Articles, Blog

How do we heal medicine? | Atul Gawande

December 22, 2019

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? 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. 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. 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. 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. 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. 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. 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. 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. 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, self-sufficiency 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. (Applause) 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. 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. 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. Thank you. (Applause)


  • Reply johndoe77774444 April 18, 2012 at 6:04 am

    I am a healthcare professional and I wish there were more TED talks on health rather than medical services. If we eat better we won't need all this expensive care. Also we can prevent infection by having all public bathrooms being "zero touch" and promoting a culture of hand sanitization by doing things like placing hand sanitizer throughout schools and having all the kids sanitize before doing anything in a large group like going to auditorium, entering the cafeteria, or returning from recess

  • Reply PlasteredDragon April 18, 2012 at 3:09 pm

    47% drop in surgical death rate, 36% drop in complications — LISTEN TO THE MAN.

  • Reply Fulton Family Reviews April 18, 2012 at 4:01 pm

    In China, you do pay for medical care, with your forced labor. It's not like they have a free society over there, and I'm willing to bet you that if you looked close at it there'd be a lot of horror stories, just like there are in Britain (which is now becoming more capitalistic.)

    And part of the reason natural supplements are not as popular, at least dollar-wise as pharmaceutical drugs, is #1 pharma drugs can do amazing things. This is not to denigrate natural supplements; I'm a huge fan.

  • Reply Fulton Family Reviews April 18, 2012 at 4:03 pm

    (Cont.) However, the government, FDA, will not allow natural supplements to advertise their health benefits. The Pearson case successfully challenged the FDA's policy; however, they still harass natural supplement makers (my point being, this is over-reaching gov't.) Moreover, the FDA has no legal authority for forcing people to obtain prescriptions for meds. This is simply a power they assumed against the wishes of Congress in the 40's. AMA holds copyrights over med codes, allowing them…

  • Reply Fulton Family Reviews April 18, 2012 at 4:05 pm

    To prevent competition. And proper information doesn't get out because the FCC limits who can be on the airwaves.

    My point? This all comes down to big government. If the market isn't acting properly, that's because the government has messed it up somehow by either choosing winners or losers or erecting some other barriers to entry.

  • Reply Liz Torres April 18, 2012 at 9:24 pm

    wow great talk

  • Reply reafdaw01 April 18, 2012 at 10:41 pm

    You know it's ted when you're clapping at home.

  • Reply reafdaw01 April 18, 2012 at 10:54 pm

    Why shouldn't herbal medecines (that's what they are not food as supplements might suggest) be regulated like all other drugs that contain pharmacologically active substances? Without goverment regualtion you could never be sure if you're not buying something poisonous. There have been several documented cases of death and serious harm to people because of natural supplements. i.e. pubmed/12495362 .
    Supplements can have positive effects but if their not tested and regualted it can be bad aswell.

  • Reply ostkartong April 19, 2012 at 12:36 pm

    In fact, I think his check list idea might even reduce costs due to lower frequency of infections, relapse, complications etc.

  • Reply KeebRocks April 19, 2012 at 7:42 pm

    "Just using a checklist requires you to embrace different values from ones we've had, like humility…"

    As a final year medical student I couldn't agree more with this. It pains me to say it, but doctors are too arrogant and surgeons tend to be even more so. In fact being a bit arrogant is seen as a positive trait by many in surgery.

  • Reply Shpaz N April 20, 2012 at 8:30 am

    great great video

  • Reply Chris Capel April 20, 2012 at 10:31 pm

    Do I really have to put the word "some" in my comment so that people won't flip out like you just did. *facepalm*

  • Reply Leonidas GGG April 20, 2012 at 11:49 pm

    Egos are the bigest problem in medical society nowadays.

  • Reply Tassilo von Gleichen April 21, 2012 at 12:16 pm


  • Reply bilaba70 April 23, 2012 at 12:46 am


  • Reply Thatcrazydoc April 23, 2012 at 3:22 am

    This is a nice lecture, but it's too simple. Short term the extra medical professionals that will be needed simply don't exist. The biggest problem in medicine isn't how physicians order tests or spend money. It's how patients, lawyers, and the gov force us to order every test due to society's sense of entitlement and self-preservation. Fix that problem to fix the "system" that already exists. We simply have to learn when enough is truly enough. We have to learn to let people go.

  • Reply Thatcrazydoc April 23, 2012 at 3:25 am

    Also, the sad part about this lecture is that people listening to it believe that we don't already have checklists and protocol. Every hospital in the U.S. already utilizes templates, checklists, and protocol to avoid infection and complications while encouraging an environment of patient safety. They already exist within a system.

  • Reply Thatcrazydoc April 23, 2012 at 3:28 am

    Well, considering that the majority of physicians that I've encountered from other countries that come over here have never worked our hours at such a high level or been a part of the sheer complexity of a medical system such as ours (technology, medication variety, journey towards patient satisfaction), it would prove fatal to both patient's and our healthcare system alike.

  • Reply Thatcrazydoc April 23, 2012 at 3:30 am

    Totally agree. Personally, I believe that the fault is with the individuals within society and not the physicians. If you're coming back for your second CABG redo or your 14th admission to a hospital for the year because you love cocaine and you're not taking your diabetic meds or showing up for dialysis, then maybe the fault is yours and yours alone. The truth is that it happens everyday at every hospital in this country. That is what is driving up prices.

  • Reply Igor Krupitsky April 23, 2012 at 3:43 am

    You must be the doctor I was talking about. 🙂 I don’t blame you. I would probably hold the same position if I were you. Upton Sinclair once said: “It is difficult to get a man to understand something, when his salary depends upon his not understanding it!"

    So basically you are implying that there is no country that has same or better standards than in US. Correct?

    As far as working hours at a high level, that is on of the problems my proposed solution is trying to address.

  • Reply Thatcrazydoc April 23, 2012 at 4:12 am

    To be honest, the problem in the U.S. is not our standards. It's the fact that we cave in to the ridiculous demands of patients. I've seen it countless times where an Oncologist was going to give chemotherapy to a patient the same day they ended up dying, because the patient refused to acknowledge their illness.

  • Reply Thatcrazydoc April 23, 2012 at 4:13 am

    Personally, I already work in a hospital system filled with templates and checklists. In fact, the hospital that I work at has been visited by multiple members within congress due to our palliative and affordable care efforts to serve as a prototype for American healthcare.

  • Reply funsukwangdoo April 23, 2012 at 7:18 pm

    you know it's ted when you get goosebumps…

  • Reply andrewtenorio April 26, 2012 at 3:11 am

    wait.. so why wouldn't the best car parts car go anywhere ?

  • Reply Matthew Jay April 26, 2012 at 6:29 pm

    To igorkrupitsky: You propose outsourcing foreign M.D.'s to come here to the U.S.A. and replace our own American M.D.'s. Really?
    Also, your same proposal "brain-drains" medical talent from other countries. Those other countries NEED their own native M.D.'s to stay in their own countries. When native M.D.'s remain in their home countries, this then improves the Human Condition globally.

  • Reply Igor Krupitsky April 26, 2012 at 7:00 pm

    Dear Matthew,

    Following your logic we should also force doctors to stay in the states where born or received their education. It would be really evil to “outsource” a doctor from another state. We also want not want to “brain-drain” some states that have too many doctors.

  • Reply Matthew Jay April 26, 2012 at 8:51 pm

    Dear igorkrupitsky,
    I do not see you following my logic. I do see, however, that you have thrown in red herrings of your own devices. When following my logic nobody should be "forced", (your word, not mine), to stay or not stay anywhere. I offered my opinion, not a dictate. Also, I used the word "countries", not "states". Hawaii to Maine and Alaska to Florida are all part of the same country, the United States of America.

  • Reply Igor Krupitsky April 26, 2012 at 11:02 pm

    Dear Matthew,

    To be kept out of a country is the same as being forced not to enter a country. Without force people would enter and leave any country at will.

    States are similar to countries. You think it is ok to move and work between states because you were born in a country that allows it. It would be Red herrings if I offered something unrelated.

  • Reply Matthew Jay April 27, 2012 at 12:47 am

    Dear igorkrupitsky, Thank-you for your courteous responses. I stated that the foreign M.D.'s need to stay in their own countries. I never stated that they must be "kept out". I embrace freedom, & if these foreign doctors want to leave their native countries, then that is their right. However, I repeat that it is my opinion that these M.D.'s should stay in their own countries so that they may heal the sick & injured of their own countries. I've never advocated using "force" in any of my comments.

  • Reply RK85 April 28, 2012 at 8:05 pm

    what u was talk about is protocol by WHO & we do it in our hospital
    the problem is protocol has been st for a long time & not all hospitals around the world
    applying this !!

  • Reply littlemas2 May 1, 2012 at 3:23 pm

    Having a son with kidney failure, I will say that I have experienced both kinds of care. In one hospital people obviously did not talk to one another. At Mayo Clinic in Rochester, MN the care has been fantastic, and it is obvious that they work as a great team.

  • Reply wubbalubbadubdub May 6, 2012 at 10:28 pm

    the checklist manifesto is surprisingly empowering

  • Reply KnurdShogun May 8, 2012 at 8:25 pm

    i think it's crazy and upsetting that something so obvious as a checklist has not already been in application. wow.

  • Reply Graceful Tenacity May 14, 2012 at 5:58 am

    i'm also among the many who've had close harm & healing encounters of the iatrogenic kind. i all-ways consider it a blessing when expanded thinking, dialogue and actions like this afford the people some helpful insight. See more, related at tinyurldotcom/psalmbody36

  • Reply varuviv May 14, 2012 at 11:07 pm

    Huge fan of Dr. Gawande. Simply brilliant!

  • Reply Ross Kyle Gordon June 21, 2012 at 11:43 pm

    Somebody's read freakonomics hehe

  • Reply Amardeep Karodkar June 28, 2012 at 10:58 pm

    One of the best Ted talk I have ever watched. Dr. Gawande is the master in medicine. He is trying to change the entire world of healthcare by doing genuine work. I am humble to you Mr. Atul Gawande. you are genius. Thank for making health care more efficient. I wish you all the best for your future work.

  • Reply Marshal Peris September 5, 2012 at 2:11 am

    I am a spine surgeon and love the "Lifewings" program we have instituted at our hospital. All the surgeons and staff are on board and believe in it.

  • Reply Ryan Rybarczyk September 17, 2012 at 5:50 pm

    All major chronic diseases are the result of poor nutrition. Modern medicine almost completely disregards the role that nutrition plays in health and healing. There isn't nearly as much money to be made in prescribing nutrients. Most pharmaceutical drugs are toxic and have numerous adverse side effects. If doctors were really concerned with their patients health and not their pocket books then they would abandon the insanity of trying to heal with a pill.

  • Reply Hana Ascar October 7, 2012 at 6:04 pm

    Healing plants, visit: m

  • Reply bcornels October 9, 2012 at 10:05 pm

    I have been in a nurse in surgery for three years and boy is this spot-on.

  • Reply ThirdDeadPresident October 22, 2012 at 7:03 pm

    Well, except for most forms of cancer. And most forms of respiratory illness. And many forms of cardiac disease.

    And any competent doctor will discuss the importance of proper nutrition with their patients.

    Honestly, virtually everything you've said is an unfounded and widely generalized accusation.

  • Reply DAZ December 7, 2012 at 4:42 pm

    wow, you really haven't a clue what you are talking about. oh well, facts don't matter, maybe you will indoctrinate a few more into your cult. happy preaching.

  • Reply DAZ December 7, 2012 at 4:44 pm

    you should watch the one by Abraham Verghese if you haven't already – very moving perspective on medicine, and the relationship of physician and patient.

  • Reply Sinwan Basharat December 8, 2012 at 6:59 am

    It's sad actually, because some alternative therapies may heal certain diseases, however. You have some extreme pseudo-scientists claiming nutrition is the ONLY way. Reminds me of something else I've heard,"…is the the only way, the only light".

    Greater research needs to be done in things like Homeopathy, this 'preaching' is not helping the cause. (btw, I guess mutations are also cause by 'bad nutrition', tell that to a patient with CF)

  • Reply veganath March 23, 2013 at 5:14 am

    In spite of the trillions of dollars thrown at medicine in the USA the state of health of the populace is the worst it has ever been! Medicine is an unmitigated failure in terms for healing but hey it's great for business

    Pharmaceutical companies understand that a patient cured is a customer lost… they have no monetary incentive to cure anyone.

  • Reply veganath March 23, 2013 at 5:20 am

    Couldn't have said it better myself, fortunately there is a growing number of people like us who get it… Thumbs up from me

    When pharmaceutical companies understand that a patient cured is customer lost, the medical system is inherently disingenuous.

  • Reply veganath March 23, 2013 at 5:29 am

    The largest study ever conducted into the links between disease & nutrition, "The China Study" has concluded that most chronic diseases e.g. cancers, coronary heart disease, diabetes, osteoporosis.. etc are attributable to lifestyle choices of foods consumed. Thumbs down from me!

  • Reply veganath April 1, 2013 at 2:54 am

    PROBLEM: A PATIENT CURED IS A CUSTOMER LOST!! Modern pharmaceutical companies know this, it isn't in their economic interest to cure you!
    SOLUTION: A health care system in which Doctors are paid only when you are healthy!! Additional, the last thing a convalescing patient needs when faced with a debilitating disease is the financial burden of the health care costs!!

  • Reply veganath April 1, 2013 at 3:37 am

    What is it about my comment ur responding too that refers to veganism?

    I can agree with u that advocating a non-violent society in which we don't cause unnecessary suffering to any living creature is desirable.

  • Reply Gregg Trueman April 7, 2013 at 3:27 pm

    Not sure what veganism has to do with Dr Gawande's talk …?

    If interested in the surgical checklist, google WHO Surgical Safety Checklist

  • Reply Quoc-Dien Trinh April 7, 2013 at 7:49 pm

    america has relatively lax rules for allowing foreign doctors to work. this is coming from a canadian doctor.

  • Reply tanio12 May 25, 2013 at 10:40 pm

    hello booyah there is the answer. my relative had to drop 200 something dollars on lantus, think the price will go down I doubt it. Anytime you visit the pharmacy look at all of the medication, a walking drug house . .. the real drug house.

  • Reply veganath May 28, 2013 at 3:09 am

    I know what you mean, I'm fortunate enough to never have needed any doctor or pharmaceutical drug during the last 3 decades, health is soooo simple, eat your food as ALL other species of animals do "RAW" if it comes in a box it ain't food, if we can't eat our food RAW we probably have no business eating it

  • Reply Blake McKnight June 13, 2013 at 12:23 pm

    Veganism can be for any number of reasons — animal rights, health, environmentalist, efficiency, reduction of antibiotic resistance, or just plain preference — and they are all valid. I have been vegan since 2003 and vegetarian since 2000 for all these reasons, and you are not "more" vegan than I am. Comments like yours probably prevent more people from becoming vegan than they encourage. YOU make vegans look bad.

  • Reply jns124able July 16, 2013 at 3:44 am

    Im happy to say…the focus in family medicine in Canada in on the patient, the patients fears, expectations, goals, function of living and preferences. How many doctors continue this I dont know, but it is in the curriculum.

  • Reply Lesly O August 16, 2013 at 4:49 am

    I'm currently reading Complications: a surgeons notes on an imperfect science and its really good 🙂

  • Reply neo khan September 17, 2013 at 2:55 pm

    God. I have just become hugely envious of my nephew. He has been unattached permanently. Having said that he managed to get a swimwear model to inform him she is head over heels in love with him in less than a month. Just how can that be thinkable? He explained to me he tried the Cupid Love System (Google it!) I wish someone stunning told me that… I've never witnessed him so fulfilled. Kinda makes me feel bad.

  • Reply B. Maurene White October 26, 2013 at 7:25 pm

    Hospitals I have worked in in Canada have used checklists in some areas, like the OR and OBS case room for many years. Perhaps the first task of each and every area of a hospital, clinic, doctor's office etc. should be development of a checklist with the specific needs of that service.

  • Reply khanday rayees November 6, 2013 at 2:23 pm

    live southafrica vs Pakistan match

  • Reply supmanhowsitsgoing July 26, 2014 at 4:11 am

    This guy is taking out my thyroid in a couple months. This video and his Wikipedia page have only served to assure me that he is not just some doctor, he is THE doctor, which will hopefully make it a far less terrifying experience.

  • Reply salimm October 15, 2014 at 8:01 am

    This bozo has said nothing that anyone with common sense an d a rudimentary knowledge of the medical industry ALREADY didn't know – he just relays a feel-good message with a folksy, warm manner which resonates well with stupid people with high living standards (you know, white Americans) – just basically blah, blah and more blah to sell his books WITHOUT any real, practical application of any solid solution whatsoever. I also find it funny that an Indian-origin person is lecturing others on how to be more ethical and less corrupt; as anyone who has spent time in India will know that Indians (and Indian doctors) are some of the most greedy, corrupt and least ethical people on earth!

  • Reply Lucky P October 20, 2014 at 6:13 pm

    Algorithms and checklists are his approach to making less errors and systematizing medicine so that it is applicable for the masses as a whole. I think it just means more guidelines, and homogenizing medicine to point where it is cookie cutter. 

    Ex. diabetic patient
    not all of them need blood checks every 3 months in the clinic; some do… because of the severity of their disease
    I would not recommend all patients get HbA1c every 3 months, just because some check list tells me so.

    Medicine should be catered to the patient, each and every individual person; not one alogrithm 

    One Algorithm to treat them all, One Algorithm to diagnosis them.
    One List to check them all and in wellness shall we find them.

  • Reply Kalpana Dashora May 12, 2015 at 2:45 pm

    Excelente TED MED 2012, por Atul Gawande, propulsor del Surgical Check-list. video is motivating and show importance of checklists

  • Reply mpking1374 June 2, 2015 at 5:09 pm

    His skills to solve a complex problem remind me of George Polya's How to Solve It (most mathematicians know about this). a. recognise/define a problem, b. devise a plan, c. implement it. Except Polya has another step, d. improve it.

  • Reply larrysheetmetal July 2, 2015 at 1:27 am

    Really,   with MY  medical insurance a  Cat scan is $400 without $ 1,200 !!! Blood work $700 + plus without med. insurance about $80 with !! Cost of insurance $200 a week or $800 a month!!! for me  !!!!!!   Please feel free to check your  medical  bills and post because only by exposing this graft can you end it!!!!

  • Reply Alex Rider August 2, 2015 at 10:19 pm

    Awesome speech! Very interesting and he speaks so enjoyable. I love it! 🙂

  • Reply maryanne martin- September 4, 2015 at 1:56 pm Please read and sign, then share, who helps the PATIENTS after the mistake, no help to the FAMILIES??

  • Reply Kendall Stainton December 5, 2015 at 12:15 am

    This was a very awesome speech! I have also read Atul Gawande's book "Complications." I completely agree with it. We are too focused on doing too much, to where we make things way worse of a simple situation and stop listening to patients. So focused on this "cookbook method" where doctors are doing tests after test. Way too many cat-scans done, for issues it isn't even necessary for and just making it more expensive and more stressful for the patient. By this the patient-doctor relationship is damaged..not taking time to actually listen to the patients and listening to their symptoms inside of assuming and doing unnecessary procedures. This is a great study! To step a few steps back and focus on the basics and avoiding mistakes and even saving lives. To just go through a mental checklist and making sure everything is set. Also he is absolutely right, everything doesn't have to be this giant, grand thing, or drug. It is time again to just focus on the basics. I am surprised on how many lives this simple study has saved around the world and the crazy, ridiculous amount of cat-scans and probably MRI's have one done in one year.

  • Reply Armani garrison December 7, 2015 at 12:31 am

    so how do we differentiate between what's needed and what is necessary when it comes to expenses? because what i hear today is that some of the best treatments are some of the most expensive. is there a trade off that happens? like getting adequate care for something fast and easy? Or slow and more expensive for better care? is there a way for doctors to actually treat people while giving extraordinary care? or is that just the cards we are dealt?

  • Reply 4/40 Vibz With SanMarie May 21, 2016 at 5:04 am

    I already see the future if I ever land a job managing a healthcare office or dept. This speech had me thinking about all kind idea's to implement if when and that happens. I learned a lot from this video.

  • Reply Wall Street meme trader September 10, 2016 at 6:38 pm

    simple, just git gud.

  • Reply Abigail Lanczak October 10, 2016 at 9:10 pm

    There is not doubt about it that the prices of healthcare is out of control. It is completely ridiculous that doctors, and patients are subject to this. In addition to this, Gawande makes a great point that in medicine, doctors cannot do it all. There are far to many aspects of the human body for one doctor to know everything. I was very surprised that the number of doctors to patients has increased so greatly in the past few decades. Going from 2 doctors per patient to 15. That just seems like an excessive amount, but it makes sense. As for checklists, I really do think that is a good idea. It makes sure things aren't missed, It can be so easy to miss something small, with that checklist you have an accountability factor. I like how he focuses on the important of team work. With so many doctors being specialized, the need for them to work together for one patient is essential. As for having pit-crew's for patient, I think that is a brilliant idea. What kind of patient doesn't want a team behind them assisting in all ways possible. Pit crew's don't even have to just nurses and one doctor. All doctors need to be on each other's pit crew so the can assist when needed. I think if doctors were willing to implement this pit crew idea health care would be forever changed in a positive light.

  • Reply Broderick Flynn January 31, 2017 at 6:39 pm

    “Doctors can’t know it all.” That statement explains why we have so many professions in healthcare from physical therapist to surgeon to nurse. With each of those professions comes a price for their services. Yes, medicine has become expensive. But it is easy to see why when you look at the price of the medicine itself, the doctor’s salary, the price of equipment, and the cost of the electricity and energy used in housing and taking care of a patient in a hospital. Adding more people to have more “pit crews” is only going to make the price of healthcare go up. In my opinion, doctors need to be more educated. They need more than just four years of medical school. If doctors were to learn more about the health profession they are going into, there would be less need for so many doctors for one patient. If this were the case, costs of healthcare could possibly be reduced.

  • Reply Brianna Ranck February 13, 2017 at 4:55 pm

    Of course, the advancement of technology and treatment is going to increase the cost of healthcare. Doctors are being forced to know more now than ever which is why we have specialists. It is impossible to know everything. Doctors are performing more complex and dangerous procedures on patients. With risk comes a higher cost, unfortunately. The treatments with the least amount of risks are going to be the least expensive. Unfortunately, like he says, we always want the best. We tend to lean toward seeing the best doctors, and going through with the "best" treatments, no matter the price.

    Sometimes I think that specialists get so used to doing certain procedures that they begin to stop taking the little precautions. It becomes a habit to just assume everything is going to go well, because they have done it repeatedly. If they are forced to go through the checklist set up for them, I feel they will be more careful in going through the procedures. If we could get every hospital to follow the same procedural guidelines to a T, there would be much fewer deaths on the operating table, as well as after the operation. There are so many things that can go wrong once you open the human body up to outside air. Our skin is selectively-permeable for a reason. There are just some things in the air that should not be in our body. That is why we are built the way we are built; a system of filters, barriers, and systems that are meant to protect us. As soon as you open the body, you are putting it at risk. With a checklist, I think we can prevent surgeries from taking longer than necessary and therefore reducing the chances of infection. Also, it will force the specialists to follow specific protocols to keep them safe.

    This shouldn't just go for surgical procedures. Childbirth, physical therapy, any testing or treatment involving radiation, even things as simple as getting blood drawn, should have procedural checklists. If we can see positive results like saving lives from surgery, just think of what kind of results we could get from applying this to everything else.

    Perhaps, as the risks decreased, the cost of some of the procedures would too.

  • Reply Helena Monique Clarke February 22, 2017 at 9:26 am

    You certainly need to start by getting all The Freemasonry out of medicine.

  • Reply adwilkin14 February 22, 2017 at 5:24 pm

    I never thought of healthcare this way.  I just always assumed that when I went to the doctor I was getting the best care I needed, not the best guess my doctor had. I understand that doctors are very knowledgeable and are more than likely right when suggesting tests to correctly diagnose.  I don't expect them to be right 100% of the
    time but I do expect that if they don't know the answer to ask for help, not give it their best guess.  This is what
    Gawande is talking about when he says hospitals need pit crews.  We need an all-round knowledgeable staff that
    knows when to ask for help and not act upon what they think is correct.  Doctors have become too focused on what they believe needs to be done rather than what is in the best interest of the patient.  Performing a test that doesn’t need to be done can be costly and if the patient accepts the doctor's suggestion to do this test and it comes back negative the patient is then responsible for that cost.  Gawande states that the most expensive care isn't always the best care.  I have a friend who broke his back and the first doctor he went to said he needed surgery which was not only costly but had increased chances of complications during surgery.  He went to a second doctor and this doctor offered him an alternative to surgery which was much cheaper and had less
    chance of surgical mishaps. The second doctor was focused more on the patient than on fixing the problem.  Yes, both options would have fixed the problem but the second doctor had a more patient focused mindset.  I like the idea of having a checklist that the surgeons went through for each portion of the surgery.  I wouldn't have expected to see such a drastic drop in complication rates just by implementing a checklist but sometimes the little things get overlooked when performing the same activity over and over again.  This is ensuring that the patient is getting the best care possible and that all parts of the pit crew are on the same page.  I can't believe that they are struggling to put this in place with how impressive the results were.  If each part of an office implemented a checklist to go over even just at the beginning of the day so that everyone is on the same page imagine the increased productivity.

  • Reply Frank Mundo May 4, 2017 at 4:23 pm

    Atul Gawande has, with his work in education of physicians, has probably saved more lives than anyone else in medicine. And then there is his "must read" book "Being Mortal" which should be read by everyone who is over 60.

  • Reply Nathaniel Doromal July 22, 2017 at 11:04 pm

    This is a good talk but he conveniently avoids placing any blame of the cost on the suppliers (the hospitals, the doctors, and clinicians). It's an oligopoly essentially and supply is artificially controlled in order to keep the costs high. It has come to a head now where the high costs are warranting an examination but there is a shift of blame elsewhere to insurance and government. Nobody knows what the price of a procedure is and it "conveniently" changes depending on your ability to pay or not pay. This is covered by the book "An American Sickness: How Healthcare Became Big Business and How You Can Take It Back" by Elisabeth Rosenthal. Important read.

  • Reply Benedict Malinao August 8, 2017 at 9:12 pm


  • Reply Zeez Sleep September 24, 2017 at 8:15 am

    Really interesting talk. And hopeful. If systems work everything can be seem more clearly. I have reacted away from the frustrations of bad and inefficient systems by doing things alone / and / or controlling them. That has been great. It allowed us to develop unusual products (Zeez Sleep Pebble) but it also its own disadvantages – loneliness, the inability to see beyond oneself. If we have crummy systems than no matter what excellence we introduce, the possibility for change is limited. The change that could be effected if systems worked – and change may be simple. Hopeful.

  • Reply jessica burke November 17, 2017 at 2:08 pm

    Huge fan of Atul Gwande. This is exactly what I'm writing my term paper on.

  • Reply Shana G May 20, 2018 at 6:16 pm

    YAAAAS! I read his book Being Mortal and ever since I was hooked! <3

  • Reply JAS June 18, 2018 at 3:32 am

    Kick out all the politicians who are playing doctor and God with the lives of chronic pain pts. Then do away with the DEA, CDC, AND FDA! (ESP DEA!)

  • Reply econdemocracy June 20, 2018 at 6:38 pm

    Seven years ago(2012) Dr. Gawande said 35% (16:23) on average and they fell "in every hospital" but does that "average" decline give us an accurate picture of what to expect in the U.S. or other developed countries? Turns out after the 2009 pilot study there were follow-ups. Findings sharply more modest, like declines from 3.13% to 2.85% or 1.9% to 1.6% (I'm pasting below from TED website comment section by someone else, a comment other readers thought well of) Worth doing for such small declines? Of course. It's more like what's unsaid, that's too hot or "too" political for someone like AG to talk about, elephants in the room like the systemic things that separate U.S. healthcare (with generally same-or-lower outcomes for patients) from how national healthcare systems work in every. other. industrialized. country. For "making systems work" as he says he wants to do, you can't ignore the elephant in the room of what makes the U.S. "maximize short term profit for shareholders"-based healthcare as a commodity (which hurts both the poor and the wealthy who get unnecessary but profitable procedures etc) and makes ours in U.S. different from every other industrialized country's as not just the likes of PNHP but every (honest) analysis within the establishment as well (GAO, CBO etc) have shown over the decades. Anyway, on the narrower point of improvement rates, below is from the TED comment section by someone else, who cites all his sources (oh and, since our political duopoly is so dysfunctional and bought, I do actually wish Dr. Gawande well with the just-out press release he'll be heading the Berkshire Hathaway-Amazon-JP Morgan Chase healthcare project. A smallish island that's different, within the "maximize shorterm shareholder profit" system of healthcare in the U.S. could still make a difference, not enough, but better than nothing while we wait or work for actual national systemic change)

    Reuben Tang
    Posted 6 years ago

    The pilot study referred to by Gawande was preformed by Haynes, et al., 2009. A more careful consideration regarding the data provided by the earlier study finds that this decline in complications and mortality was not as great in hospitals in developed countries compared to hospitals in undeveloped countries (Ko, et al., 2012).

    Data collected by van Klei, et al., 2012, in a Dutch setting found that crude mortality ‘only’ decreased from 3.13% to 2.85% (P=0.19), while a study preformed by Sewell, et al., 2011, in the UK did not observe the same decline in complications and mortality as observed in Haynes, et al., 2009 (8.5% to 7.6% and 1.9% to 1.6% respectively).

    Barriers to effective checklist implementation stem not just from the above, as Fourcade, et al., 2012 identifies duplication with existing safety checks as the most commonly occuring barrier in implementing the checklist in 18 cancer centres in France.

    In a nutshell, based on current evidence, while the WHO surgical safety checklist is effective at decreasing complications and mortality, it is highly unlikely we will observe the same decrease in countries where protocol that perform a function similar to the checklist are already in place.

    Works cited
    Ko, H. C., Turner, T. J., & Finnigan, M. A. (2011). Systematic review of safety checklists for use by medical care teams in acute hospital settings–limited evidence of effectiveness. BMC Health Serv Res, 11, 211.
    Fourcade, A., Blache, J. L., Grenier, C., Bourgain, J. L., & Minvielle, E. (2012). Barriers to staff adoption of a surgical safety checklist. BMJ Qual Saf, 21(3), 191-197.
    Haynes, A. B., Weiser, T. G.,.. Gawande, A. A. (2009). A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. The New England Journal of Medicine, 360(5), 491-499.
    Sewell, M., Adebibe, M.,… Levack, B. (2011). Use of the WHO surgical safety checklist in trauma and orthopaedic patients. Int Orthop, 35(6), 897-901.

  • Reply ratfoot June 21, 2018 at 2:54 am

    I don't know if he knows it but he's spoken a lot about Lean concepts in these talks and his writing. New CEO of the Amazon Berkshire Chase Healthcare company they'll be huge

  • Reply Bill Juss June 22, 2018 at 5:03 am

    Dr Atul Gawande seems to be supporting socialized ACA/Obamacare healthcare system that sounds good in theory, but in the end, its' the same worsening regulations on actual doctors who want to treat patients, not waste scare time resources reporting worthless statements.  It doesn't work in the VA system very well, ANY HMO…  The more Ins Co have control over care, the worse the medical conditions of Americans will become and at a higher cost.

  • Reply Bill Juss June 22, 2018 at 5:05 am

    Good Medicine is NOT Politics, Its' about Patient Dr relationship, which leads to quicker, more accurate diag, and better pt outcomes.  But you have to get to a Dr. First, NOT the nurse, NP, PA, Hospital Admin, conflicted Ins Co medical dir, or their nurses…  The problem with using a pit stop crew concept applied to medical treatment again over simplifies medicine and complex diag and treatment options, its in theory is what happens with gov't and/or monopoly Ins company & hospital owned groups is goal is to treat more pt, not provide quality care — resulting in repeated hospital stays, surgeries…

  • Reply ali karakaş September 7, 2018 at 12:11 pm


  • Reply MYA October 11, 2018 at 8:53 pm

    Wow! incredible information he was truly right on target.

  • Reply Shadow Boxer October 13, 2018 at 7:38 pm

    Morgellons Disease.

  • Reply Live your Values October 14, 2018 at 6:16 am

    Stop cutting babys genitals

  • Reply Kathy Fausett October 27, 2018 at 11:29 am

    You approach the problems in medicine like a computer programmer—-layers upon layers of complexity. You never ask the fundamental question—are we treating the cause of this patient's problem. Docs are equipped with 3 fundamental tools—a scrip pad, a hypodermic needle and a knife. For 90% of patients with chronic illness, none of these tools work. Yes, medicine is now expensive, but it's still ineffective. There is some good science out there, yet nobody in medicine seems to be aware that it exists. The take-a-pill, or cut it out models dominate the trade, yet outcomes in this country remain dismal. You guys have built a castle on beach sand, and you wonder why it won't quit moving.

  • Reply Pablo Dornbusch November 8, 2018 at 12:13 pm

    All this people are compleyely wrong. Why don't we start with Nutrition and Prevention of illnesses instead of doing bad experiments with patients?
    Americans have the worst nitrition in the world. Eat far to much junk food, to much meat and saturated fats and all this is causing chronic diseases like diabetes, obesity, atheroesclerosis, strokes, high blood presure, hearth failures and Cancer. The food industry is poisoning us with highly procesed foods. We need to focus first in Nutrition and bad food habits.
    We wouldn't need to many doctors, specialists and drugs if we start a PLANT BASED WHOLEFOOD NUTRITION.
    It is cientifically proved that Vegetarians and Vegans are healthier than meat and junk food eaters.The only way to take care of our health is to get rid of our bad food habits and start eating the right way.

  • Reply valar November 14, 2018 at 5:16 am

    The only thing I wonder about and wish he would address more is longevity research. Whether he likes it or not, eventually, in 30 years, 50 or 100, some people will be living very long lives in a state of eternal youth or whichever age they choose. Now, for some time, probably decades, it will be the rich. That is not a good recipe for social peace. Nevertheless, it will happen.

  • Reply Russ McClay January 26, 2019 at 2:26 pm

    The problem of high medical care costs are not the government or insurance companies; it is the culture of greed of the doctors themselves.

  • Reply PKMKB Indian army April 22, 2019 at 8:50 pm

    Indians are the best in medical science.

  • Reply Hakan Kan April 27, 2019 at 5:27 pm

    I agree with doctor in the world

  • Reply davinder singh May 16, 2019 at 5:40 pm

    amazing video. checklist manifesto…is must read book of him…

  • Reply Reid Sheftall December 18, 2019 at 10:44 am

    Oh my God. I wrote an Op-ed in the Florida Times-Union about this (and a solution that would save trillions of dollars) 20 years ago. I sure wish Dr. Gawande would contact me. I wrote Warren Buffett, Jeff Bezos, and Jamie Dimon when I heard they were doing Health Ventures but never heard back from any of them. I hope someone sees this. My email is [email protected] Please help me contact someone if you work for Amazon, Berkshire Hathaway, or JP Morgan. It will save US healthcare hundreds of billions of dollars a year. Thank you.

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