[MUSIC PLAYING] TOM SMITH: OK, I'm thrilled to
welcome Atul Gawande to Google during the week that
marks a paperback publication of his number
one New York Times best seller, "Being Mortal: Medicine
and What Matters in the End." Dr. Gawande is a
surgeon at the Brigham and Women's Hospital in Boston,
a staff writer for The New Yorker, and a professor
at Harvard Medical School and the Harvard T.H.
Chan School of Public Health. He's won the Lewis
Thomas Prize for writing about science, a MacArthur
Fellowship, and two national magazine awards. In his work in public health,
he is executive director of Ariadne labs. A Joint Center for
health systems innovation and chairman of Lifebox,
a nonprofit organization making surgery safer globally. And honestly, I'm
a little surprised it doesn't say, like, Olympic
gold medalist or five time Grammy winner. Please join me in giving
Dr. Gawande a warm welcome. ATUL GAWANDE: Thank you for
taking time on your lunch to come talk about death. I'm looking forward
to a conversation. I'll probably talk for
about 15, 20 minutes about the basic thinking
behind the book, and then we'll go from there. So why would I write
about death and dying? And the core of it was that
I'm a surgeon, but also in public health and became
interested as I was going through my training and then
in practice about the fact that I was slowly becoming
confident in learning how to deal with problems
where we had fixable problems. We had solutions that we
could offer to many things where the human
body could go wrong. And yet, we are all mortal. And what I never learned was how
do we deal with the unfixables? How do we deal with the
reality of mortality? And the thing I found that
came up again and again as I entered into practice
and continue to practice is that we have a substantial
number of people who come in who have incurable problems. They are the problems of
the frailty of old age. They have terminal illnesses. They have chronic illnesses
that are just getting worse. And then the puzzle
becomes, well, how far do we go in
fighting the consequences of an incurable cancer? Of an organ failure? Of old age? For example, a piano
teacher comes in. She has an advanced
cancer in her pelvis. It's spread to her liver
despite two different lines of chemotherapy
that we've tried. Now what do you
want to have happen? What do we all want to
have happen at this point? Should we do something? Part of the discussion
with her was, well, there are no
conventional options. So there are experiments
we can try, however. We can try an experimental bone
marrow transplant and high dose chemotherapy. There's something
we can come up with. Or alternatively, should
we keep her comfortable? What she heard as we're having
this discussion is should we fight or should we give up? Now, what I knew was
instinctively that didn't feel like the right
question to be asking, but I didn't know how to
think about it differently. This is the way we
always think about it. And so I ended up
writing the book out of a desire to try to figure
out what is the way out of that? Getting to a better question
and not just a better answer. Along the way, I
ended up interviewing more than 200 people. More than 200 families,
patients about their experiences with very old age,
with terminal illness, with incurable conditions. And what I found was
that the discussion about how we deal with mortality
was not what I expected. It wasn't really about
dying, it was about living. That the goal was
to be able to have not a good death, but
a good life all the way to the very end. And that's where
gradually the key lesson emerged from this,
which is that people have priorities in their
life besides just surviving. They have reasons
they want to be alive. What those reasons are,
what those priorities are, you have to ask. Especially when people have
a serious illness or frailty, advancing frailty of old
age, you have to ask. Otherwise our priorities, well,
our priorities for their care can be out of alignment
with their priorities for what matters to them, and
that's when you get suffering. I interviewed people in
old age homes, for example, and they'd tell me about
how miserable they were. And they'd tell me about-- the most common thing you'd hear
from people in old age homes would be, when do
I get to go home? Try to probe, like, why does
this not feel like home? What is it about this
that is not home? And they said, well, I
couldn't have my own furniture because, you know,
it's not safe. You can't have a drink
because it's not safe. You wake up at a set
time, get in the pill line where the prescribed close
when they have you do that. And they choose who you
might have as a roommate, you don't have any choice
about those things. You don't have any privacy. What does that
sound like to you? Prison. Exactly. And that's what they thought. They were in prison. I interviewed an
85-year-old woman who had Alzheimer's disease and
she had a medically ordered, pureed only diet, and she would
be caught stealing cookies from her neighbors. And so they'd
confiscate the cookies and then they'd write her up. Send notes home to their
adult kids, you know. And you just want to say, let
her have the damn cookies. But what we were
not figuring out was that we weren't
identifying what were her priorities besides just
surviving, besides just living longer, besides just not
choking on cookies, for example. And she was telling you
what those priorities were by the very fact that
she was stealing cookies. That her joy-- here's
this one joy she's got-- was food and the sheer pleasure
of getting to enjoy that. And why couldn't
that matter to us? And you see that same problem
in medicine in general. You know, here's this
woman with a piano teacher with advanced
cancer and her pelvis that had spread in the
hospital, in pain, and we had no
imagination that there might be something about
her life worth living for. We say, so our
conversation becomes, should we try something
or should we not? And then I've seen
the result. We always have something to try. We always have an
operation I can do. And I've taken people to the
operating room out of hope that we would find
something only to have them in the Intensive Care Unit
never to wake up again. Declining over a couple
of weeks, never getting to say I'm sorry, never
getting to say I love you, never say anything
to say thank you, never getting to
set their legacy. And that's when
I realized that-- well, I'd been
realizing all the way that something was
wrong with that, but that there might
be a way out of this. There was a study done of
advanced lung cancer patients stage four. This is we don't have a
treatment, a cure for. We have treatments, but
we don't have a cure. The average survival is 11
months for the patients. Half of the patients
were randomized to receiving the
usual oncology care, and the other half received the
usual oncology care and a visit with palliative care clinicians. Palliative care clinicians
focus on making sure that you are getting
the treatments that improve the quality
of your life, and it starts with first
identifying what does quality of life mean to you? Asking those questions about
what your priorities are. And the result was
that those people who got the oncologist and the
palliative care consultation had a very different
outcome from the ones who just got the oncology care. As a cancer surgeon,
people would say, should I see the palliative
care clinician now? And I'm now embarrassed
to say I used to answer, no, no, no, no, it's
not time for that now. As if, you know, we
still have options. As if focusing on
quality of care was opposed to quantity of care. And so the result
was that the group who got the early palliative
care ended up choosing-- they were 90% less likely to be
on chemotherapy at the last two weeks of life because
they stopped it sooner. They were 50% less likely
to receive chemotherapy in the last three
months of life. They had more time at home. They spent less time in
the hospital by a third. They were less likely
to die in the hospital. They started
Hospice care sooner. They had less suffering
by multiple measures, including less
depression and anxiety. They had one third
lower costs, including hospitalization chemotherapy. And the kicker was
they lived 25% longer. If it was a drug, this would
be a multibillion dollar blockbuster and the
FDA would, like, put it on expedited approval. But instead, it was just
having these conversations. We can't scale everybody having
a palliative care clinician. And in fact, it doesn't
make sense to say, I've got my specialist looking
after my quality of life and I've got my
specialist looking after my quality of life. What you really want is
to put them together. So then how do you do that? And what I found was that when
I would ask palliative care doctors who do
this kind of work, what exactly--
you're in this trial. What were you doing differently? How do I scale what you do? What is your checklist
that I should be following the next
time I have a patient that has this question? And the first thing they pointed
out was that I talk too much. They said, you
know, your problem is you're an explainaholic. When you have someone
who has a potentially difficult or unfixable problem,
a serious illness, a terminal illness, then you
want to ask questions that help you learn what
their priorities are. And that means you
have to listen. You have to listen at
least half of the time. And that means asking questions. What kind of questions? Well, start with, what's
your understanding of where you are right now,
what your situation really is? What are your fears
for the future? What are your hopes
for the future? What are you
willing to sacrifice and not willing to sacrifice
for the sake of more time? What's the minimum quality of
life you would find acceptable? And that gives you
a very different way of thinking that I'm not just
there to be a retailer giving you the facts of your
options, your pros, your cons, your risk, your benefits. Do you want the red shoes or
do you want the blue shoes? Tell me what you want now. It's to say, what
are your goals? And then how do I serve
as a counselor who can match what I know
about the options to what your goals might be. I asked the questions to that
piano teacher, for example. I wrote about it in the book. And I said, so what's your
understanding of where you are with your health? And she said, I'm going to die. I know it. I've been here in the
hospital for two weeks just getting worse every day. People are giving me blood
transfusions and treatments, but I'm going to die. And her husband
later said that was the first time she'd heard
her just name it, just say it. This is our situation. Then I went to the
second question the palliative care
doctor gave me. I said, so what are
your goals then? And she said, I don't know. I can't imagine having
any goals at this point. The palliative care
doctors didn't tell me what to do with that one. So I just went to
the next question. So I said, then
what are your fears? What are your fears for the
future with your health? And then she gave me a litany. She feared being
in more pain, She feared that she already
was becoming incontinent and that she would lose even
more of her dignity lying there. She feared she would
never get to go home. There were people
she wanted to see, and she feared she
wouldn't see them. Now I understood something about
what really mattered to her. Along the way I'd
also spent time interviewing people like Hospice
nurses and traveling with them, or nursing home directors, or
home health aides and others. And one of the Hospice
nurses had said to me that medicine's goal is to
sacrifice your life and time now for the sake of time later. Her goal was to give you as
good a possible day today using the same
medical capabilities, regardless of what it
might mean for the future. So the opposite of
sacrificing your time today. She wanted to give you
the best possible day now and then to see what happened. And so I said to the
teacher, her name was Peggy, I said, well, I'd met
this nurse and she said that the goal
of Hospice was to see if you can have the
best possible day you can. I said, is that something that
we could try fighting for? This isn't about do you
fight or do you give up, this is what are
we fighting for? And what if what we fought for
was that you could have one good day? Seemed like a long time
since you'd had a good day. She said, yes. It's been a very long time. That, she felt like,
was worth fighting for. 48 hours later she
went home on Hospice. And I knew her, I
didn't tell you this, but I knew her because she
was also my daughter's piano teacher and was seeing me
for advice about what to do. And so when she
went home, I also had to tell my daughter
that she wouldn't be getting piano lessons anymore. And she asked why, and I had
to explain that Peg was dying. My daughter was 13 then. She wanted to go
see her and I said I didn't think that was possible. But then a few days later,
I got a call from Peg and she wanted to know if it was
OK with me and OK with my wife whether she could start teaching
my daughter, Hunter, piano again. That blew my mind. Here was this woman laid
out, bedridden, incontinent, in pain, and now she was
calling about the idea that she could start
teaching again? I got to talk to her
Hospice nurse sometime later and I said, what happened? What did you do? She says, well, she got
home and we spent some time, and we talked, and we
said, you know, what would a good day be for you? And on the first
couple of days it was just get the
pain under control. And so she increased
the pain dosages. They got a bed put
in in the dining room so she didn't have to go up the
stairs or go to the bathroom. They got a bedside commode. They figured out how to
get her bathed and dressed, and just get a
life under control. And as those
challenges got solved, her anxieties fell and
she lifted her sights. She didn't have children. She was a teacher and she wanted
to teach again in the time that she had. My daughter ended up getting
lessons for the next four weeks with her. She lived for six more weeks. In the last week, they then
had two recitals for her. One of the students
that she'd had in the past who flew in
from all over the country to play for her, and then the
other of her current students from elementary
school to high school. And we sat in her living room
and listened to these children play. And then afterwards, Peg
took them aside one by one and she had a little
something for them. And what she had set aside
for my daughter, Hunter, was a book of music
that she wanted her to learn and to keep. And then one more gift which
was she put her arm around her and said, you're special and I
don't want you to forget that. And she wanted all the
children to know that. That gap was
extraordinary to me. We never imagined to ourselves
that there was that life worth living, and that medicine
was actually in our neglect and in our unwillingness to
ask those questions about what matters to people. That we were actually
sacrificing those abilities. And that furthermore, it's
not just at the very end that we need to ask
these questions, we need ask these questions
from the minute people start needing our help. When you have a parent
who's frail enough where a question comes up of whether
they can live at home or not anymore, or where they
have other illnesses that aren't going to go
away, being able to ask, what are your priorities? What really matters? Her priority was
she wanted to teach. Another person I
spoke to, they said, if I can eat chocolate
ice cream and watch football on television, that
would be good enough for me. I'd be willing go
through a lot for that. If I can't have that, let me go. It's like the best
living will ever. And I tell the story of my
dad, who had a brain tumor. And I said, chocolate ice cream
and football on television? What do you think? Not good enough for him. For him, it was
sitting at the dinner table with family and friends. He was an extremely
social person, and it was food and talk
that was life for him. And his tumor would eventually
take that away, and we knew it. And being able to know
and have that discussion, and to have that clarity that
there can be goals besides just living longer, and that we can
fight to be able to have people have those. The striking thing to me, and
where I'd love to open it up is that in medicine
and in society we fail to recognize that just
fixing problems and making them go away is not the only
way we can provide help. That in very
difficult situations, a serious illness, a
disaster of any kind, being able to say for a
minute, what is the goal? What are we fighting for now? What are we willing
to lose along the way, and what are we not willing
to lose, is transformative. And somehow, we haven't
had those conversations. We have to have them earlier. We have to have the more. We have to do it better. We've had a 50 year experiment
in the medical world of not taking that approach of having
a very narrow focus on defeating disease without thinking about
the larger idea of well-being. That well-being is bigger than
just health, independence, and survival. We want to be healthy, we
want to be independent, we want to survive for
reasons, and that we can still serve those even when health and
independence aren't possible. By failing to
recognize that, we had 50 years of
medicalizing mortality, and the result has been
suffering, incredible cost. But we are capable of taking
a wider view, of becoming consistent and more
systematic about being clear about our goals. Whether it's in our senior
retirement communities, nursing homes, medical
practices, or elsewhere. It is not actually
that much to change. In the three years since
we released the book, we've gone from thinking
that these conversations were death panels about whether
you fight or give up. As if the choices are we should
be getting people all give up. But instead to be about
what are we fighting for for you along the way? And so it's not
that much to change, and yet it's everything. Thank you. [APPLAUSE] TOM SMITH: Thanks so much. In the circles I run in,
discussion of your book is really like
cocktail party talk. Many of us-- ATUL GAWANDE: Do you
sit there talking about, would you want the
chocolate ice cream? TOM SMITH: Well, certainly
many of us in my social circle and demographic have had parents
who've faced aging and terminal illness, and your book has
provided many great models for us to help us refine
our thinking about this. So I've got a
bunch of questions. ATUL GAWANDE: OK. TOM SMITH: I'm going to try
not to monopolize your time to give the audience a
chance to ask a few, too. One simple but profound
point that your book makes is that aging is really
a recent phenomenon. For most of human history,
people didn't really get old. And medicine really pushed
out the frontiers faster than society and policy has
been able to keep up with. We've been trying to
adapt, and some of the-- you write about
some of the people who have been real
innovators in trying to address some of
the issues that you discuss today and discuss
at length in your book. You write about Karen
Wilson, the visionary who pioneered the concept
of assisted living, and I was really surprised to
hear what the origins were. So can you tell us what she
originally had in mind and how that all played out? ATUL GAWANDE: Yeah. Let me try to put it a
little bit in context. So 1900, so a century
ago, the average survival of the United States
was your life expectancy was in your mid 40s. And that was a typical life. You'd have seven
kids, and you would have them as early as possible
so they could be helping take care of you when you
were 45 because at that point, you were getting pretty old
and it's hard to even function or work in the same way. That said, you had 5%
or 10% who would live, you know, about 70 years or
so, but it was very small part of the population. And where that
dramatically changed-- so in the course of
this century, we have added on average
more than 35 years to people's life expectancy. And that is a dramatic shift. Now, we also have
made it so that you have phenomenally better
health along the way, but you still likely have
eight years of dependency. And we don't like
thinking about that. Now, the further thing is
that as you get older-- a psychologist at Stanford
named Laura Carlson-- I devoted a whole
chapter because she's completely fascinating. She's followed people
for 30 years as they age. And as people age, she found,
yes, your health goes down. Yes, you start losing functions. Sorry, that's just what happens. But they also become happier. They are more likely
to be fulfilled. They become more likely to
have love in their life. They become less likely to
have anxiety and depression. They become less focused
on acquiring stuff. You know, getting more toys,
bigger house, all the status symbols. They become less focused on
building their social network. They become more
focused on deeper, more intimate relationships with
a smaller, tighter group of people and spending
real time with people. And so the recognition that what
we build for that phase of life is a health system that
assumes your goal is health and survival, that without
health and independence, that surely life sucks. But the truth of the
matter is that even as your health and
your functions decline, you can have an even
more fulfilling life as time goes on. Karen Wilson's mother
had a stroke at age 50 and became paralyzed on
one half of her body, but she was otherwise there. You know, wheelchair bound,
she needed help and assistance in daily life. But you can imagine
in your 50s then, you're in a nursing
home needing assistance and no one thinks you have
a life worth living anymore. That the only thing
worthwhile is just being fed, and getting the
right medicines, and being safe. And the people who make
decisions about where someone will live in old age is
usually not the old age person themselves. It's usually the adult
children of that person, and they're usually
pushing them to go do these visits
because they feel like they're not safe at home. And so their number one
question when they go around is will my father,
will my mother be safe? Not will they be lonely? Will they be happy? Will they be satisfied? Will they be fulfilled? Are they going to be helpless? Are they going to have
things they can do? Can they still grow? Can they learn stuff? And Karen's mother
was young enough and bull headed
enough to say, I want a place where I have a lock
on the door, where I can cook my own food, do my own thing. You mean, in the
refrigerator you could have whatever food you want? You know, like, that's totally
against the regulations. A diabetic could have a
soda in their refrigerator? And the revolution
of assisted living was the idea that
you would genuinely have control over your life. That people would be coming into
your home, it's your apartment, and helping you have the
independence of making choices for yourself. And that was originally
the way that she built it. It spread, it was very popular. And then as it became a
Wall Street phenomenon where then the two things
happened-- number one, we started applying the
rules of nursing homes to it where the
focus became again on more the safety than on
the filling notion of it. And second, the whole
training system behind it came out of the
nursing home world and so they lost
that sense of being about enabling people's
privacy, autonomy, capability along the way. I do profile a
bunch of innovators who have made pockets work. One guy named Bill Thomas who
calls himself a nursing home abolitionist and
builds places where you can have your
own pets, you live in small groups of
10 to 12 people, and they make them all no
more expensive than what Medicaid will pay for. And they've built these places
in every state in the country now. But the innovation-- let me
just add another point here. I know I'm going on. But one thing that is
very interesting to me is some of the most
exciting innovation that I see going on in this
particular space of recognizing the fact that people are going
to get to live on average 85 years or longer in
their lives, but we don't build products or capacity
innovations for that community. And I think it's partly because
the innovation cycle, you know, is that engineers often build
for the problems they know, and they see, and they have. On my board of my
Public Health Institute is David Ebersman, who
is the CFO of Facebook. And he would explain
to me, you know, whenever they had any game
released on the Facebook website site, Mark
Zuckerberg, they would get emails at 2:00
in the morning on Saturday. What the hell with this game? This sucks. Like, I tried to play
it and this goes wrong, and this goes wrong. It is constant
iteration about stuff that you know and
are deeply part of. Whereas going into the
space of this world where you might have
a 75-year-old trying to figure out how to
navigate the world, we don't think about how
it's designed for that. Five years after the
book ends, my mother has lived without my
father now for five years. She turned 80, she
had a car wreck, I'm trying to figure out how
to get the keys away from her. That is freedom for her. That's like one of the
most important things that she does not
lose that control. I had her visit the places
in the book that were some of the pioneering places. She Actually picked
one of them to move into as a senior
retirement community. And one of the first things
she did there was she taught a class to the
other senior citizens about how to access
Lyft, because that became her freedom. It is not designed for
the 85-year-old people in this institution. You know, my mom just
happens to be incredibly savvy at being able to
navigate on a very small screen how to pull up Uber and access
it, and get them to recognize which of the buildings
in this 250 unit complex is the one that you
need to come to find me, and et cetera, et cetera,
et cetera, et cetera. Because you don't
have an engineer who is iterating over
and over again like, yeah, I ran into this
problem 50 times this week. I've got to fix this. So getting into that innovation
cycle where you are in that world and you understand
what's needed for expanding the freedoms and autonomy-- just
a side point while I've got you here-- is worth gold if you understand
how to go after these problems. TOM SMITH: There are a number
of people in the audience and I know a number of people
on the live stream who will resonate with this being the-- we have an employee group
called the Greyglers, who are-- ATUL GAWANDE: The Grigglers? TOM SMITH: Grey. ATUL GAWANDE: Oh, the Greyglers. TOM SMITH: Greyglers, yes. ATUL GAWANDE: Yeah. OK. TOM SMITH: And who
are fierce advocates for making technology
accessible to aging people because we know some. You mentioned the car
keys for your mother. That's a real symbol
for so many people. It was a struggle with
my father even after he was functionally blind. And what we ended up with
was that he kept the car keys in the drawer
by his desk, but we didn't have the car anymore. It worked out well. You write that the
practice of geriatrics can really increase the chances
that patients stay independent, do not become
depressed, et cetera. But Medicare doesn't reimburse
for many of these services, although they will happily pay
for a pacemaker or whatever. So how should insurers,
or more broadly, society think about
these services in a way so that more people can
get the benefit of them? ATUL GAWANDE: I think it's
really important, actually, and I wrote a follow up article
in the New Yorker this January about this general phenomenon. What we're recognizing is that
we built the health system especially in the
1950s and 1960s when the major value of
scientific discoveries in health care was that
they could rescue you. Penicillin is the
classic case, right? You've got the pneumonia,
now I can cure it. Or a surgical procedure where
we can take out the cancer or something like that. As we develop
computational capability in the '60s and the
'70s, you started to be able to look at
what's going to happen to people ahead of you. There's a famous study called
the Framingham Heart Study that followed the population of
Framingham, Massachusetts over many years of time,
and then could really look at the predictors
of what's going to happen in the most crude
ways, much cruder than anything that you know how to do now. And that's where we figured out
that high blood pressure, which we didn't even
know was a disease, was, in fact, one of
the biggest causes of cardiovascular disease,
including heart attack, stroke, and dementia. And that if you could control
it with very cheap drugs that were available, you
had remarkable effects on people's lives. Well, fast forward
to where we are now. Add in genomics, add in
the ability to look at-- zip code is even more powerful
than your genetic code in predicting what kinds
of illnesses and conditions you may be facing. Being able to look at
your buying patterns to see what the indications are
about your pattern of living and other things like that. Being able to have
wearables that now contract not just your pulse,
but your sleep habits, your eating habits,
and other things like that. Build those in and
then make it so we begin to integrate
that information back into our understanding. A clinician and a
patient working together around the goals they
consider they've identified as your most important goals. That's what a geriatrician
is doing in analog. A geriatrician is
following people over a long period of time. Not doing any procedures,
but acting ahead of problems. Problems like, is this person
going to be at risk of falling? Having a geriatrician
reduces the likelihood that someone who's
elderly has a serious fall that results in a fracture. Increases the likelihood they
can live at home independently. Those kinds of things. Well, that analog
capability we under-resource because we've built a system for
rescue, not for, as I call it, incremental care. Not for prediction, maintenance,
and systematic care. That ability is
only exploding now. In fact, I've argued
that our evidences that our ability to act
predictively and incrementally has now exceeded the value
of our rescue capability, and that will only increase. We sell insurance
on a yearly basis. It's built for rescue payment. We are instead
acting now on things that will take five, six, ten
years to make a difference. And so insurers
typically only have you for a little bit of time
before they bounce you to something else. And so that whole
market has to change. We have to move from a insurance
model to a subscription, or really I'd argue
almost a mortgage model where you're in for 30 years
and you make investments now together that pay
off down the road. And how much you're
able to keep on working and be productive for
society and contribute in all kinds of different ways. So there's pretty
fundamental things that I think are seeded in
computational capability that right now doctors
do in very analog ways, and it's reflected in how we
take care of people in aging. TOM SMITH: I'm going to
ask another question. But if we have
audience questions, feel free to line up at the
microphones in either aisle. You mentioned the zip
code being important. So that leads me to ask about
socioeconomic factors in terms of access to care,
the kinds of care that people seek,
things they care about. Is there a significant
interaction of various socioeconomic
factors with the topics you discuss in your book? ATUL GAWANDE: Yes, there
are very significant ones. On the one level, let's start
with the very narrow subject of do you have a relationship
with the clinician where you've had a discussion
and have discussions about what your priorities are? It is much more
likely among college educated women and
people who are better off socioeconomically that they will
have those conversations, have a relationship, a trusting
relationship with a clinician, and that the result is that they
get better care along the way. The least likely are high
school education only male and especially minority. But give me a high
school educated male and they're the least likely to
have longstanding relationships in health care, and
especially with someone who would have these
conversations to have the goals set and to be able to
have that before crisis comes. You go a little bit farther,
and this is my now public health hat on, I'd done
an analysis that got some press a
couple of months ago while the ACA was under
attack and under an effort to repeal it. And what we found was looking
at the last 10 years of data around people who'd
gained Medicaid-- so there have been Medicaid
expansions and then the ACA expansion. And the interesting thing
is that the biggest benefit first for people's health wasn't
that they got emergency care. They were getting emergency
care, it just bankrupted them. So the most immediate
effect was that they receive financial protection,
and debt went down bankruptcies went down. Then as people get a regular
source of care over time and get access to
needed medication, they are much more
consistently getting care. And it took about
five years, but you start to see mortality
reduction at five years. It's about a 6%
reduction in mortality, and then it's about a
1% increase in mortality after that. And the biggest gains are in
the chronic disease arenas. So it's gains in
hypertension, and diabetes, and heart disease,
HIV, and cancer care. So people with those
kinds of conditions are the ones that fare
the best, and it's a reflection of the fact that
it's consistent care over time and that the people
who are getting that are really at the highest
socioeconomic ends. We have about a greater
than 15 year difference in life expectancy between
the top 10% earners and the bottom 10% earners. But we see between cities
like San Francisco and Boston, it's only a six year difference
between the bottom and the top. Go to Las Vegas and it's
a 25 year difference. So those socioeconomic
factors are very important and powerful. And I think the way they play
out are in the likelihood that you have consistent,
regular source of care, the needed medication. Because I think
that's the evidence of what is ultimately lifesaving
and improves quality of life. TOM SMITH: Thanks. We've got a number
of people who are interested in asking questions,
so if we can start over here please. AUDIENCE: Hello. Thanks for being here. My aunt passed
away this morning. ATUL GAWANDE: Oh, gosh. Sorry. AUDIENCE: Well, actually,
everyone was quite happy. She'd been a vegetable
for about four years-- ATUL GAWANDE: OK. AUDIENCE: --because
of Alzheimer's. I was wondering what the
state in the medical community was right now about
not treating people. The place she was
in was just so good at making sure she didn't
catch the pneumonia, and was well-fed, and didn't
get the bedsores by flipping her over correctly. Which sounds good in some
sense, but for her it led to a much longer life than
she would have rather had. So I was wondering if you could
comment on the state of what things are now. ATUL GAWANDE: Did
you feel that you knew that she had
expressed what she would be willing to go through
and not willing to go through? AUDIENCE: Well, she
was very religious so, like, a doctor assisted
suicide would have been out of the question for her. So she wanted some
sort of system where she would catch a
disease like pneumonia and die. ATUL GAWANDE: Right. AUDIENCE: But they weren't
letting that happen. ATUL GAWANDE: So I think that's
really crucial that when-- the first thing
that has to happen is people have to
have the conversation. And it's amazing, actually,
that she as she was progressing with
Alzheimer's, that you all had a conversation
enough to know that those were the kinds
of decisions she would make. Then the second question is,
can people follow through on what she's asked? Do we actually listen
and then follow through? The first world is
the clinical world, and a lot of the
time people are very uncomfortable being willing to
listen to say, look, it is-- sometimes people call
pneumonia man's best friend because it is
painless and it is not uncommon in Alzheimer's
disease that you either get a urinary tract
infection or pneumonia. And then people may say--
my father was one of them, he got a pneumonia
towards the end. My mother did not
follow through on-- I told the painful
part of our story, which is that then when he
could no longer make decisions, my mother reversed
Hospice, called 911 when he got
difficulty breathing, came to the hospital,
they resuscitated him, gave him antibiotics,
and he signed himself out at 5 AM in the hospital
saying, goddamn it, this is not what I wanted. I woke up and here
I am, and now they won't give me pain
medicine because they say it stops me breathing. So he was in terrible pain. And he'd had an easy way out,
and now that wasn't happening. So then he said, now,
you, Atul, are the one. You have to listen to me. This is what I want to say
that we really are going to do. And even his own
colleagues in the hospital wouldn't follow through and
listen to what he had to say. There was no, like,
lawsuit at risk here, they just couldn't wrap
their head around the fact that he had priorities. And those priorities were
about the kind of life that he wanted to
be able to live, and if he couldn't live
it, then let him go. And so one barrier are
the clinical places. And they can be very
safe, take wonderful care, really be caring
people, but not listen to what she has indicated
is the quality of life. They would be the kind of
place that also would say, you know, if she was
stealing cookies, wouldn't let her have
the cookies because it wouldn't be safe, right? And being able to recognize
that you have a right to express what your
goals are and have people follow those goals. And so this is a movement. And it's important that we
really drive it as a movement. Medicare-- I testified
before the Senate last year on this,
and Medicare, sorry, nursing home regulations
for the first time became included that
you would have a right to decide what your
sleep schedule is, that you should have a right
to decide when you want to eat, and that you would have
a right to have privacy, and within certain
limits, some choice about who your roommate is. And, you know, that's
like the beginning. Like, that's the
most meager level of rights you can imagine,
but it's the start of being able to do that. The last thing is that
the families sometimes are the ones that can
violate it as well. One of my colleagues has
called it the seagull syndrome. The family member who lives
farthest away flies into town and craps all over the plan. And so you have to come to-- we have to be able to
name, what is the plan? who will make decisions
when you can't, and what are your instructions for them
about what really matters? AUDIENCE: Thank you. TOM SMITH: Well,
let's see if we can get through another question. ATUL GAWANDE: Sorry, my
answers are all long. I'll try to be pithier. AUDIENCE: Hi,
thanks for the talk. Didn't expect to cry
at work today, but-- ATUL GAWANDE: Sorry. AUDIENCE: In the cancer
study you mentioned earlier, you said that the people who
also received palliative care lived 25% longer. Seems like one
explanation could be that they had something
to fight for, to live for, and their body's natural
defenses may be stepped up? Is their any research
into this topic? ATUL GAWANDE: Yeah, it's
hard to know exactly, but my suspicion is that we
know, for example, getting chemotherapy or surgery
that is non-beneficial only makes you worse. They're toxic. Surgeries is easy to imagine. Almost 10% of the
population has an operation, a last ditch operation in
their last week of life. You've got all of
the complications, you have all of the
setbacks from that, you haven't had time to heal
to actually benefit from it. And chemotherapy can
be that way as well. But we have a hard
time, it feels like giving up to
say I'm not going to go for the chemotherapy. But if the chemotherapy
is sacrificing, making you lose what was worth
living for in the first place, then that can be harm
in and of itself. So we know at least some
of it is just taking away the toxicity of therapies
that are harmful to most even if they benefit some few. The second component
may well be that story. In the nursing home
I wrote about where Bill Thomas, the nursing
home abolitionist, was the medical
director, he got a start by deciding he was going
to let people have pets. And of course,
everybody freaked out. The staff, the director,
the regulators. You know, it's not safe. You can't let a pet-- suppose
someone has allergies. Who's going to
clean up the poop? All of those kinds of questions. But he got it through. People got to have
their own pets. And suddenly getting
to have something that you cared for, something
that gave you love, life as part of what you're doing,
something to look forward to, whatever it was about it,
the use of anti-psychotics and anti-depressants fell by a
third and survival increased. So there's something to both. AUDIENCE: Hi. It seemed like
reframing the question and addressing the
problem in a different way was crucial to this book. What other areas of
medicine or society at large do you think really need to
have the problem reframed? ATUL GAWANDE: More
and more I find that having had that problem
reframed in that way to say, which is basically,
now what's the goal? Knowing that the
goal has to be bigger than the survival question. I find I run into this all
the time and that people who run into it frequently. That basically bad situations,
handling bad situations are often where organizations
and individuals hit the wall. You made a plan,
it was to achieve X, goal you forget
the goal, and then you start plowing
ahead on the plan. But when it doesn't
work out, things aren't really what you hoped
they would be, we don't often reset and really ask, what
is the goal along the way? What are we actually
trying to accomplish? And then how do we align what
we're doing with that goal? So that can be as
simple as any situation where you require
the help of others. That coordination is always
about setting the goal. In retrospect, I'd
written my previous book, for example, about surgical
care and the use of checklists, and trying that out in
surgery in applying, you know, the ways that people had
handled safety in aviation and everything else. And what we were
slowly learning about-- so in that book I talk about how
we designed a checklist where you would run through
19 key steps out of data showing us where the
biggest failures in surgery were that could be averted. That this two minute checklist
before every operation reduce deaths 47% across
eight cities in the world. We now have replicated it. We rolled it out in France. It was a 35%
reduction in mortality across France, 21% in Scotland,
22% in South Carolina. And then we've slowly picked
apart what has made it work. And we're getting bigger
benefit than just, you know, it's like make sure
you have an antibiotic and make sure that you
identified the right patient. That you're operating
on the right person, doing the right operation. The biggest values comes
from the team actually stopping and figuring
out, all right, what is the goal here today? You know, it's the nurse, the
anesthesiologist, the surgeon saying, just for a minute-- the surgeon reviews what's the
goal of the operation, what's the plan they're planning
to go through it with. The anesthesiologist
reviews what are the medical issues of
the patient and the concerns that the team should be aware
of that's in their mind. The nurse reviews what's
the equipment situation, infection control, any
questions that they have. And only then, you proceed. And that's where the biggest
benefit is turning out to come from, is the
ability to be coordinated around a complex
goal and then having feedback points along the way to
say, has the situation changed? Do we have to reorient
in other ways? So they reset again at
the end of the operation. Now what's the goal for the
next 24 hours of recovery and have we made sure
all of the orders and all of the
plans are lined up and the communication
is set that way? It sounds so kindergarten. Like you would think, you mean,
you didn't do this already? And the answer is, we don't. And unless you make it a kind of
systematic part of what you do, you really do end up with
suffering in whatever form you're dealing with. AUDIENCE: Hi. You touched on this
topic a couple of times peripherally already
but in your book, you have a couple of examples
of people who ended up having to go to assisted living
facilities because of the very real health hazards they face. And so where do you draw the
line between allowing them autonomy and like where
they're at real risk, especially for patients
who might not fully comprehend their situation? ATUL GAWANDE: Yeah. It's a hard question, right? So do you allow
autonomy for people to make mistakes in their life? And the answer is that
just because you now are in a wheelchair
shouldn't mean you lose all ability to
have that set of rights in that discussion. Someone with Alzheimer's is not
able to make those choices with full appreciation of the
situation they're in depending on what stage they're in,
if they're in advanced Alzheimer's. That said, the family
is able to do that. And opening up the door
to being able to say, well, just like the
person who talked about earlier, the family-- about 70% of us
will come to the end of life with a decision
maker, someone else having to make decisions for us. And that person is ill
equipped if they've never had that discussion about
what really matters to you. But then at that
point, they have to be able to know,
with that person, for example, that said
chocolate ice cream and football on television was
what really mattered to them, the person I heard it from
was his health care proxy, his daughter And she talked about how
important and meaningful that was for her. Because then when he
turned out to have a bleed in his spinal
cord where they said, well, we can take him back
to the operating room now but he will likely
be quadriplegic, she could ask the
question, well, will he be able to eat
chocolate ice cream and watch football on television? And they said, oh, yeah. This is not at the level where
that would be sacrificed. And she said it was
an enormous relief to be able to know that
I can make this decision and understand what
he really cared about, and to fight for him to make
sure that the team followed through on what he
really knew about, and that they could hold
the whole family together as they did that. So I think that
that ability to even if people can't make
decisions for themselves, you can know by
talking before crisis comes and be better
equipped to be able to offer the
right direction when that moment comes. AUDIENCE: So hi. First of all, thank
you for the book. My own father also
died of cancer, and it was a hard
and necessary read. And I think it's interesting
that your book came out about three years
ago now and there seemed to be these various
sprouts of a larger discussion about end
of life care coming up not only from you, but
from various other sources. One thing I found interesting
is that in the book you touch only very
briefly on the subject of physician-assisted
suicide, et cetera, and it's been three
years since I read it so I don't want to
mischaracterize your position, but you seem to largely sort
of not so much rule it out, but your position seemed
to be that there were more important topics to discuss. But at the same time, these
other sprouts coming up. California recently passed
its assisted suicide law. My friend, Hope
[? Faulk ?] was part of that process of doing that. I'm curious, like, where is
your thinking now about this? Is this something that we
need to be talking about? ATUL GAWANDE: Well, so
the main concern I have is that the difference I
have with the people who have been in favor of assisted
death is that the goal to me is not a good death,
the goal is a good life all the way to the very end. And we have neglected
that process so deeply. And it starts not just in
the last weeks of life, it goes years ahead of that. For example, at the
extreme, in India, there is a bill that may
well pass for assisted death. Now, India is also a place
where you cannot get narcotics at home for, say, cancer pain. Or even after, like,
orthopedic surgery, you can't get that
kind of pain relief. And so if you're in severe
pain and we don't treat it and you're offered
assisted death, I would absolutely
take that option. That would be the
merciful thing. But not when we have
the treatment available. And so my great fear is
like the piano teacher lying incontinent in
pain in a hospital, life doesn't seem
to be worth living. If you'd said,
well, you might be able to actually get home
and teach for the time that you have, she would not
have said that assisted death. So knowing that she
wasn't depressed-- in other words, the rules are
know that you're not depressed, that you have a judgment from
two independent clinicians, and that you're making
this with sound mind. It doesn't address the
question that we don't actually take good care of people
towards the end of life. And as we try to take this
nationwide, in general, I'm not that alarmed by
assisted death in the sense that it's less than 1% of the
population that choose it. And then when people
get the medication to be able to take their
own life, less than half actually use it. It's often just a comfort
to know it's there as an option for them. So I have complex views on it
because I'm not totally 100% anti. I have lots of reasons why I
think that we're not valuing life adequately, however. AUDIENCE: I would worry if
anyone thought this was simple. ATUL GAWANDE: Right. Thank you. TOM SMITH: And
the last question. AUDIENCE: Hi, thanks
for being here. I'm curious about what
your vision for our country is in terms of health
care education. Whether you think there needs
to be a restructuring in the way that health care providers are
thinking about end of life, or if more of the onus is
on common day people, right? To be thinking a little
bit more carefully about what they want towards
the end of their life. And in further as you were
researching for this book, I'm wondering if you
noted different trends within this country that maybe
changed the way we thought about death, and also if you
noted maybe other cultures or other countries that
maybe have healthier or have had healthier
views on end of life. ATUL GAWANDE: Well, in
general, what I would-- this is a complex
question so let me try to answer it succinctly. I think that people
often differentiate between Eastern and Western
attitudes towards death. But when I write a lot
about the situation in India and now I've seen it in
China and in parts of Africa, and what we see is that
as economies improve, people move away from
extended families, they move into cities, they
become more independent. Economics gives young people
freedom and old people build up more wealth. What they choose at
that point is that often that dying in those
places too also becomes rapidly medicalized. 70%, 80% of dying in big cities
like in Beijing or in Delhi is now in hospitals,
and families going through this whole cycle
of bankrupting themselves over care that no one is really
having a discussion about it providing very little of value. In fact, increasing suffering. So my larger view of
it is that we actually are coming out the other
side in US health care. We have now gone from
less than 20% of people being on Hospice when they
come to the end of life to now it's 50% are there. It's become something that-- I didn't see a single death
when I was growing up. My kids have all had their
friends in the neighborhood where someone has died at home
and they were part of that. They saw that process
unfold over time and saw it be part of our
culture again in a way. And I think that's
a very good thing, and it's becoming a
less threatening thing. And we've come a long way from
three years ago when the book came out and it was about death
panels discussions at that time, to where now
there's not only my book, but Paul Kalanithi's
"When Breath Becomes Air," and you have Oliver
Sacks' "Gratitude," published after he died, and
a wealth of other discussions that are opening out and
recognizing that we can be thinking about how to live
a good life across the whole lifespan. And then the last thing about
education is that along the way we have formed a
coalition in Massachusetts that we're testing out the
proposition of it clearly can't be just the
public campaign, but you need ways that we are
all having these conversations more generally. But when people come into
contact in the clinical world, less than 15% have
this conversation with their clinician
even when they've had a hospitalization
in the last year. And if they're going to have
it, the vast majority of time they have to start it. The clinicians are unwilling to. Clinicians aren't trained to. Very uncomfortable. And so we have gotten agreement
with all four medical schools in the state of Massachusetts
to now incorporate the training into the curriculum
and start that process. We're trying to get
the nursing schools now to incorporate it as well. So I think we're
starting to create the pathway that these
communication skills become more widespread, but it's
still an uphill left. It's still a small percentage
where the clinicians really are comfortable and understand
what I had to go out and write a book to learn about. TOM SMITH: So thank you so
much for taking time out of your jam packed schedule. And the hard core fans that are
still here should join me in-- ATUL GAWANDE: Thank you. TOM SMITH: Thank you. [APPLAUSE]
