[Applause] [Music] [Applause] [Music] conversations with Tyler is produced by the mercada center at George Mason University Bridging the Gap between academic ideas and real world problems learn more at marcus.org and for more conversations including videos transcripts and upcoming dates visit conversations withth tyler.com I'm here up in Boston with the tul goand and we're going to talk about Health
Health Care Health Care policy and a tool goand himself so let me start with a question about artificial intelligence how far are we from having an AI that is capable of actually doing diagnosis to people that is they might speak into a Skype connection something like Watson would hear what they say and they would then diagnose the person well enough that this would be a usable form of
health care it's that far close massively far I think it's I think is one of the hardest things um you you want me to tell why tell us why yes okay so um the diagnosis process people imagine what it is is that people come to you with a crisply defined problem I have symptom one two three uh I have data and uh to add to it and now give me the answer and the reality is first of all people come to you often unable to
explain what their problem is I have pain where hm well it's sort of here and they'll point with a hand well do you mean there under your rib cage or is it you mean in your chest or you know so you have this probing process that is part of it and the and and how they tell the story and then there's also how the their story had evolved over time and they often have to put it in their words
so it's it's more of a narrative than it is a straight set of data so that's that's problem one you know when I think of IBM Watson put their AI on this problem and it is it would never be the problem I would have put them on the second part of it is that it changes over time and you're adding data along the way and so um uh and and you know you you're integrating it with a little
bit about your view of the understanding of the person and their likelihood to com to to you know bring to to even say that something is a major symptom or not there is no question that you can augment the human capability and um but the idea that you know uh uh that you know pull out your phone and it will be uh it'll it would give you the diagnosis it is still one of the hardest problems in reducing error in
medicine is the fact that we um uh that we still have a high rate of error and and the sources of the error have to do with the human being rather than the calculation but say you only get 15 minutes with your doctor which is pretty common and as you know those conversations don't always run so well people are intimidated they forget the right question to ask you could have three hours talking to something like
Watson maybe 80% of the dialogue is nonsense but at the end you apply machine learning and keep in mind the alternative now is that people use Google which is in a sense the world's number one doctor right so AI only needs to be better than Google which is already a form of AI so in that sense isn't it just around the corner that it would be a marginal Improvement on what we have today yeah so one is the the
replacement question right so can I simply have something that will make the diagnosis and lots of reasons why that's difficult but now to augment the human capability absolutely um there already is a a pro there are programs one example is called Isabel where um if the clinician having a listed at all of this information can simply put the the um uh the observations into a list it will uh
allow them to recognize okay fine you think it's problem uh that what they have is diagnosed one but here are eight others in rank order of consideration compared to the one that you think and there have been um uh plenty of studies and it's been around for more than a decade without the need for AI this is just this is just crunching some basic data to begin with um that uh that that can add and that can add add real value
um the I think the the puzzle of it is that um you need that capability to integrate information coming from the person interpreted and be able to to to get it into these kinds of systems and and in many cases people may be able to do some of that uh over time uh for themselves how worried are you about crisper imagine parents sitting down trying to shape the children they will
have using advanced technology of some kind or another will those parents on average make the right choices improving choices will this be a disaster what's your view so crisper the the great thing about this podcast is I'm going to presume we don't need to explain what Gene editing is for this audience you're right but um so there are plenty of reasons to be worried about crisper in my mind um the
one you just named is not one of them um just like in the days of you know the first invitro fertilization and the and and um baby Louise who was the first test Tu baby and now what's going to happen and we're going to we're going to we're going to destroy humanity and all of those kinds of things um uh I don't think that's that's the case yes there will be some forms of selection we
already have massive amounts of sex sex selection in the world which um uh uh is is a problem is a serious problem that's that's very harmful but has nothing to do with uh Advanced Technologies it has to do with the basic capabilities of ultrasound and um uh and uh selective abortion going on all over the world the uh the issues with crisper um have to do with the capacity to uh add other first
of all there's unpredictable things that people will discover that you can try to do with Gene editing and then you couple it with capabilities for example um crisper enables Gene editing uh that you know is basically is fairly fixed um but if you now can at that edited Gene uh in a mosquito or in another organism now you can have rapid cycle uh diffusion of those kinds of capabilities and I don't
think we've uh thought through that in the least but won't parents discriminate against having strange or weird or unusual children that his parents will be too risk averse so maybe a stranger person has a higher chance of being a genius a lot of parents they just want kids who are sort of 15% better than they are and more or less along the same dimensions there's a great artic article this week uh about George Church's
narcolepsy yes uh in uh in stat news and uh and the the the danger to me isn't crisper the danger is the larger culture that it goes into of which crisper is just one of many capabilities so George Church um uh famous uh uh genomics uh Pioneer uh biotech researcher uh who's had tremendous influence and has been one of the most creative forces in the field um has narcolepsy he attributes a
lot of his um uh insights and capabilities the fact that he falls into a deep REM sleep at the drop of a hat and then wakes up during Seminars the best time right right he had to stop driving because of what happened during driving but he would drop into these dream states and then wake up with unbelievable ideas and there's lots of ways in which he is a you know a unique and uh and and a parent might think uh
uh you know uh aberant person person um and you wouldn't select for what he has brought to the world and there are lots of you know neuroatypical uh uh phenotypes the crisper capability is just another uh uh bullet in the holster that can be fired but we're we are uh narrowing that neurotypical range in in lots and lots of different directions whether it's how we employ people what kinds of options we put out
there for uh people to have their uh their aberant thinking uh recognized and and taken advantage of to the medic the ways we medicate and uh and control people um and I think crisper it actually will be exceedingly difficult uh to be able to pick many of these capabilities out in part because they're multi- Gene the these are not uh conditions that have to do that are very
often have to do with point mutations that you just adjust they are interactions among many gen you run big data and every generation the chance of outliers Falls by 1% and then over time it's going to make a big difference right that's right it's not that you control the kid who's going to pop out of the womb in nine months but over time uh it seems it will compound uh it seems more and more patients are awake during
surgery right yes awake procedures how is this changing the culture of the operating room oh yeah so it's been very interesting um we uh one of the things I brought into surgery with our team has been uh running a series of uh running a checklist just like a pilot's checklist in the operating room and one of the things you realize is that when you have an awake patient in the operating room
they can be part of the team sure and and you know not just someone sitting there um who is uh annoyingly awake and so they're actually piping up to tell you they'd like to change the music you're playing but also that's what I would do right but there's but also that you're um you know so so in neurosurgery you are actually they're actively part of the operation because they're often
speaking and telling you things so that you know if you're causing any difficulties but what we've found um even in the kinds of operations I do which are not brain operations is that uh being able to um ask them at from the very beginning of the operation to be part of the team by saying you know are we on the same page about what your medical issues are what your goals are for the operation what we
have to look out for um uh in addition to the usual safety things but also you know what are the what are the key things oh you know I tend to have a bad back and um and I don't want to line this position for too long in many ways having people um awake can be far safer the other thing though is that there are people who when they're awake uh don't handle it very well and you have to be
able to uh adjust on the Fly and people have to understand that you may need to why do surgeons sometimes leave sponges behind in the bodies of patients who are being operated on you zered in on the first um uh one of my very first projects in creating intervention uh so we had done a case control study of of this problem of people of Surgeons leaving sponges inside people um uh and got it published in the New England
Journal partly because of our whole method of going about solving this problem which was um we studied 60 people who had sponges left inside them compared to 240 people at the same institution at the same time with the same operation who didn't have sponges left inside them and that was an interesting problem to me because the the rate of sponges being left inside people had been steady for 30 years we
had not made it go down at all it was right around 1 in a th000 to 1 in 3,000 or so operations a sponge would be left inside and it would be a disaster you would have to go back about 2third of the time people had become infected um one of the 60 was a patient who died because a um a small sponge had been left in their brain and uh the usual way that we track these things is by
counting everything at the beginning of the operation twice and everything at the end of an operation and what we found was that uh it wasn't because people were skipping the steps along the way the nurses were consistently Counting everything at the beginning and Counting everything at the end so it wasn't a broken uh system it was a fallible system so it's like counting whether you have 52 cards in the deck
and you have 51 and you or you have 53 um on a at a predictable rate of getting the count wrong and sure enough about 1 in 1500 to one in 3,000 times they would just get it wrong and not know it so we in that case um identified that we would need to create a in uh a technological solution so it was um uh you know that in the end we came up with a barcoding approach it's an interesting economic
problem there areund it's 140 at the time we were doing this it was $140 million sponge industry for which there was half a billion dollars spent per year on lawsuits for sponges being left inside so from a pricing point of view it worked out to about a penny of sponge so you had to have a solution that you know could double the price um to two cents or three cents uh but you couldn't stick a uh uh you you had to increase
the costs a lot if you're going to stick a microchip or a RFID system on there so we just put barcoding on there kept the costs pretty minimal and it and it completely eliminated the problem uh because now you have teams scanning them in as they uh as they do the operation at the beginning of the operation and then scanning all of the sponges out and the only fallibility is that that uh
people will ignore the machine and those are so there's the only times there have been sponges left after tens of millions of these kinds of cases do your awake patients ever come in with a checklist and at the end say hey if you got all your sponges um so I definitely have had uh I've not had people come in with a checklist but invariably and and uh and we actually they should right ask well
it's not that you want people to come in with their checklist right because each place has a flow and a way that they do it but you want to know is do you have does you does the place you go to do they use a checklist now they will always say that they do because because everybody does at some level but the key is uh does the checklist have them stop before the incision not to check that
you have the right person uh and the right side of the body which is something everybody standardly does but to actually make sure everybody in the room is introduced to one another and they've reviewed the goals of the operation and the key your key medical issues as well as the um the key points of the operation like what equipment are needed those are the big parts that the teams skip um but make a really big
difference what are the biggest mistakes and how checklists are used keeping in mind most of the people who do or could use them they're not people like you who've written books on checklists and who know many many different things but they're highly imperfect fallible people who are making mistakes anyway and if allowed to codify their mistakes in the form of a checklist can make things
worse rather than better what's your main worry about checklists yeah so um basically we rolled it out in uh in in our initial trial in eight cities around the world and found a 47% reduction in death when the teams took up the checklist the main barrier since then has been that it either becomes uh a tick boox effort or no one uses it at all so um the it was designed to turn people's brain on by enabling a
conversation about the critical events and concerns of the operation um and so what we see is a couple of things we we gathered for example uh we had people send in um the current the version of the checklist that they're using uh and about 150 places sent them in and part of it what was interesting is almost 100% change the checklist you have to change it to fit into your environment
for example um in England uh you put the patient to sleep outside the operating room and then you um and then you roll them in so the check has to the order of it has to change so one concern is that if you just use it out of the box um you're not really using you have to adjust it to your environment the second uh concern so looking at these 150 uh we'd see places that had turned our 19
item checklist the the most extreme example they turned it into an 81 item checklist it was impossible to use we specifically designed it to be something you could run through in 60 seconds or less at each each pause point so you weren't distracted from the main operation and you could see that the administration in the hospital had got a hold of it and they were using it to try to impose their ideas and if essentially
the clinical team was was not the team that had were designing and and controlling the checklist and so invariably you look at that and you know that everybody is completely ignoring it and it's become just a tick boox effort instead of a um uh an enabler of Greater capability let's say one of your kids further on is thinking of getting married and says Dad should I use a checklist yes or no yeah well I think
every every wedding planner this is the not for the ceremony for the choice of spouse oh for the choice of spouse so that's a very good question uh I suppose the first question is is it an arranged marriage or not an arranged marriage because if it's an arranged marriage that's practically a checklist process right but um but you know know love is uh if it's a love marriage love does not follow the
checklist there are now so many papers although there are probably some mistakes I could put on a checklist that would be really smart to consider you're leaning back toward the I Am there's so many papers you probably know all or most of them that appear to Show Low marginal values for health treatment on actual Health Care outcomes so Amish people who don't get that much health care they've good life expectancy
Christian Scientists there's the old 1970s Rand randomized control trial study where free healthcare only made the poorest of people healthier there's the Oregon Medicaid paper there's a few papers when the doctors go on strike more people don't die when they're sent to the hospital what do you make of all of this strand of literature and why does it seem to be such a weak connection
between health care and health outcomes yeah so I think it depends on what you measure and over what period of time so now there's been an accumulation of enough data about um uh for example uh coverage expansions like the ACA like the Massachusetts uh reforms Etc that I think there's actually some uh good understanding of what there is first of all they consistently show that people
get a range of services that they um that they uh get increased access to Primary Care Specialty Care medications chronic illness Care Emergency Care um the uh the the one the there are elements of it that are much more powerful than others um and so chronic illness care primary care and Mental Health Care seem to produce really substantial improvements in people's self-reported Health their physical
health and their uh and their mental health but self-reported health is tricky you look at life expectancy you look at the yish it's hard well I'm going to say two things about that number one is it's not obvious to me that um that uh that may not be a primary goal so first of all that your uh your reported well-being about your physical and mental health is in fact when people come in to see clinicians
what they're trying to optimize um the second part of it though is uh on in terms of survival then what you see is it takes time so uh the Oregon study for example was uh on aage only four years I think it was not even four years it was under a year and a half um for a small group of people and the um and the death reduction was not signif nonsignificant but the amount of death reduction you'd
have to achieve would have had to been greater than 50% reduction in death which is a a massive level in fact it measured a 16% reduction in death but it just wasn't significant the um the subsequent studies that have looked over longer periods of time they see two things first of all there are significant reductions of death the estimates are from 1 and 300 to one and um 800 people who gain coverage will per
year have their life saved um which is a high high level of value translates into tens of thousands of lives um uh but second is that you wouldn't be surprised that people getting treatment for their HIV for their cancer for their chronic diseases like high blood pressure and diabetes and so on it takes time to accumulate and um and it appears to be some years so like the Massachusetts
data where uh where basically what they show is that the strength of the value gets higher as time goes on there's a further underlying point which is though that um you know we are not actually maximizing by any reasonable measure those outcomes so the biggest killer in the country is high blood pressure we have uh a third of adults have high blood pressure um 60% uh are uh receiving incomplete and
inappropriate care within the medical system yes um and so they're they're not actually getting the biggest killer under control and that don't follow instructions well that that's that's a mix of um not necessarily getting the right treatment in the first place not getting the right followup and and yes it might not be not following instructions but when we poke into why well there's co-pays and deductibles
that can block out being on those medications and then people are making choices some people are having side effects that um lead them to stop it uh some people are just way disorganized and need um you know there's actually uh CVS has uh been able to track why people stop medication they have six different kinds of patterns with which people are not adherent to their medications Each
of which actually have effective Solutions uh to Target so you know the the the big point is high blood pressure is one of the simplest things that we can take on we're we're terribly organized for being able to deliver on it it's the biggest killer in the country Kaiser followed through on being able to take it instead of from only 40% appropriate care to greater than 80% and saw their entire population flipped from
the number one killer being cardiovascular disease they also worked on improving Statin use and um flipped from it being number one to no longer being the number one killer cancer now is the number one kill in their population Minnesota followed through on a similar program got adherence up to 70% and made the same flip as well and now we have several states where cardiovascular disease is no longer the
number one killer by getting some of these basic measures under control and that's just about Healthcare being good uh but uh having really poor reliability given the amount of money we spend in healthcare what's the number one thing missing in medical education today for doctors I think the number one thing is an education around the fact that we are no longer a craft it's no longer an
individual craft of being the smartest most experienced and capable individual um it's a profession that has exceeded the capabilities of any individual to uh have have to manage the volume of knowledge and skill required so we are now delivering as groups of people and knowing how to Be an Effective group how to solve problems when your group is not being effective and uh and to enable
that capability um that I think is not being taught um it's not being researched it it is it is the biggest opportunity to advance human health and we're not delivering on it the famous late 19th century early 20th century Dr William Osler he once said here's a quotation look wise say nothing and grunt speech was given to conceal thought true or false um false but uh there's a grain of Truth so one of the
things that I learned in writing my last book being mortal um was uh talking to paliative care clinicians and geriatricians and others who uh who who really have a different kind of approach to to practice they uh examining the way I practice what they would say I do is talk too much um and and as one put it your problem a tool is that you're an explain aholic our model of what a clinician does is that they are doctor
informative they give you um uh data about what condition you have data about the options here are the option a option b option C risks benefits Pros cons and now what would you like to do uh we Pro it's a conversation where we do 95% of the talking and then the patient does 5% and what they point out is that they the clinicians of the future really need to be oriented in a counselor mode where
they are not just telling you what the options are but also eliciting from you very clearly what your goals are and then making a recommendation about What mo most matches your goals so what are your priorities for your quality of life as as well as quantity of life so you know people have priorities besides mere survival when we don't ask and don't know how to ask what those priorities
are the treatment is often mismatched with those priorities and that's where you get suffering and that's where you get lots of hot air from doctors and you have you have total misalignment when you are able to elicit those goals and then align the care with it you have massively better outcomes both for quantity and quality of life do you ever worry that doctors become corrupted by their own authority not corrupted in the
sense of taking bribes but they have such Authority people look up to them they say well you know take off your clothes sit on the table people do it people are in the mode of obeying and a lot of patients frankly are probably a pain so doctors in a sense can manipulate patients to make each interaction easier because they're such high status figures and then doctors fall into this mode of being used to
doing that with people in general right what do you think are the main psychological dangers of corruption that can stem from being a doctor and having such high status control over life or death you can cure people the gods cannot that's what Sir Thomas Brown said right so I think this um there is uh uh I think that the health system of every country every country is a demonstration
of our corruptibility um the uh Kenneth Arrow's 1960s essay on asymmetry of information used Healthcare as its prominent example that sellers are more powerful than buyers when we not only um control the uh the the decision Set uh we control the option set and uh and the opportunity and ability of the individual to um understand all of those to be able to make choices among them uh is hindered especially when you are sick
so the most powerful um uh tool that a clinician has is their pen and is the power to um uh order medications uh to tests to doing an operation so yes the the power of the fact that um look it's uh it's an it's an unusual profession uh in that yes we can ask you to sit on the table and um make yourself you know the most vulnerable in in the most vulnerable way possible not only to ask
you to uh take off your clothes but then you know to actually have permission to cut you open and do what I choose to do inside you um that is a tremendous power and the ways in which we see that just the payment incentives alone dramatically affect whether I tend my tendency is to give you overtreatment in certain situations and under treatment in others is a reflection of our um uh
of our failure to follow through on being able to deal with the variability in in that um and how we use that asymmetry of information a lot of critics have charged that to get a new drug through the FDA it takes too many years and too much money uh and that somehow the process should be liberalized do you agree or disagree uh so um I generally disagree uh there's a uh there are op here it's a trade-off in
values at some basic level so in the 1950s we had no real FDA um and you had uh the opportunity to put out um to innovate you know in uh in all kinds of ways and that Innovation capability gave us modern cardiac surgery and gave us steroids and antibiotics but it also gave us frontal aboto and it gave us you know um the um the the Tuskegee experiment and a variety of other things
the process of asking that um that our uh that our that we have regulation around both the ethics of what we're doing and that we have um some safety process along the way um is totally appropriate now I think a lot of the lessons about um when the HIV Community became involved in the FDA process to uh Drive approaches that smoothed and and sped up the decision making process and also got the public enough involved to
be able to say we that you know that Community said look there are places where we're willing to take greater risks for the sake of speed right that is um that to me is that people are trying to treat the FDA process as a technical issue when what it is is it's an issue about what are the risks we are genuinely willing to take and what are the risks that were not so but the big
risks seem pretty invisible so some drug you've never heard of it doesn't even exist yet you never get it and you die that's not very Salient to people so it seems in so far as the public judges the risk maybe they're getting it wrong no that's right the um the the way to think about it though is um that we have a certain speed with which we have accelerated Passage through the FDA um we are doing surveillance
afterwards and then finding that the approval process leads to drugs being withdrawn from the market that is a decision that we have decided to accept acceleration um especially of drugs that have to be tested on small numbers of people and then we'll monitor afterwards to be able to catch problems after they happen and the some of the disasters that have occurred like Vio and um uh uh others where there were you know
substantial cardiac uh effects happening to many many thousands of people um we uh we have we have you know there's been a backlash against that uh on the whole I though I think we have decided to trade that we're going to lead cause some passage allow that we've decided to trade letting lots more drugs through in a little bit more quick uh process but then try to have surveillance afterward
now of course the result how the one of the results is we're not investing very much in that in that surveillance the the worst of all worlds is speed drugs through and then close our eyes to what harm is being done after the drug has hit the market and that of course is where all of the incentives are from the uh from the drug maker point of view um and uh and and then when the Public's
not paying attention that's where we start dialing back and that's one of my fears in the current regime is that okay fine we speed up the approval process but then gut uh the ability of the FDA to hold um uh hold the medical community to having surveillance of what happens and then pull pull the drugs on the market that are actually causing harm new surgical procedures should the FDA have a greater ability to regulate them
than it has right now yeah so one of the really interesting things is that basically surgical procedures are not easily protocolized correct and uh and so that you know we're still in that sort of Craft World in surgery and so as a surgeon I can kind of do whatever operation I deem appropriate and the only thing that regulating me is the malpractice um uh the threat of being sued for malpractice and colleagues
saying that what I did was way outside the standard of care and made absolutely no sense um the uh the challenge is that uh that in a certain sense operations are crafted for each person and so the the devices you use and the drugs you use are highly regulated but the procedures you use are not I don't think it makes sense for the FDA to regulate the procedure however I do think it
makes sense for the organizational organization to be held accountable for tracking uh what kinds of outcomes people have for procedures so the part that gets to me is that for a given procedure proven procedures we have at least 250% variability in the outcomes depending on the institution you go to it is primarily a function of the institution not the individual surgeon and uh we have no tracking uh virtually
no tracking certainly no transparency about um about what those outcomes are and what the factors are going into them um and I think that's where we need to have much more uh information now there's a middle segment of all of these conversations overrated versus underrated you're free to pass on any of these of course but I'll toss out a few things and you tell me what you think uh
underrated or overrated Stevie Wonder um I think he's now become underrated he was over he might have been overrated at one point but now he is uh significantly underrated and what's his best album oh gosh uh I'm gonna have to pass out because I lived in the world of singles like sir duuk was my my favorite song songs in the key of life yeah well so um what I might go to is uh uh going back
to that era so songs in keia life I would say bring that back Michael kryon Dr Harvard writer what do you think where is he now I would say he might be um uh I think he I think he's been overrated um I say this is someone who was totally inspired by Michael kryon the fact that he uh graduated from um medical school and then a year into his residency left to do everything from um uh directing
movies like coma to riding The Great Train Robbery and then onward to Jurassic Park but as a uh as a kind of uh influence on medical writing and on um writing RIT large uh um I think that the the power his power has way is waning it's his power is now uh well now see I'm switching from over under now you're sounding like underrate sphere is my favorite book of his he was also a
brilliant art collector he bought a lot of Jasper Jones before and I just realized and the critical way he's underrated was in creating programs like er which showed how you know it really has become now uh that the that the medical procedural just like the uh the criminal procedural is a now a Mainstay of television and I think ER created that and that was a brainchild of Michael kryon so yeah I've reverted the
idea of nudge um I think overrated why um I think the that there are important insights in nudge units and you know um in that research capacity but when you step back and say what are the biggest problems in uh clinical behavior and delivery of healthcare um the uh the nudges are focused on small solution ions that have not demonstrated uh capacity for major scale um nudge is something that the kind of nudge
capability is something we've built into the stuff we've done whether it's checklists or coaching but it's been only one we've had to add other tools you could not get to massive reductions in deaths in surgery or child birth or massive improvements in end of life outcomes based on just those Behavioral Science insights alone we've had to move to organizational insights and to um uh
it you we've had to piece together uh multiple kinds of layers of understanding in order to drive high uh CH high volume change in uh in healthcare delivery wearables wearables I think underrated why so um wearables right now don't do terribly much and uh and I think there's a real downside that uh you know what we see right now are wearables that might say track your heart rate um in a uh uh you know and
catch variations in your EKG and so on what what the problem is is that the wearables have not um been able to be integrated into uh the practice of medicine in a really um critical way so right now what the way a wearable is used whether it's for tracking cardiac events or your or or your mental state or other things like that is that then it says notify your doctor or it's a it's a dump of a ton of data that a
clinician is supposed to use and and know how to integrate into practice that uh it hasn't been able to be used in such a way you're actually demonstrating major improvements in people's outcomes however um we are entering this phase where we are going to we are now starting to be able to track uh take your genomic data take your laboratory data take your uh Imaging scans you've done couple it with information from
wearables uh like uh how you're doing over time um you you're getting the medications you should be getting um our team here is actually just deploying a version of a wearable which is just turning on the sensors in your phone to track patients after surgery um to see whether we can Define uh what they're how long their recovery pathway is um how long before they are back in their
normal sleep habits are back mobilized and moving moving around much more I think that ability to have knowledge of the well-being of people that goes beyond just whether you had a complication or a death um you know success of what we do for people uh can be enormously um uh improved with uh followed by wearables and then that creates these incredible learning loops where we can we can maximize those right
now invisible indications of the outcomes of care so I think the wearables are being used on the diagnostic side where it's semi- powerful but not not critical but as part of how you're doing in your care and whether we're helping you achieve the goals very powerful Carl Canard uh koward uh overrated I I've read about half of the trilogy I'm totally absorbed and loved uh loved them
but um you know I feel like Elena uh fante is an example of someone who was doing much the same uh deeply mining the territory of some over uh history of time but managed to do it by fixing them in a place and a time and a history and a dramatic change in in in in Social conditions and and everything else that took it to this whole another level in my mind What Makes You Weep what makes
me weep you know what um invariably makes me weep is uh when it might be a movie or it might be just seeing someone tell the story of devoting uh years of time to a problem or to um something they're trying to do at Great pain but sticking with it and then actually um getting to the end I think we under value I'm going to give two examples the movie Bliss um this Australian uh uh film um based on Peter
um oh my gosh I'm blanking on the Australian writer's name Peter wire uh no Peter um did Oscar Peter car Peter Cary yes um has this moment where the man is uh uh in love with a woman and plants the seeds of a forest and it takes the next decade or more before she realized this thing he built out of love and it grew um and that's when she realized that in fact he loved her and that was just extraordinary and uh and
of course made me ball like a baby um and then uh this coming week will be our surgery graduation and it's eight people who have given the last decade of their lives to trying to craft and become who they are and they will tell the story they each get 15 20 minutes of time to tell their story of what they'd gone through and they have um had uh had families and had family tragedies and
they've had things that they've missed along the way and it always makes me cry because those uh that ability we have to commit ourselves to something larger than ourselves over a long period of time not knowing whether it'll turn out the way you think it will uh that is I think the most incredible thing that human beings do now you've written about yourself uh that you are highly indecisive by nature
and that you will agonize over many choices uh is there any way in which you feel this which you describe as your weakness is actually your strength um yes so I I chose surgery I and um I wrote in the passage you might be reflecting on that I chose sergy in part because I was drawn to the character of people who um had that kind of decisiveness took action when in action was the worst thing and um and then you
know lived with the consequences B took responsibility for whatever happened learn from it and then and then uh brought it to next time so uh I've brought to surgery um my particular Persona which is um to want to have more planning and more deliberation inserted into situations where there doesn't seem to be time and one of the really striking things is we get this complaint for example that using a checklist in in
surgery well that's fine but in emergencies we don't have time for that kind of thing and we demonstrated that in that situation taking the one and a half minutes for the very beginning part of it um has enormous value it's in fact the group in whom we have the highest reduction in death are those in which the time is the most pressing and so um I think I've flipped my weakness into a
strength where I can but um but by you know battling with it to a certain degree so are you a good Healthcare patient I'm a terrible Healthcare patient what do you do wrong um so for starters I don't see doctors okay we share this I I I don't go in hardly hardly at all and I haven't had to you know so I've crossed 50 and I have never had to really be in the hospital or have a major uh event but to the extent that
the minor conditions I've had I've come um uh had addressed I invariably come way late in the game when the mild infection has become a a much more significant one and uh and you know it's partly because I know too much about the about the ways in which Healthcare um really is pretty unreliable I think of ways in which I am good at being a patient is once I'm in the door um I
pick my team I'm really careful about picking my team and then um uh turn myself over to their process I'm trying to pick them for their ability to run a process that that seems appropriate and so I think the interesting thing about doctors is that they do tend to not micromanage their doctors very much do you feel you've underachieved in life that's a hard question I mean I know objectively that
it's kind of ridiculous that I would think I've underachieved and that um I'm proud of all the random things that I've been able to be part of but I bear a kind of chronic dissatisfaction and sense that um uh I've got much more to follow through on than I've managed to and uh and so yeah I I I think underachieved is the wrong word but um and yet I don't feel I've achieved nearly enough and that
half of what I've achieved I wish I could go back and fix yeah I'm of the view the Clinton era uh welfare reforms were mostly a good idea but they've come under more and more criticism lately and you had a hand in that early in your career what's your 2017 view of all that how has it gone well I think the fact that um uh that we have the number of people who are living on under what is it $4 uh a day in
income uh and that that number is Skyrocket skyrocketed that is unconscionable and a fundamental um error and failure uh that we have um uh sought to there are a variety of things that we that we sought not to punish people for being married that we sought to um not punish people for working the shift to the Earned Income Tax Credit the um the you know there's a uh a deep
and fundamental and maybe this is a Midwestern Midwestern enemy um uh belief that we um need to reward work it's one of my sort of core concerns is that the people who are at the 30th and 40th percentile are served by none of the major political agendas um AG on the left and on the right and uh and that um even Obamacare uh provided its uh great Aid to those under the 20th percentile
but that people at the 40th percentile are not getting the subsidies still don't have a system that works for them and and actually had to pay more into the system along the way so um you know the the welfare failure of uh that is my great concern is the number of people that are uh are subsisting on uh horrendously little um but the value of taking away the things that were punishing people for moving in the right
direction still feels like an important agenda there are many smart people in medicine in surgery in writing books for that matter in writing medical books right what would you say is the Atul Gand production function I asked Raj chedy this I said Raj you get a lot done uh what's the skill you have that other people don't have what would your answer be to that question um I think uh it is to constant I think part of it is
that I uh I'm pretty clear about my goal which is I'm trying to have um impact uh and and to try to do stuff that feels cool along the way that you know um my team knows that my Mantra is I want to do cool stuff that lasts and let's see if we can do that and uh and uh and so I think that from early on I was always iterating against that set of goals and that I'm more or less I mean I'm I
organize my life around it I I'm I don't watch that much TV I um I get enough sleep but I'm I'm so you're decisive well I've learned um I I've learned that I say yes too much and so I've learned to say no a lot to saying yes to this podcast yes sometimes yes um it's serving some part of that production function there's a cool it's cool Will it last we will have to test that question over time we don't talk
about Obamacare too much we want people two years from now to still consider the content fresh that's how I that's how I write my New Yorker pieces I I want it you know my ideal is that my New Yorker pieces I'm I'm always thinking about am I writing them in such a way that in five years um uh they could still justifiably be read and I I hope would would be that way while trying to address something
that feels really sharp and of concern in the moment as well but those are your goals that's your framework what's the talent you have that say your competitors don't I really think it's just um I when when I get into our uh Hospital settings whether we're working in surgery or medicine or child birth or other areas invariably all the main thing we have to work to do is identify what are your priorities and
people in the system number one uh usually can't say what that is and if and then if You observe what their priorities are it's actually far away from uh delivering the best possible care to patients at the at the uh lowest possible cost um that that that actually is a very tiny portion of the healthcare industry that's trying to deliver that and so I in my in my individual capacity
I think it's that I'm able to spend a really high percentage of my time on uh on my priority I think that's all it is now where in Boston we're at a place called Ari Adney which is well known but maybe not to all of your readers it's become one of your major projects could you tell us just very briefly what is Ari Adney well so it stems out of the out of the recognition that um we it is
a Center for Health System Innovation it's a for-profit nonprofit part of Harvard or how does it fit into the universe yeah so it is a it is an academic center that is part of um Harvard Chan School of Public Health and the brigam and Women's Hospital but it sits as a platform we've created for people who want to do experiments in how we bring science and Innovation to the delivery of healthcare um in the same
way that you bring science and Innovation to biological sciences and uh and so we have people come here from all of the different hospitals in the area from the business school from the School of Public Health from economics department and uh and then really built it as a place to enable capabilities to do large experiments like the experiment we just finished with the state of uh
South Carolina uh five years are working with them to see whether you could get the surgeons in state to adopt the safe surgery checklist uh without regulation because it's a reg Red State and they didn't want to mandate it um but without uh Financial in incentives because they didn't have the money to pay for pay for performance and we got a program that uh successfully got 40% of the population
through adoption lowered the death rate 22% but to get the other 60% on board we believe you would have to bring on some mandate or other component so that's kind your director here is that that's your I'm I'm the director here we are now we launched uh it'll be five years this year uh and so we launched in 2012 we now are running about projects in surgery child birth and end of lifeare improving how you come into
the world that the surgery you the average American has eight operations in their lifetime it's the highest risk highest cost highest um failure moment in your lifetime and then uh how you leave the world end of life care and about half of our experiments are in the United States and half are abroad for uh demonstrating ways to get uh better and better so there's a lot of people here
it looks great great if you're director you play some role in hiring oh we all want people who are smart have experience dedicated Cooperative diverse and so on but what what's the quality you look for that you think other people doing hiring are undervaluing what's your entrepreneurial secret to hiring well yeah so I think the the it's again it's that that thing like what is your goal right all
what is your priority yeah so the secret to the hiring is actually before you ever meet anybody know what the heck you're trying to hire so the hardest part sometimes to get people to understand is what is it you are asking them to do in 2 years give me the list the their scorecard what is their what are the five things that they will have accomplished and then make sure you show
it to them when they come in the door and ask yourself as you are interviewing them and then assessing who you're going to pick not do I like this person or are they you know would they be fun to be around or all of those kinds know those are factors um uh the ultimate question is will they be successful in this list of things that you said would Define their success in two years and being
again faithful that that that is maybe it is my focus Talent like you know intend do what you intend to do and and do do it with intention so uh and and it is over and over that's what people fail to do you know we we've got up to now 90% consistency in delivering on people who as we call them a players and it's most of it is in that front end before they've even walked in the door being clear about that that set of steps
and then and then it's that they don't tell you all of it and it's how you talk to their their references that's the other real big mistake people make last question according to your chat with Ezra Klein uh you're a big fan of what you might call Contemporary independent music but Define it as you wish what would be a musical group that you love or is Meaningful to you that maybe the
rest of us haven't heard about that you would recommend oh gosh so I think one of the most underrated bands is frightened rabbit um do you know them out of Scotland tell us about frightened rabbit so frightened rabbit they're sort of the bars of sorrow and um uh and nonetheless sticking it through like the their their their album Midnight organ fight is the great breakup album of all time and you have to listen to it now you
know they're Scottish so there's a whole lot of cussing going on and they are uh and you know they're it's painful and it's dark and all those kinds of things and and but I always find like there's this glimmer of um of hope that that that runs through it despite the um uh despite their ability to sort of uh express pain and heartbreak and uh and disappointment and uh being betrayed
um while still nonetheless waking up and and and sticking it through the next day on that note we close a tool goand day it's been a pleasure thank you thank [Music] you thanks for listening to conversations with Tyler you can subscribe to the podcast in iTunes Stitcher or your favorite podcast app and if you like this podcast please consider rating it on iTunes and leaving a review this helps other people find the show