Atul  Gawande:  Cowbows  vs.  Pit  crews    

0.          Pre-­‐listening  reading  material:  read  this  information  about  the  speaker.  A  general  and  endocrine  surgeon  at  Brigham  and  Women’s  Hospital  in  Boston,  Atul  Gawande  is  also  a  staff  writer  at  The  New  Yorker  who's  changing  the  way  we  think  about  best  practices   in  

medicine   (and,   necessarily,   about   the   state   of   the   US  healthcare   system).   In   1996   Gawande   wrote   his   first  piece   for   Slate,   an   analysis   of   the   then-­‐controversial  illness  known  as  Gulf  War  Syndrome.  At  The  New  Yorker,  he   turned   in   a   shocking   June   2009   piece,   “The   Cost  Conundrum,”   about   McAllen,   Texas,   the   town   with   the  second   most   expensive   health-­‐care   market   in   the   U.S.,  taking   on   America’s   high-­‐cost   low-­‐quality   healthcare  system.  (The  piece  was  cited  by  President  Obama  during  his  campaign  for  healthcare  reform.)  Gawande   approaches  medicine  with   a   personal   outlook,  

emphasizing  the   importance  of  a  doctor’s   intention  and  reliability,  and  urging  doctors  to  make  small   changes   to   improve   performance.   In   his   most   recent   book,  The   Checklist   Manifesto,  Gawande   shows   how   even   a   simple   five-­‐point   checklist   can   decrease   up   to   two-­‐thirds   of   ICU  infections.  He   suggests   that   as  modern  medicine   -­‐-­‐   and   indeed,   the  modern  world   -­‐-­‐   becomes  increasingly  complex,  we  should  respond  with  ever-­‐simpler  measures.    1.  Listening  for  detail:  fill  in  the  missing  words  as  you  listen.  It's   hard   enough   to   learn   to   get   the   ______________,  try   to   learn   all   the   material   you   have   to  _____________  at  any  task  you're  taking  on.  And  then  in  the  ____________  of  all  this  came  this  new  context  for  thinking  about  what  it  meant  to  be  good.  If  you  were  in  a  hospital,  he  said,  it  was  going  to  do  you  good  only  because  it  offered  you  some  _______________,  some  food,  ____________,  and  maybe  the  _______________  attention  of  a  nurse.  If  you  had  early  signs  of  _______________  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  _____________  and  _____________  -­‐  as  long  as  you  didn't  overdose  them  and  kill  them.  As  a  result,  we  built  it  around  a  culture  and  set  of  __________  that  said  what  you  were  good  at  was  being  daring,  at  being  _________________,  at  being  __________________  and  self-­‐sufficient.  But  when  we  look  at  the  _________________  deviants  -­‐-­‐  the  ones  who  are  getting  the  best  results  at  the  _________    costs  -­‐-­‐  we  find  the  ones  that  look  the  most  like  systems  are  the  most  successful.  And   yet   we   see   unconscionable   levels  of   death,   ___________   that   could   be   avoided.  And   so   we  looked  at  what  other  _____________  industries  do.  And   he   said,   "We   have   the   cowboys   stationed   at   _____________   places   all   around."  They  communicate  electronically  _________________,  and  they  have  _________________  and  checklists…    2.  Comprehension  questions:  answer  the  multiple-­‐choice  questions.  1.  According  to  Atul  Gawande,  what  brought  on  the  main  realisation  of  the  global  medical  crisis  in  the  last  few  years?  a.  too  many  people  died  from  diseases  that  still  have  no  cure  b.  the  government  has  been  spending  too  much  money  on  medical  research  c.  hospitals  need  to  much  money  to  function  and  help  people  

2.  What  does  the  speaker  say  about  being  a  doctor  in  1920s?  a.  doctors  couldn’t  help  anybody  then,  only  nurses  did  something  useful.  b.  it  was  about  being  a  skilled  manual  worker  like  a  wood  carver  or  an  artist  c.  it  was  very  difficult,  because  with  little  technology  it  was  hard  to  remember  all  the  information  3.  What  was  the  highest  value  of  a  medical  professional  in  the  beginning  of  the  century?  a.  independence  b.  reliability  c.  intelligence  4.  The  “perfect  car"  thought  experiment  is  used  to  illustrate  what  point  about  medicine?  a.  to  improve  medicine  we  need  better  ambulances  b.    different  specialists  are  not  efficient  if  they  don’t  work  as  a  team  c.  medical   professionals   should   try   to  make   their   knowledge  more   systematic   to  becom  better  specialists    3.  Summarizing:  Answer  the  questions  with  your  own  words,  BUT  rephrase  ideas  from  the  talk  you  hear,  don’t  use  your  own  ideas  (you’ll  have  a  chance  to  do  that  in  Discussion).  1.    How   has   medicine   changed   over   the   last   60-­‐80   years?   How   is   being   a   doctor   nowadays  different  from  what  it  was  two  generations  ago?  ______________________________________________________________________________________________________________  ______________________________________________________________________________________________________________  ______________________________________________________________________________________________________________  2.  What  is  the  common  opinion  doctors  have  about  the  question  of  cost  in  medicine?  ______________________________________________________________________________________________________________  ______________________________________________________________________________________________________________  3.  Which  considerations  went  into  creating  the  checklist  for  surgery?  ______________________________________________________________________________________________________________  ______________________________________________________________________________________________________________  ______________________________________________________________________________________________________________  4.  What  was  the  result  of  implementing  the  checklist?  ______________________________________________________________________________________________________________  ______________________________________________________________________________________________________________  5.  How  would  you  describe  the  main  idea  of  the  presentation  given  by  Atul  Gawande?  ______________________________________________________________________________________________________________  ______________________________________________________________________________________________________________    4.  Discussion:  prepare   for   the  discussion  of   the   following  questions   in   class.   Please   feel  free  to  use  the  empty  space  below  for  your  notes.    Atul  Gawande  describes  doctors  of  the  pre-­‐penecillin  times  in  the  following  paragraph:  

What   they   were   trying   to   do  was   figure   out   whether   you   might   have   one   of   the  diagnoses  for  which  they  could  do  something.  And  there  were  a   few.  You  might  have  a  lobar   pneumonia,   for   example,  and   they   could   give   you   an   antiserum,  an   injection   of  rabid   antibodies  to   the   bacterium   streptococcus,  if   the   intern   sub-­‐typed   it   correctly.  If  you  had  an  acute  congestive  heart  failure,  they  could  bleed  a  pint  of  blood  from  you  by  opening  up  an  arm  vein,  giving  you  a  crude  leaf  preparation  of  digitalis  and  then  giving  you   oxygen   by   tent.  If   you   had   early   signs   of   paralysis  and   you   were   really   good   at  asking  personal  questions,  you  might  figure  out  that  this  paralysis  someone  has  is  from  syphilis,  in  which  case  you  could  give   this  nice  concoction  of  mercury  and  arsenic   -­‐-­‐  as  long  as  you  didn't  overdose  them  and  kill  them.Beyond  these  sorts  of  things,  a  medical  doctor  didn't  have  a  lot  that  they  could  do.  

   

o How  are   the  mentioned   conditions   treated   today?   In  what  ways   has  medicine   changed  over   the   last   two   generations?   Do   you   agree   with   the   speaker   that   it   is   almost   like   a  different  world?  

o Does   medicine   feel   like   many   parts   not   working   together,   specialists   that   do   not  communicate  well  in  your  experience?  How  do  you  think  it  can  be  fixed?  

o Read  the  checklist  devised  by  Atul  Gawande  and  his  team  (given  as  a  separate  pdf).  Are  the   items   included   really   the   things   that   get  missed   in   your   experience?  Would   you  be  willing   to   try   and   work   with   the   system   of   checklists?   Was   the   result   of   using   this  innovation  surprising  to  you?  Why  is  this  system  slow  to  spread?  

o Do  you  agree  with  the  main  values  of    being  a  good  doctor  the  speaker  mentions?  Do  you  agree  that  the  ability  to  work  in  a  team  is  more  important  than  being  independent?  

o What  does  it  take  to  become  better  at  what  you  do?  Atul  Gawande  says:  "Better   is  possible.   It  does  not   take  genius.   It   takes  diligence.   It   takes  moral   clarity.   It  takes  ingenuity.  And  above  all,  it  takes  a  willingness  to  try."  

Do  you  agree?  What  is  more  important  for  success  –  hard  work  or  talent?