Krishna Chinthapalli on Atul Gawande—thinker, leader, doctor, writer

In 2009, Obama convened senior politicians in the Oval Office to discuss one magazine article: why were there Medicare costs of $15,000 per person per year in the Texan town of McAllen, when a neighbouring town had costs of $7,500 per person per year? Especially when the hospitals in McAllen were performing worse than its neighbour.

“He came into the meeting with that article having affected his thinking dramatically. He, in effect, took that article and put it in front of a big group of senators and said, ‘This is what we’ve got to fix,’” recalls one of the senators.

For the article’s author, Atul Gawande, influencing US healthcare reform is just another item in an impressive list of achievements. This is a man who studied at Stanford, Harvard, and as a Rhodes scholar in Oxford. He worked as a health policy advisor to President Clinton when he was a medical student. He has written three New York Times bestsellers. He has spearheaded the introduction of surgical safety checklists worldwide—leading the World Health Organization’s campaign—which could potentially save half a million lives per year. He is one of the top global thinkers according to Foreign Policy and Time magazines. He is the chair of Lifebox, a global charity to reduce surgical mortality. He is associate professor and director of Ariadne Labs, a research offshoot of the Harvard School of Public Health and Brigham and Women’s Hospital. And he is a practising endocrine surgeon.

Last week, he came to London and spoke of the immense challenge in changing our mindset when it comes to healthcare. “I was trained with a motto of ‘Trust no one’. You do it yourself and you take the time it takes to do it yourself because no one else is going to do so,” he said. “Our system was built on a concept of autonomy. But in the modern world, you cannot hold all the knowledge that’s relevant to your patient’s care in your head and you cannot have those skills by yourself. We’re in a world where we share the responsibilities and we’re dividing the tasks amongst us.”

To illustrate this, he told us of his mother’s three day hospital stay for a knee replacement operation. “I watched all of the people coming in and out of the room and started counting how many individual people were making decisions or executing on those decisions, touching her, getting her out of bed, deciding she could walk, deciding she couldn’t walk, giving her medication, etc. And it was 63 people.”

“We’ve built, hired, and rewarded people to be cowboys in healthcare, but it’s pit crews that we need.” Pit crews in which everyone works in synchrony with a shared purpose. But do such pit crews exist? Gawande thinks there are some examples of successful and innovative teamwork in medicine. One was in the military tents of Iraq, where the US military kept its lethality rate for war wounds to 10%—it had been hovering around 25% for every other major war in history. The lethality rate is the proportion of soldier deaths out of the total number of soldiers wounded in action and the decrease is not due to any technological advance in Gawande’s view.

One of his residents was a field surgeon on duty in Iraq, and Gawande explained how the army deployed hospitals that could be set up in one hour at the frontline. “The whole approach fundamentally changed. They took an approach that limited them to just two hours of surgery, because the equipment in these hospitals lacked the ability to have someone recover for longer than six hours and lacked the material to have an operation longer than two hours. They therefore focused on damage control surgery: to stop the bleeding, clean out contamination, pull a sterile plastic drape over the open belly, leave the soldier asleep, pin a note on the front explaining everything that you’ve done, send them on to Baghdad and say ‘Please finish!’”

Although this was completely against his instincts as a surgeon, such collaboration and innovation helped save many soldiers’ lives. Gawande witnessed this happen in his hometown too, in tragic circumstances. During the bombings in Boston this month, he noted that three people had died, but that they also, “had zero who died who were reached alive at the scene.” Despite the first patients arriving to hospital a mere eleven minutes after the explosion, eight operating theatres and staff were freed up and ready to cope with the wounded.

“What I saw last week was teamwork and collaboration of a kind that we simply would not have had a decade ago. In each case what you saw was an alignment of mission.”

“Is this what it means to be a good doctor? Yes it does… Yes it does.”

The BMJ selected Lifebox as its holiday charity for 2011 and 2012.

Conflict of interest: I have no conflicts of interest.

Krishna Chinthapalli is the BMJ clinical fellow.

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