Health Care Needs a New Kind of Hero

In his latest book, The Checklist Manifesto, surgeon and writer Atul Gawande describes how asking some simple questions before surgery starts—such as “Did we give the patient her antibiotic?” and even “Did we introduce ourselves to one another?”—can reduce infections and deaths by more than a third. Easy as this exercise is, it’s often met with hostility, because it challenges doctors’ cherished notions about status, autonomy, and expertise. In this edited interview, HBR senior editor Gardiner Morse asks Gawande what checklists reveal about the culture of medicine and how its dysfunctions might be fixed.

HBR: Despite doctors’ resistance to new ideas, surgical checklists are gaining a foothold. What does that tell us about how to speed up other changes in health care?

Atul Gawande: If you try to impose a new practice by simply telling the front line “Do this,” it will fail. That’s particularly true for something like a checklist, which many surgeons at first felt was beneath them. To get people to embrace a practice, it has to be easy and quick to use, adaptable to a variety of settings, and of obvious benefit. In hospital after hospital, checklists reduced mistakes and saved lives, and clinicians who used them saw greater efficiency and teamwork, which made them willing to continue using them. My operating room finishes up earlier in the day than others, which is one reason people like our checklists. The other crucial thing is having senior people who practice what they preach. When we piloted checklists in hospitals around the world, we asked the chiefs of surgery, anesthesiology, and nursing to be the first people to use them.

Health care is moving toward teams, but that collides with the image of the all-knowing, heroic lone healer.

That’s right. We’ve celebrated cowboys, but what we need is more pit crews. There’s still a lot of silo mentality in health care—the mentality of “That’s not my problem; someone else will take care of it”—and that’s very dangerous.

“We’ve celebrated cowboys, but what we need is more pit crews.”

How do we move toward a culture where effective teams are the norm?

Part of the answer is a change in medical training. Most medicine is delivered by teams of people, with the physician, in theory, the team captain. Yet we don’t train physicians how to lead teams or be team members. This should begin in medical school. One of the most fascinating experiments along these lines is at the University of Nevada at Reno, where the schools of medicine and nursing have combined facilities and courses. Doctors and nurses in training are learning how to work together. It’s a brand-new thing.

But simply training people in team techniques isn’t enough, is it? To get effective collaboration, don’t you have to change doctors’ self-image?

The stories we doctors tell ourselves about what it means to be great are very important to who we are, but they create a cognitive dissonance. We like to imagine we can be infallible and be that heroic healer. But the fact is, it’s teams and, often, great organizations that make for great care, not just individuals. So we need to change these stories we tell ourselves and reshape the discussion.

How can you do that?

Well, for instance, when you use a checklist in the OR, there’s a moment when you ask all the people in the room to introduce themselves by name. That’s been the source of the greatest resistance, actually. It seems hokey. But when you do it, people say, “I’m Bob, the anesthesiologist; I’m Susan, the anesthesia resident; I’m Tim, the nurse.” So when it comes to you, are you going to say, “I’m Doctor Gawande”? Or are you going to use your first name? The list actually helps to change the culture. Over and over again the feedback—especially from nurses and, often, the junior people on the team—has been that it’s one of the most valuable steps. It raises the question “Is the hierarchy flattened here? Are we going to be a team?”

You wrote, “Maybe our idea of heroism needs updating.” What did you mean?

Think of Sully Sullenberger, the pilot who landed that plane on the Hudson River. The way the public saw him was similar to how it wants to see doctors, and how doctors want to see themselves. The story the public had about him was that he was an unbelievable pilot, and that’s what saved the plane. He was the hero. But he kept saying no, it was adherence to protocol and teamwork that allowed us to safely land the plane. Heroism in medicine ought to mean having the humility to recognize that we are more likely to fail on our own, and embracing teamwork to help us provide the best care.

But that works only if patients are willing to meet doctors halfway. Don’t most patients want their doctor to be the old-fashioned kind of hero?

Not necessarily. When he was sick, Ted Kennedy wanted a heroic team, not a heroic individual. He had the neurosurgeons actually sit in his living room in Hyannis and argue with one another, and he conducted it like a seminar. “Well, Dr. X is arguing this—why wouldn’t I do that?” he’d say. “Can you guys sort it out? I’m not the expert here. You guys are. Don’t tell me, tell each other.” As a result, he got wise care that allowed him to achieve a longer and more effective run at the end of his life than many of his doctors thought was possible. It’s what we would all wish to have.

Isn’t that what second opinions are for—to produce wise care?

The second opinion is a tremendously flawed institution. The idea is that you get two assessments and then pick the best doctor, the one you’ll go with. But what you usually get is two different opinions, and then you don’t know what to do. What you really want is for those two doctors to talk to each other.