Gawande Quotes & Sayings

So this is the way it unfolds. In the absence of what people like my grandfather could count on - a vast extended family constantly on hand to let him make his own choices - our elderly are left with a controlled and supervised institutional existence, a medically designed answer to unfixable problems, a life designed to be safe but empty of anything they care about. — Atul Gawande

You would think that this would be whether the entrepreneur's idea is actually a good one. But finding a good idea is apparently not all that hard. Finding an entrepreneur who can execute a good idea is a different matter entirely. One needs a person who can take an idea from proposal to reality, work the long hours, build a team, handle the pressures and setbacks, manage technical and people problems alike, and stick with the effort for years on end without getting distracted or going insane. Such people are rare and extremely hard to spot. — Atul Gawande

We yearn for frictionless, technological solutions. But people talking to people is still the way norms and standards change. — Atul Gawande

This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. — Atul Gawande

But as your horizons contract - when you see the future ahead of you as finite and uncertain - your focus shifts to the here and now, to everyday pleasures and the people closest to you. — Atul Gawande

human beings fail the way all complex systems fail: randomly and gradually. — Atul Gawande

Each year, about 350,000 Americans fall and break a hip. Of those, 40 percent end up in a nursing home, and 20 percent are never able to walk again. — Atul Gawande

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. — Atul Gawande

She was doing impressively well, he said. She was mentally sharp and physically strong. The danger for her was losing what she had. The single most serious threat she faced was not the lung nodule or the back pain. It was falling. Each year, about 350,000 Americans fall and break a hip. Of those, 40 percent end up in a nursing home, and 20 percent are never able to walk again. The three primary risk factors for falling are poor balance, taking more than four prescription medications, and muscle weakness. Elderly people without these risk factors have a 12 percent chance of falling in a year. Those with all three risk factors have almost a 100 percent chance. — Atul Gawande

I think the extreme complexity of medicine has become more than an individual clinician can handle. But not more than teams of clinicians can handle. — Atul Gawande

This was not guilt: guilt is what you feel when you have done something wrong. What I felt was shame: I was what was wrong. — Atul Gawande

A study led by the Harvard researcher Nicholas Christakis asked the doctors of almost five hundred terminally ill patients to estimate how long they thought their patient would survive, and then followed the patients. Sixty-three per cent of doctors overestimated survival time. Just seventeen per cent underestimated it. The average estimate was five hundred and thirty per cent too high. And, the better the doctors knew their patients, the more likely they were to err. — Atul Gawande

I was never born to write. I was taught to write. And I am still being taught to write. — Atul Gawande

It turns out that inheritance has surprisingly little influence on longevity. James Vaupel, of the Max Planck Institute for Demographic Research, in Rostock, Germany, notes that only 3 percent of how long you'll live, compared with the average, is explained by your parents' longevity; by contrast, up to 90 percent of how tall you are is explained by your parents' height. Even genetically identical twins vary widely in life span: the typical gap is more than fifteen years. If our genes explain less than we imagined, the classical wear-and-tear model may explain more than we knew. — Atul Gawande

It is not death that the very old tell me they fear. It is what happens short of death - losing their hearing, their memory, their best friends, their way of life. As Felix put it to me, "Old age is a continuous series of losses." Philip Roth put it more bitterly in his novel Everyman: "Old age is not a battle. Old age is a massacre. — Atul Gawande

As medical progress has extended our lives, the result has been what's called the "rectangularization" of survival. — Atul Gawande

As people's capacities wane, whether through age or ill health, making their lives better often requires curbing our purely medical imperatives - resisting the urge to fiddle and fix and control. — Atul Gawande

need to understand how much you're willing to go through to have a shot at being alive and what level of being alive is tolerable to you. — Atul Gawande

Even worse than losing self-confidence, though, is reacting defensively. There are surgeons who will see faults everywhere except in themselves. They have no questions and no fears about their abilities. As a result, they learn nothing from their mistakes and know nothing of their limitations. As one surgeon told me, it is a rare but alarming thing to meet a surgeon without fear. "If you're not a little afraid when you operate," he said, "you're bound to do a patient a grave disservice. — Atul Gawande

Cost is the spectre haunting health reform. For many decades, the great flaw in the American health-care system was its unconscionable gaps in coverage. — Atul Gawande

What is the alternative to understanding the complexity of the world? — Atul Gawande

Death, of course, is not a failure. Death is normal. Death may be the enemy, but it is also the natural order of things. — Atul Gawande

Just using a checklist requires [doctors] to embrace different values from ones we've had, like humility, discipline, teamwork. — Atul Gawande

Medicine was just another a tool you could try, no different from a healing ritual or a family remedy and no more effective. — Atul Gawande

The risk of a fatal car crash with a driver who's eighty-five or older is more than three times higher than it is with a teenage driver. — Atul Gawande

The evidence is that people who enter hospice don't have shorter lives. In many cases they are longer. — Atul Gawande

You may not control life's circumstances, but getting to be the author of your life means getting to control what you do with them. — Atul Gawande

All we ask is to be allowed to remain the writers of our own story. That story is ever changing. Over the course of our lives, we may encounter unimaginable difficulties. Our concerns and desires may shift. But whatever happens, we want to retain the freedom to shape our lives in ways consistent with our character and loyalties. — Atul Gawande

When I do an operation, it's half a dozen people. When it goes beautifully, it's like a symphony, with everybody playing their part. — Atul Gawande

I think we are faced in medicine with the reality that we have to be willing to talk about our failures and think hard about them, even despite the malpractice system. I mean, there are things that we can do to make that system better. — Atul Gawande

If I get hit by a bus tomorrow, my patients will not even be postponed. Another surgeon would step in and take over. The reason to do research and writing is that it at least makes me feel not entirely replaceable. If I didn't write, I don't know if I would do surgery. — Atul Gawande

they have priorities beyond merely being safe and living longer; that the chance to shape one's story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone's lives. Inevitably, — Atul Gawande

We are used to thinking of doctoring as a solitary, intellectual task. But making medicine go right is less often like making a difficult diagnosis than like making sure everyone washes their hands. — Atul Gawande

We are increasingly the generals who march the soldiers onward, saying all the while, "You let me know when you want to stop." All-out treatment, we tell the incurably ill, is a train you can get off at any time - just say when. But for most patients and their families we are asking too much. They remain riven by doubt and fear and desperation; some are deluded by a fantasy of what medical science can achieve. Our responsibility, in medicine, is to deal with human beings as they are. People die only once. They have no experience to draw on. They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come - and escape a warehoused oblivion that few really want. — Atul Gawande

Was once on trauma duty when a young man about twenty years old was rolled in, shot in the buttock. — Atul Gawande

The health-care sector certainly employs more people and more machines than it did. But there have been no great strides in service. In Western Europe, most primary-care practices now use electronic health records and offer after-hours care; in the United States, most don't. — Atul Gawande

She felt her sanity slipping. She wanted to be a good daughter. She wanted her father to be safe, and she wanted him to be happy. But she wanted a manageable life, too. — Atul Gawande

The core predicament of medicine - the thing that makes being a patient so wrenching, being a doctor so difficult, and being a part of society that pays the bills they run up so vexing - is uncertainty. With all that we know nowadays about people and diseases and how to diagnose and treat them, it can be hard to see this, hard to grasp how deeply uncertainty runs. As a doctor, you come to find, however, that the struggle in caring for people is more often with what you do not know than what you do. Medicine's ground state is uncertainty. And wisdom - for both the patients and doctors - is defined by how one copes with it. — Atul Gawande

If the conversation people think is coming is the 'death panel' conversation, that's a total failure. — Atul Gawande

The volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. — Atul Gawande

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 healthcare, education, climate change, making a pathway out of poverty - is the great task of our generation as a whole. — Atul Gawande

Modernization did not demote the elderly. It demoted the family. It gave people - the young and the old - a way of life with more liberty and control, including the liberty to be less beholden to other generations. The veneration of elders may be gone, but not because it has been replaced by veneration of youth. It's been replaced by veneration of the independent self. * * * — Atul Gawande

It's easy to hide in a statement. It's hard to hide between statements," Cook said. — Atul Gawande

Checklists turn out ... to be among the basic tools of the quality and productivity revolution in aviation, engineering, construction - in virtually every field combining high risk and complexity. Checklists seem lowly and simplistic, but they help fill in for the gaps in our brains and between our brains. — Atul Gawande

The routine requires balancing a number of virtues: freedom and discipline, craft and protocol, specialized ability and group collaboration. And for checklists to help achieve that balance, they have to take two almost opposing forms. They supple a set of checks to ensure the stupid but critical stuff is not overlooked, and they supply another set of checks to ensure people talk and coordinate and accept responsibility while nonetheless being left the power to manage the nuances and unpredictabilities the best they know how. — Atul Gawande

Faulty memory and distraction are a particular danger in what engineers call all-or-none processes: whether running to the store to buy ingredients for a cake, preparing an airplane for takeoff, or evaluating a sick person in the hospital, if you miss just one key thing, you might as well not have made the effort at all. A — Atul Gawande

Consider the case of La Crosse, Wisconsin. Its elderly residents have unusually low end-of-life hospital costs. During their last six months, according to Medicare data, they spend half as many days in the hospital as the national average, and there's no sign that doctors or patients are halting care prematurely. Despite average rates of obesity and smoking, their life expectancy outpaces the national mean by a year. — Atul Gawande

There was a succession of roommates, never chosen with her input and all with cognitive impairments. Some were quiet. One kept her up at night. She felt incarcerated, like she was in prison for being old. The — Atul Gawande

The earliest portions to shrink are generally the frontal lobes, which govern judgment and planning, and the hippocampus, where memory is organized. As a consequence, memory and the ability to gather and weigh multiple ideas - to multitask - peaks in midlife and then gradually declines. — Atul Gawande

Lacking a coherent view of how people might live successfully all the way to their very end, we have allowed our fates to be controlled by the imperatives of medicine, technology, and strangers. I wrote this book in — Atul Gawande

When we lived in a society where we had large families that lived together, especially in agricultural societies like my grandfather and father grew up in, the result is you always had family around to take care of you. — Atul Gawande

If end-of-life discussions were an experimental drug, the FDA would approve it. — Atul Gawande

It is unsettling to find how little it takes to defeat success in medicine. You come as a professional equipped with expertise and technology. You do not imagine that a mere matter of etiquette could foil you. But the social dimension turns out to be as essential as the scientific
matters of how casual you should be, how formal, how reticent, how forthright. Also: how apologetic, how self-confident, how money-minded. In this work against sickness, we begin not with genetic or cellular interactions, but with human ones. They are what make medicine so complex and fascinating. How each interaction is negotiated can determine whether a doctor is trusted, whether a patient is heard, whether the right diagnosis is made, the right treatment given. But in this realm there are no perfect formulas. — Atul Gawande

Our health-care morass is like the problems of global warming and the national debt - the kind of vast policy failure that is far easier to get into than to get out of. Americans say that they want leaders who will take on these problems. — Atul Gawande

When, as the researchers put it, "life's fragility is primed," people's goals and motives in their everyday lives shift completely. It's perspective, not age, that matters most. Tolstoy — Atul Gawande

For all but our most recent history, death was a common, ever-present possibility. It didn't matter whether you were five or fifty. Every day was a roll of the dice. — Atul Gawande

There are, in human affairs, two kinds of problems: those which are amenable to a technical solution and those which are not. Universal health-care coverage belongs to the first category: you can pick one of several possible solutions, pass a bill, and (allowing for some tinkering around the edges) it will happen. — Atul Gawande

Health care confronts us with a difficult test. We have never corrected failure in something so deeply embedded in people's lives and in the economy without the pressure of an outright crisis. — Atul Gawande

There are good checklists and bad, Boorman explained. Bad checklists are vague and imprecise. They are too long; they are hard to use; they are impractical. They are made by desk jockeys with no awareness of the situations in which they are to be deployed. They treat the people using the tools as dumb and try to spell out every single step. They turn people's brains off rather than turn them on. Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything - a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps - the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical. The power of — Atul Gawande

Alice insisted the accelerator had got stuck. She thought of herself as a good driver and hated the idea that anyone would think that the problem was her age. The body's decline creeps like a vine. Day to day, the changes can be imperceptible. You adapt. Then something happens that finally makes it clear that things are no longer the same. The falls didn't do it. The car accident didn't do it. Instead, it was a scam that did. Not long after the car accident, Alice — Atul Gawande

Thinking about averting plane crashes in 1935, or stopping infections of central lines in 2003, or rescuing drowning victims today, I realized that the key problem in each instance was essentially a simple one, despite the number of contributing factors. — Atul Gawande

So you want to keep the list short by focusing on what he called "the killer items" - the steps that are most dangerous to skip and sometimes overlooked nonetheless.
The wording should be simple and exact, Boorman went on, and use the familiar language of the profession. Even the look of the checklist matters. Ideally, it should fit on one page. It should be free of clutter and unnecessary colors. — Atul Gawande

I learned about a lot of things in medical school, but mortality wasn't one of them. — Atul Gawande

So for any new checklist created from scratch, you have to pick the type that makes the most sense for the situation.
The checklist cannot be lengthy. A rule of thumb some use is to keep it to between five and nine items, which is the limit of working memory. — Atul Gawande

We are not omniscient or all-powerful. Even enhanced by technology, our physical and mental powers are limited. — Atul Gawande

accepted stoically, without fear or self-pity or hope for anything — Atul Gawande

Courage is strength in the face of knowledge of what is to be feared or hoped. Wisdom is prudent strength. — Atul Gawande

I was willing to be rejected. That's what allows you to be a good salesperson. You have to be willing to be rejected. — Atul Gawande

In the face of the unknown - the always nagging uncertainty about whether, under complex circumstances, things will really be okay - — Atul Gawande

Sometime over the last several decades - and it is only over the last several decades - science has filled in enough knowledge to make ineptitude as much our struggle as ignorance. — Atul Gawande

We've been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. — Atul Gawande

But it's not only the breadth and quantity of knowledge that has made medicine complicated. It is also the execution - the practical matter of what knowledge requires clinicians to do. — Atul Gawande

The hardest question for anyone who takes responsibility for what he or she does is, What if I turn out to be average? — Atul Gawande

For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by the significant moments, the ones where something happens. Measurements of people's minute-by-minute — Atul Gawande

Death is the enemy. But the enemy has superior forces. Eventually, it wins. And in a war that you cannot win, you don't want a general who fights to the point of total annihilation. You don't want Custer. You want Robert E. Lee, someone who knows how to fight for territory that can be won and how to surrender it when it can't, someone who understands that the damage is greatest if all you do is battle to the bitter end. — Atul Gawande

Living is a kind of skill. The calm and wisdom of old age are achieved over time. — Atul Gawande

The striking thing is that WHO doesn't really have the authority to do any of this. It can't tell governments what to do. It hires no vaccinators, distributes no vaccine. It is a small Geneva bureaucracy run by several hundred international delegates whose annual votes tell the organization what to do but not how to do it. ... The only substantial resource that WHO has cultivated is information and expertise. — Atul Gawande

And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us. — Atul Gawande

Just ticking boxes is not the ultimate goal here. Embracing a culture of teamwork and discipline is. And if we recognised the opportunity, the two-minute WHO checklist is just a start. — Atul Gawande

Here, then, is our situation at the start of the twenty-first century: We have accumulated stupendous know-how. We have put it in the hands of some of the most highly trained, highly skilled, and hardworking people in our society. And, with it, they have indeed accomplished extraordinary things. Nonetheless, that know-how is often unmanageable. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields - from medicine to finance, business to government. And the reason is increasingly evident: the volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us. That — Atul Gawande

The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don't want a general who fights to the point of total annihilation. You don't want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn't, someone who understood that the damage is greatest if all you do is fight to the bitter end. — Atul Gawande

The third requirement for success is ingenuity - thinking — Atul Gawande

Gawande reports that research has shown that patients commonly prefer to have others make their decisions for them. Though as many as 65 percent of people surveyed say that if they were to get cancer, they would want to choose their own treatment, in fact, among people who do get — Barry Schwartz

In every industrialized nation, the movement to reform health care has begun with stories about cruelty. — Atul Gawande

The purpose of medical schooling was to teach how to save lives, not how to tend to their demise. — Atul Gawande

I asked her about this. But she couldn't put her finger on what made her unhappy. The most common complaint she made is one I've heard often from nursing home residents I've met: "It just isn't home." To Alice, Longwood House was a mere facsimile of home. And having a place that genuinely feels like your home can seem as essential to a person as water to a fish. — Atul Gawande

A nurse has five seconds to make a patient like you and trust you. It's in the whole way you present yourself. I do not come in saying, 'I'm so sorry.' Instead, it's: 'I'm the hospice nurse, and here's what I have to offer you to make your life better. And I know we don't have a lot of time to waste. — Atul Gawande

There is, however, a skill to it, a developed body of professional expertise. One may not be able to fix such problems, but one can manage them. And until I visited my hospital's geriatrics clinic and saw the work that the clinicians there do, I did not fully grasp the nature of the expertise involved, or how important it could be for all of us. — Atul Gawande

Terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression. — Atul Gawande

If there is a credo in practical medicine, it is that the important thing is to be sensible. — Atul Gawande

No, the more familiar and widely dangerous issue is a kind of silent disengagement, the consequence of specialized technicians sticking narrowly to their domains. "That's not my problem" is possibly the worst thing people can think, whether they are starting an operation, taxiing an airplane full of passengers down a runway, or building a thousand-foot-tall skyscraper. — Atul Gawande

MODERN SCIENTIFIC CAPABILITY has profoundly altered the course of human life. People live longer and better than at any other time in history. But scientific advances have turned the processes of aging and dying into medical experiences, matters to be managed by health care professionals. And we in the medical world have proved alarmingly unprepared for it. — Atul Gawande

We don't like checklists. They can be painstaking. They're not much fun. But I don't think the issue here is mere laziness. There's something deeper, more visceral going on when people walk away not only from saving lives but from making money. It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us - those we aspire to be - handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists. Maybe our idea of heroism needs updating. — Atul Gawande

In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality and created a new difficulty for mankind: how to die. — Atul Gawande

Effort does matter; diligence and attention to the minutest details can save you. — Atul Gawande

In the past, surviving into old age was uncommon, and those who did survive served a special purpose as guardians of tradition, knowledge, and history. — Atul Gawande

Those of us in medicine don't help, for we often regard the patient on the downhill as uninteresting unless he or she has a discrete problem we can fix. — Atul Gawande

They provided assisted living, but no one seemed to think it was their job to actually assist him with living — Atul Gawande

The writing I love has something memorable in it - an image, a smell. It's the connection between the moment and the whole concept, weaving the micro together with the macro so that it has a hold on people - that's writing. — Atul Gawande

There have now been many studies of elite performers - international violinists, chess grand masters, professional ice-skaters, mathematicians, and so forth - and the biggest difference researchers find between them and lesser performers is the cumulative amount of deliberate practice they've had. Indeed, the most important talent may be the talent for practice itself. — Atul Gawande