care for cystic fibrosis patients and ask them what patients did they see that week and to tell exactly what
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they're doing for them. it's a, it's someone looking over your shoulder in a way that many of us actually would be uncomfortable with, but imagine as a patient that you've seen a doctor and then you would have all the benefit of the expertise of all the doctors in their d. as they -- this their department as they run through the cases for the week. most of them are routine cases, nothing terribly exciting going on, but then you come up against a patient like jenelle or an obscure case and you have the benefit of that wider wisdom. and he had the ingenuity to create that on his own and figure out this was a way that he could see those lung function measures that he cared so much about improve for all of his patients. he also could decide to take his skills in a whole other direction. he's not an engineer for oig like that -- or anything like that, but he noticed that when he started in practice the patients he took care of died on average before the age of 6.
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and he was part of a revolution in treatment in cystic fibrosis that has allowed them to live as long as they do today. and as he started to have teenagers, college students, he began to see problems that he hadn't seen before. the care for a cf patient requires that a parent beat on their back in 14 different places in order to help bring all of those she cessions that blew up their lungs -- glue up their lungs and get it all out. but what happens when they're teenagers? i mean, a teenager isn't interested in seeing their mother or father three times a day, let alone having them beat on their back. so he decided that something else had to be invented, and he came up with a vest, an enrace in bl vest that basically -- inflatable vest that basically beats on their back for them, for the parents, and allows that teenager, college student and now adults to live in the world and work and be independent in a way that they couldn't before. and lo and behold, he also found that the vests were often
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better, because they didn't get tired. [laughter] they didn't get annoyed with the teenager who didn't want to listen to them. so this kind of bedside ingenuity, i think, is the other important component of those who are really great at what they do. and i think there were, you know, having told that story, part of the reason why the book came about though was that i didn't understand there were deeper implications in the idea of understanding performance in medicine. but after starting to work on that cystic fibrosis question and chapter and essay, i had a conversation in an operating room that helped me realize that there was a whole other perspective on this. i was doing a pretty routine case. it was going very smoothly. i had the ipod on, and as i
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tended to, i started chatting in the case, and there was an anesthesiologist working across the drape. his name is mark simon, he's 29 years old, he was a second-year an thesology resident, and i started telling him about all these things i was finding out about in cystic fibrosis that was puzzling and interesting to me and how variable the care was despite how well trained and seemingly great the care system would be. and mark was visibly uncomfortable with the line of conversation, and i didn't really get it. until he fessed up that he has cystic fibrosis. i had no idea. he'd had, he'd been diagnosed since he was a child. he had done well through most of school. when he got to medical school, though, in his last year he ended up spending about a month in the hospital during the, his internship year he spent six
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weeks in the hospital with pulmonary exacerbations from cf. this was now his second year, and he'd already spent a month more in the hospital. and he'd become all too acutely aware that the average survival for a patient with cf is 33 years. so our conversation shifted. and we began to talk about a troubling thing but also a fascinating question which was what can we do to save his life? what was, what are, what is our best bet for helping mark live? if you ask most of us, we would say to fund research on discovery, but this is where we should put our money. we have to find a cure. and, in fact, that's where the cystic fibrosis foundation has put its effort and its resources over the years, it's where the
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nih has put it money, it's where the u.s. government as a whole has put its strategy. and in 1989 when the gene for cysticfy cystic fibrosis was discovered, it was thought that strategy was going to pay off in very short order. it would surely be only a few years away now that you found the gene to having a cure for the disease. but here we are, it's almost 20 years later, and a cure still has not been found. even if we did find one tomorrow, by the time it's tested, brought into market, how likely would it be to get to mark? well, the other thing we talked about then was is there a possibility of using the know how that already exists to help him live longer? and the answer is, yes. there's a bell curve. and there is know how already in the system for people to live 14 years longer than the average. so how do we make that knowledge
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more available? that is our key, and i think fundamental question. there are two froeser if -- philosophers i admire who wrote an essay in the 1970s on the nature of human fallibility. and what they pointed out was that there are two key sources of fallibility in anything we do as human beings, two ways in which we can go wrong. the first is ignorance; that is, we have a general lack of knowledge about how the world works in all of it particulars. and that's why we may fail. but the second one they called ineptitude, meaning that the knowledge is there, but an individual fails to amy it correctly. apply it correctly. well, our world if -- in medicine has become fascinating because both are now our struggle.
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for the longest time, ignorance was our biggest battle to overcome. we as recently as 50 or 60 years ago had very little we could do for the major problems that human beings faced that shortened their lives or left them his rabble. miserable. heart disease, stroke, cancer, infections. fast forward to where we are today though. 6600 drugs available to us. be hundreds of different ways in which we can make a right diagnosis. thousands of potential procedures, surgical and otherwise. be that we can do. and so now our struggle is not just discovery, but perhaps even more how to make that whole realm of know how available person by person across an entire country, across an entire world.
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and there's something of a science to it. there's a discipline to this. there is knowledge to be had about how you do that that we haven't taken seriously as an idea. or at least we're just beginning to. well, one of the things i think i've come to realize is that ideas about performance and being able to shape the direction we go matters to the point that we will -- we can save more lives in the next decade trying to change how we perform in medicine around the world than we will by doing all the research we want to do in stem cell therapy, than we will doing research on cancer vaccines, indeed, on everything else that we hear about in the news. part of the reason is when you think about a place like india where i traveled to and spent some time as a surgeon what they need more than anything is not
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just resources, but the know how to cope with the whole change in the demographics of the world. india's longevity has gone to 65 years, china is now 70. longevity in vietnam is 72. so their number one cause of death is cardiac disease nowadays. it's no longer diarrheal illness. cancer is in the top ten, trauma in the top fife. and on only $20 per person per year, they don't know how to make care available for this new, much wider range of problems that patients come with. well, beyond trying to think about it on a global scale, even at home here with as much advancement in care as we have, we all experience the frustration and daily ins and outs of trying to think about how we make care actually work, actually get that knowledge. and make it happen day by day, person by person. the bell curve is just one idea
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that i try to talk about in the course of the book, but i think it's a key one. and i want to finish with one further set of thoughts about that. once we acknowledge that there is a bell curve, that it matters and that it isn't going away, we're left with all sorts of questions. will being in the bottom half, for example, be used against doctors? will we be expected to tell our patients how we score? will patients leave us if we do? will those at the bottom be paid less than at the top? the answers to all these questions is likely, yes. recently, for example, there's been a rapid shift towards paying for quality. no one ever says docking for mediocrity, but it amounts to the same thing. across the country insurers like
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medicare, et that and the blue cross blue shield companies now hold back 10% or more of payment to physicians until specific quality goals are met. medicare has decided not to pay surgeons for intestinal transplant operations at all unless the doctors achieve a predefined success rate, and it may extend that practice to other procedures. not surprisingly, this makes doctors anxious. i once sat in on the presentation of the concept to an audience of doctors hearing about it for the very first time. by the end, some in the crowd were practically shouting with indignation, we're going to be paid according to our grades? who's doing the grading? for god's sake, how? we in medicine are not the only ones being graded nowadays. firefighters, ceos and salesmen are. even teachers are being graded and in some places paid accordingly. yet we all feel uneasy about being judged by such grades.
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they never seem to measure the right things, they don't take into account circumstances beyond our control, they're misused, they're unfair. still, the simple facts remain there is a bell curve in all human activities, and the differences you measure usually matter. i don't have to consider this for very long before i start thinking about where i would stand on the bell curve for the operations i do. in my area of surgery, i do a lot of surgery for endocrine tumors. i would hope that my statistics prove to be better than those of surgeons who only occasionally do this kind of surgery, but am i up in warwick-ian territory? do i have to answer this question? the hardest question for anyone who takes responsibility for what they do is what if i turn out to be average? if we took all the surgeons at my level of experience, compared
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our results and discovered that i am one of the worst, the answer would be easy. i'd turn in my scalpel. but what if i were a b-? working as i do in a city that's mobbed with surgeons, how could i justify putting patients under the knife? i could tell myself someone's got to be average. if the bell curve is a fact, then so is the reality that most doctors are going to be average. there's no shame in being one of them, right? except, of course, there is. what is troubling is not just being average, but settling for it. everyone knows that averageness is, for most of us, our fate. and in certain matters -- looks, money, tennis -- we would do well to accept this. but in your surgeon, your child's pediatrician, your police department, your local
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high school when the stakes are our lives and the lives of our children, we want no one to settle for average. thank you. [applause] >> we have a few moments for questions. that was spectacular, and i'm looking forward to reading the book and perhaps afraid to think where i fit on the bell curve. [laughter] any questions? just raise -- actually, there are microphones here on each end. if you don't mind coming forward. >> come to the microphone. >> so that you can be picked up for our c-span audience. >> while we're, while we're waiting, i have a question. so you, i think you're younger than i am --
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[laughter] i've been wondering for a long time without this grading system and as you observe our foibles, one of the concerns i have in medicine is insight, especially in surgery. so if no one gave us a grade, how do you think we would be doing for insight as to what we should be doing in the operating room and maybe in my case when i should quit doing it altogether in the operating room? >> it's a, it's a fascinating question because in the absence of any way that one can know how you're actually doing as a surgeon you only have your own impressions. you feel like a case went really well, you know the feeling of a case that didn't go really well. and, you know, in the course of a year i'll do about 350 or 400 operations, probably pretty
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typical for a lot of surgeons, and you don't have, you know, the average complication rate is around 3%. so that means that, you know, in a given year you'll have anywhere from 6 to 10 patients who will be harmed along the way. and you may not have a good feel for when that 10 becomes 12 and when 12 becomes. 14 and the 14 becomes 18. it can a creeping, sort of insidious process until someone brings it to your attention. and then it's, you know, all that defensiveness and everything else creeps in because you feel like it's your soul, you know, that's being evaluated here. it's who you are. one of the difficulties then we have is that, you know, i talk about virginia apgar in obstetrics who i regarded as something of a hero of mine. she's a woman who invented the apgar score for newborns. every parent knows about the apgar score because their child
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is graded on a score of 0-10 about how healthy they were when they were born. and if they are blue and limp and not doing well, they get a score of less than 5, and that's baby in trouble. and we all engage in a certain amount of wishful thinking. and she saw this happening. this was in the '50s where a child would not do well, and she was simply set aside to die as being stillborn. or they would engage in a certain degree of wishful thinking and think, oh, this baby's going to be fine and give it a pat on the butt and warm it up, and it's going to be okay. no. the number forced the obstetricians to look at the baby closely, to see that baby for doing how he or she really was and then act. if the score was less than 5, they need to be indue baited. put right in the incubator, you didn't fool around. and then the numbers being saved rose tremendously, and you saw inventions and ideas creeping in about how those scores could get better and better. and in a sense, we need an apgar
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score for everything we do in medicine. how do we know if a psychiatry patient who's being treated for depression is actually doing better and better or not? is there something else besides our own impressions? how do we know if as a surgeon i'm doing better or not doing better? and so in the absence of that, we have the situations that often occur. you have, you have physicians and surgeons, nurses, others who have real insight into themselves and recognize when it's time to stop. or time to take a break or a time to recognize you're burning out. but then there are the others who simply don't have that insight, and then we get trapped. we don't have good ways to take the car keys away from grandpa. >> hi, i'm -- [inaudible] children's hospital here, and i just wanted to make a comment and then ask a question. in newborn medicine, one of the things that's been very helpful
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has been the setup of registries, neonatal rebelling cities set up on 60,000 -- [inaudible] and took the next step of saying let's compare thein and the yang, the top and the bottom foremost, and we'll get them together and find out where gaps are. the interesting thing that it revealed is that although there are minimal visible differences, there are major -- in medical prescribing -- there are major differences in the systems within the way success is afforded or allowed or evolved. and, in fact, the evolution of, you know, an incorporation of new treatments and new practices and ongoing quality assurance that -- [inaudible] clearly was very successfully done in the high achieving and poorly done in the low achieving. and now have put all of our efforts into understanding in collaboration with management -- [inaudible] ourselves as physicians in a
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system of how -- [inaudible] where the responsibility comes, and we need to -- [inaudible] so i wondered if you could comment about our responsibility and our feelings about our performance, but how we take that more broadly into success within the system. >> it's, the description that you have of how in neonatology how the children do being monitored across the country has led to these fascinating findings as you've described, and we don't pay enough attention to it. when you think about the bell curve in neonatology, in cf and other places, there are things you can do to shape the curve. and at the bottom of the curve, what you often see is all of the problems of poor hospitals, all of the problems of a lack of insurance for some patients and all of the problems of some systems that are just dysfunctional, without good leadership and and other issues like that. and so when we think about how do you shape the bell curve, part of it is being able to do
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something about that bottom end like addressing the lack of insurance, addressing and trying to think hard about why there are such deep racial disparities in the country. and then you start to look at this other component which we've never, you know, really taken seriously in medicine. you will search long and hard for a good study showing that leadership saves lives. and yet we know the difference between having a hospital that's well run and one that's not and its capacity to save lives. about a few months ago in november the cystic fibrosis foundation did a really unusual thing, they put all of the results for the centers for cystic fibrosis on the web by name so that you could know what the shape of the curve is and which institution is where. and then they've been having meetings for a couple years now sharing information among centers about where each other stand and a process of becoming more open to the public. and you've seen a shift in the
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curve. the bottom has started to come up. they've recognized some of the resource and systemic problems. but you also saw a really curious thing. the university of minnesota was one of those places that came and other people tried to earn from them. everybody moved up, but university of minnesota pulled even farther ahead. what they had was the capacity to learn and to change and to incorporate as an institution in a way that some places just don't. let me go ahead with you. >> my name is -- [inaudible] i'm one of the med sal students here -- medical student thes here, so you spoke about possibly compensating physicians according to their grades, and one of the next steps is passing that cost down to patients or providers or insurance companies. and so what are your thoughts on the that? i mean, if you go the grocery store, you pay more for a better cut of meat, and so will people come to the doctor and pay more for a doctor with higher grades?
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>> yeah. i have a couple of thoughts about that. number one is, you know, there's a process like that already happening. i recently got in the mail from my insurer that i'm a class ii rather than a class i physician and that patients who come to me actually have to pay more for their co-pay. the grading happens to be done primarily on the basis of efficiency; that is, that -- i don't know whether i take too long with the patients or i order too many tests or things like that. and so there's a danger in this, if that who does the grading can determine what the incentives are and what really matters, and it can provide a kind of perversity. but with enough information people can choose where they go, and potentially you can see differences in how that payment works in fairer ways. what you find be, though, is, for example, in that cf example -- i know i keep coming
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back to that -- but the patients haven't fled. it's a massive experiment in what happens with transparency. they are not leaving their doctors, they are either oblivious to the fact that the information is there and they could use it, or with some of the cases of the patients they trust in their doctors to try to do better and learn from people at the top of the curve. and so what you see this lots of walks of medicine -- in lots of walks of medicine in the military, for example, for instance, they can't afford to have soldiers in one battlefield live longer than soldiers in another battlefield. and they insist on the sharing of information, being transparent all the way. and the result is that they have closed their bell curve and made their survival rates more equivalent. the people who use that information the best were the doctors and nurses and teams themselves. i would love to know who is the best team in the country doing the operations that i do.
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because i would go learn from them. and all i know right now is who has the best reputation. i've gone to watch them, and i've learned things from some of them. they really were good. but there were others where you really wondered why they had that reputation at all. let me make in the last question. >> my name's jim keating, i'm a pediatrician. if you hook at it from the point of view of the oplation, then the average -- population, then the average people are the reason that we get along. if the top people were asked to do all of the procedures, ten they wouldn't be the top people, or their performance would be not. so the top people owe a lot to the average folks. and the population in general owes a lot to the average people. so, you know, i think that focusing on the individual as you have is a good spur to all of us, i think. but if we're planning to have the kids better off, we have to
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accept the fact that the average folks are the people that are doing good, doing most of the good for the people. the top people only see a small number of folks. the middle people see a lot. so if we're looking for the greater good, we ought to go for strengthening the average. >> i think there's something that's deeply important about what you said, and i didn't get to talk about it very much. the, number one, we're in a country where 97% of the patients who come through a hospital do not have complications, do welcoming along. it's only 3%. but that bell curve within that 3 percent is wide enough that there are differences we care a lot about. ..


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