Atul Gawande: for the first time in human history, ineptitude is a bigger problem than ignorance

You can get a little dizzy just thinking about how much Atul Gawande gets done every year.

Gawande’s main job is as a cancer surgeon — he performs around 200 surgeries a year. He’s also executive director of a Harvard center dedicated to improving critical care, works with the World Health Organization on running his large-scale experiments, and is the chair of a separate nonprofit that works to reduce surgery deaths globally.

Oh, and on top of that? Gawande finds time to write truly gorgeous, award-winning feature stories for the New Yorker about his surgery and research.

Gawande recently appeared on an episode of Vox’s The Ezra Klein Show (you can listen to the full discussion by streaming it here or by subscribing to the podcast on iTunes). In the episode, Klein and Gawande discuss Gawande’s story about chemical castration for prisoners, his time working in Bill Clinton’s White House, and why Gawande thinks ineptitude has overtaken ignorance as medicine’s key problem.

This transcript has been edited for length and clarity. For the full conversation, subscribe to the podcast!

Why Gawande thinks ineptitude is now the major challenge to human health

Ezra Klein: There’s been this theme in a lot of your work which is that human beings often do very basic things more poorly than they realize they do.

And one thing I’ve taken from your writing is that so much writing about health care is about the margin — the brand new cancer therapy, the brand new medication. And you’ve been very focused on the improvements we can get not from tremendous innovations but to be able to apply what we already know more uniformly and rigorously.

Where did that outlook come from?

Atul Gawande: To me, failure has been the thing I’m most interested in over time. The intersection between failure and suffering. I remember reading an essay when I was doing philosophy on the nature of human fallibility by Samuel Gorovitz and Alasdair MacIntyre.

They point out that there are two key reasons people fail at whatever it is they set out to do. One reason is because of ignorance. We just don’t know all the laws that apply to the physical universe, and we don’t have a complete staid description of the universe that those laws apply to, and therefore we have research and discovery.

The second reason we fail is what they called ineptitude. Meaning, the knowledge exists but an individual or group of individuals fails to apply that knowledge correctly. What’s really interesting to me about living in our time and in our generation is that that is a remarkable change of living now: that ineptitude is as much or a bigger force in our lives than ignorance.

[For] most of human history, we were ignorant about the diseases that affected us — why do our bodies go wrong, and what can we do about it? What can we do about the world we live in and our environment? What can we do about many, many things?

We still have huge areas of ignorance — whether it’s Alzheimer’s disease or some cancers or fundamental aspects about how the economy behaves. But now we know a ton. In health care, we have enumerated the more than 60,000 ways our 13 organs can go wrong. And for those 60,000 diseases and conditions we have created more than 6,000 drugs and more than 4,000 medical and surgical procedures, and we have an uncounted number — easily in the thousands of ways — to prevent diseases or the occurrence of those disease. Our job is to deploy that capability town by town to every person alive.

Now, in your life, the reason we may have suffering is more likely to be because of ineptitude — our inability to deliver on existing knowledge — than it is because of ignorance. And that is incredibly interesting to me. I want to understand how we solve those problems, and I want to understand why we even have that feeling: We apply a word like ineptitude as if it’s a moral failure that things can go wrong. And it’s actually not that often about an individual’s malfeasance.

It’s about the ways we’re all set up for failure under the conditions of complexity. And delivering on that capability may be the most ambitious thing human beings have ever attempted. This is all about trying to deliver on that discovery and capability.

And we’re about to have a whole separate lump of incredible discovery — whether it’s cancer care or something from genomics. So I find it incredibly interesting, curious ... but also incredibly important. This is the challenge of our generation and the next couple of generations — how we have systems to realize the benefits of all this discovery we’ve had. We’re nowhere close to capturing it.

EK: I’m really interested in this idea that we look at someone who could have done something that could have been done but didn’t, and we look at them as failing.

We have this idea that competence is not making mistakes and getting everything right. As opposed to: Competence is knowing you will make mistakes and setting up a context that will help reduce the possibility of error but also help deal with the aftermath of error.

AG: I am drawn to these really mundane things like hand-washing. It’s 2 million people who pick up infections in hospitals and 900,000 people who die from those infections, and most of them would be prevented if they washed their hands correctly.

The fact that we can’t and haven’t figured out how to solve that ... seeing the ways hand-washing becomes incredibly onerous if you’re a nurse and have to manage eight patients and have to wash your hands every eight seconds and the bells are going off and they’re calling me from the other room.

But what if we add Purell? That cuts time, but then we have to make sure the dispenser is full. What if the dispenser is not full? And then you add those components along the way, and then to deliver on all this care for these places.

Competence requires us not only to be a little forgiving for how difficult it is to be competent but also to recognize that there’s no mistake too dumb for us to make. We make a lot of mistakes all the time. There’s enormous gains that come from just reducing some of these mistakes enough to knock it down 10 or 15 percent.

The third part of this is entering a culture that can be forgiving about mistakes. If we expect perfection from our politicians — if we expect them to take no chances, no risks, and make incredibly complex things happen in the world — we can always find where things go wrong. And the real measure is if things are getting better.

How Gawande came to combine surgery, public health, and politics

EK: One of the reasons I admire you is that you seem to have integrated a set of skills in your life in a way that I can’t think of anyone else having done.

You work as a surgeon, and you see things that are wrong or you learn things that are encouraging. Then you take the things that your work in clinical settings alerts you to, and you create beautiful essays and books and reports on them. And then you take the work you do in those essays books and reports, and you try to find an answer to the question that you asked by turning them into large-scale experiments that actually change the way people practice medicine.

When did you begin to see these things as not separate, but as actually all one pursuit? Or do you not see them that way?

AG: I do see them as part of one thing, but it took a long time for me to figure out how it all fit together.

I came out of college — I’m the son of two Indian doctors — so what are you supposed to become? Another Indian doctor. And I was very resistant to that.

That’s not who I wanted to be. I worked in politics for a while — way back in college, I worked for the Gary Hart campaign until it ended. ... In ’92, I worked for [Bill] Clinton and ended up being his health care and social policy adviser. I’d tried rock music, that didn’t work very well. I tried being a philosopher; I got a master’s in politics and philosophy and found out that I had a hard time understanding the questions, let alone offering original answers...

I learned that I didn’t love having my future controlled by the fates of politicians. So I decided to go back and do what my parents always knew I would do — go to medical school. Along the way, I was trying to figure out how I could feed the part of me that cared about policy and cared about how we make a difference in people’s lives on a large scale, while I was working on improving people’s lives on a very small scale.

EK: So you decide that politics isn’t for you. Then what?

AG: Well, yes, working for politicians wasn’t for me. I still loved policy, and I still love how we move ideas.

I went back to medical school because I felt like I needed to have my own experience in the world and have my own kind of relevance and skill set that you couldn’t take away. Medicine turned out to be fantastic. Having grown up with parents who were two doctors in a small town, there was just a familiarity to it.

But the second part was you’re deeply inside people’s lives. And you feel the complexity of how all these forces in the world — from economics to social forces in people’s lives to science and technology — all come together.

And then I ended up in an operating room and finding that I had to try and do it. It seemed insane.

You were opening people up; you were going to make them better, and things are complicated and wrong and you had imperfect information. And you had to come out the other end.

And 97 percent-plus of these folks we were making better. So it introduced an entirely different level of complexity and understanding that I couldn’t pull it all together.

Does Oregon suggest we get way less from health care than we thought?

EK: There’s been research about Medicaid, suggesting that health insurance may do a lot less to actually improve people’s health outcomes than we thought.

But it isn’t clear that the care we’re getting is doing all that much. So you talked about these particular operations where you’re making 97 percent of people better, but has this strain of research led you to update or change your views on the worth of the medical care that we get in aggregate?

AG: Katherine Baicker is the economist who did a ton of this work out of Oregon, and Oregon was this amazing natural randomized experiment because they ran out of money and gave Medicaid coverage away in a lottery.

And for two years, the lottery winners were the only ones to have that coverage, and so we could compare the two who got coverage and who didn’t. And you’re exactly right: [The ones with coverage] got more doctors visits.

Kate took it even deeper than that — not just more doctor’s visits; you had more operations, more emergency room visits, more hospital stays. You could begin to see what they got more of — they got more mental health care, more diabetes checks, more medication for blood pressure, more medication for their diabetes. But only certain things got better. Their diabetes didn’t get better; their high blood pressure didn’t get better; their mental health did get better.

Over the course of two years, there are modest to little effects of getting access to more care in terms of survival or in terms of the control of specific chronic illnesses like diabetes and high blood pressure. What that said to me is that it reinforced what I feel like I was recognizing: The health care system massively underperforms.

We already knew by that point that for people with high blood pressure, 60 percent do not have their blood pressure under control, even when they’ve been seeing people in the medical system. We know that 40 percent of people with coronary artery disease are receiving incomplete and inappropriate care. We know that for mental health conditions it can be upward of 80 percent receiving incomplete and inappropriate care.

[As detailed in Gawande’s book The Checklist Manifesto]: In surgery, more than half of the deaths and major complications that occurred were from failure to deliver on existing knowledge on how to do better.

We designed a checklist approach — basically, it’s like a preflight checklist: Did you have all the equipment you need? Have you taken into consideration the medical issues of the patient? Is there anything that needs to be adjusted before you start in? Did you have the blood in the room? Does everyone in the room know each other by name? Have the antibiotics been given? And doing that, we lowered the death rate 47 percent in each city.

You have this partisan debate over this research. The Republicans, or at least some Republicans, would attack it and say, “Coverage for health insurance? You don’t even need it. It doesn’t do any good.”

And you have some Democrats saying, “No, no, no, the research is wrong.” When the truth is you do need the coverage and the system is incredibly wasteful and disorganized. We’re entering that space where you have to solve those problems of ineptitude, and we’re starting to offer some solutions.

EK: What is something you believe is true that most people believe is false?

AG: I think the thing I believe that others don’t necessarily is that we fail all the time. That the reasons we’re successful are because we set up systems that allow us to fail, get up, and move on — and that we’re insufficiently forgiving of those kinds of failures.

When you state it that way, people say, “Yeah, I believe it.” But you look at their actions, you look at the way we have the expectation of perfection. You know, I certainly see it every day as a doctor — the urge to say, I’m perfect. That nothing will go wrong. That we completely know what we’re doing and everything will go smoothly.

It’s just not true. And yet you’re better off going with me, our team, and doing what needs to be done. And people want to believe there is that perfection, there is that infallibility, and that’s a blinder. It’s a problem.

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