Dr. Atul Gawande, is the New York Times bestselling author of Better: A Surgeon's Notes on Performance , Complications: A Surgeon's Notes on an Imperfect Science, and The Checklist Manifesto: How to Get Things Right .
CHARLIE ROSE: Atul Gawande is here. He's a surgeon at Brigham and
Women's hospital in Boston. He's an associate professor at the Harvard
University teaching at the medical school and the school of public health.
He's also Staff writer for the “New Yorker” magazine. Over the past
year he has emerged as an important voice in the debate over health care
His articles have become required reading in the Obama administration.
He has written about the regional differences in health care expenses, the
history of health care reform around the world, and other subjects.
His book is called “The Checklist Manifesto: How to Get Things Right.”
I am pleased to have him back at this table. Welcome.
ATUL GAWANDE: Thank you for having me, Charlie.
CHARLIE ROSE: Health care reform, if it passes, the president
believes it will be the most important social legislation in a long time.
What do you think of it?
ATUL GAWANDE: It is two things — an amazing leap forward in
coverage, finally committing ourselves to the idea that people shouldn't be
excluded from care because of preexisting conditions or because you don't
have enough money to get that cancer treatment.
That alone is an enormous leap. I'm a cancer surgeon and it was a
routine part of my life that you would have uninsured patients struggling
for how they get their care.
The second part that this reform bill is beginning to tackle and that
we're just coming to grips with as a country is what we do to make our
health system better in terms of improving the quality and lowering the
cost that have become crippling for our economy.
And the answers for how to deal with coverage, we've been debating
them, but they've been on the shelf through 30 or 40 years. You can cover
through private insurers, you can cover through government insurance, we
can battle that back and forth.
What to do on cost and coverage, how to make care actually better for
you, that we're just unlocking now.
CHARLIE ROSE: And what are we finding?
ATUL GAWANDE: We're finding that if we don't pass reform we'll just
continue muddling along not generally improving the organization of care.
But when we pass reform, the unnerving thing is this is just the start of
solving these problems.
We know, for example, we don't pay physicians the right way. Paying
fee for service means we're paying for quantity instead of paying doctors
to be organized…
CHARLIE ROSE: So in other words it encourages doctors to do things
that are not really necessary.
ATUL GAWANDE: It can, and we've seen it.
The idea of being able to change the way we pay physicians in
hospitals, we know we have to do it. We don't know what the best way to do
it is, and so the reform package offers pilot programs, ideas that are
experiments for communities to try different ways of paying their
physicians and hospitals and seeing what the results are.
That's going to mean community by community tough things to try, but
rewards for those who begin to get it right.
CHARLIE ROSE: OK, let me ask you this — suppose your best friend is
serving in the United States Senate.
ATUL GAWANDE: Odd job for my friends, but we'll…
CHARLIE ROSE: Let's assume. And he or she says to you “Look, a lot
of things I wanted are not in this bill. But is this a sufficiently good
bill — the one passed in the Senate — so that it will make a difference
and it's important that we have it now, or should I vote against it because
I believe we need to start all over and do what's right?”
ATUL GAWANDE: In my mind it is no question that it is more than
sufficient to vote for the reform bills that are emerging.
It may be that I'm partly easy to please. Having struggling as a
clinician and someone seeing the kind of ways in which our health system is
harming people, I'm interested in forward progress, and I see significant
forward progress here. It is enormous progress to be able to provide ways
to cover people across the country.
I would have loved for there to be a government insurance option as a
backstop for people's coverage.
CHARLIE ROSE: And also to become competitive with the insurance
ATUL GAWANDE: Yes. But in Massachusetts we've had a system that
looks a lot like Switzerland's, and it's only been in place for two years.
But we offer for people who are not insured, you can sign up through the
web, private insurance options that are subsidized, limited so you don't
pay more than eight percent of your income but you can get your coverage.
CHARLIE ROSE: But has that mess coverage been fault-free?
ATUL GAWANDE: No, but we've covered 98 percent of our population.
It's been two years since I've had a patient who couldn't get coverage for
CHARLIE ROSE: Two years — every patient who had cancer who need
coverage in Massachusetts who was a patient of yours has gotten insurance
ATUL GAWANDE: I had 15 percent of my patients who couldn't cover
their bills because they didn't have adequate insurance coverage two and a
half years ago. And now it's been two years since I've seen anyone where
we've had to struggle through those problems. And in fact, it's so much a
thing of the past you almost can't remember when this kind of problem was
That's a huge step forward.
Where are the faults? There was nothing in that plan for controlling
costs. The costs have not exploded in Massachusetts. Our costs are going
up just like everyone else in the country. We've been able to afford the
But we are only now coming to grips with controlling the costs and
trying the experiments that start to make the right kinds of clinical
This is where the debate really gets interesting. Health care costs
are not about the insurance companies. It's about the time when you sit
down with your doctor and you have a headache and you ask yourself “Do I
need a head CT? Can I get a head CT? Do I need an MRI? Should I get
blood tests? Should I get an operation?”
The answers to those questions are we haven't made it so we're
organized to get good answers for people's care. We are sometimes over-
providing. We're getting way too many of these kinds of tests in
situations where we actually add harm to people. And then we miss it as
key times when that headache was a tumor that should have been caught.
So getting these steps right is about organizing that front line of
care to be smarter, better, and less wasteful in our decisions.
CHARLIE ROSE: Do you think we'll be surprised about the cost and it
will not be as expected by the Obama administration?
ATUL GAWANDE: Yes. I think that there are a couple things that will
happen. We will find unexpected places where the costs are going to
actually be controlled better than we thought and we'll have unexpected
places where the costs are higher than we thought
CHARLIE ROSE: More the latter than the former?
ATUL GAWANDE: If we break it down, when we implemented the coverage
system in Massachusetts, it came in under budget, to our surprise. I think
we'll find that the economic burden is not as severe as we imagine and fear
it to be.
I think that our effort to control costs — the bill expects that our
costs will not be well controlled at all. I think we will find areas where
the costs will be better than we imagined, and that on the whole because
costs are better that we'll find that that will work out to be an
But there are some budget gimmicks in the system. There's savings,
for example, by creating a long-term care plan, which is going to be a
fantastic thing. But because people are paying premiums into it ahead of
time, we're counting it as covering the cost of the bill. That's a
gimmick. It will not cover up the fact that we have to get our health
system costs under better control.
So on the whole, the test for us is I think we can in the next five to
ten years control our costs to be less than they're targeted to be.
CHARLIE ROSE: If we can't we're in deep trouble, aren't we?
ATUL GAWANDE: If we can't, we're in deep trouble. And this is about
community by community working to make our systems better. And answers are
not really going to come out of Washington after this bill.
And so that's why I said I think we'll have communities where the
costs are going to skyrocket just as much as they've been. But we will
find communities that have taken the tools that the bill has had and found
answers, and then our tests will come about three to four years from now.
Will we use those answers and bring — make everybody adopt them
across the country?
CHARLIE ROSE: You pointed to regional differences in an article that
got enormous attention. Why are there these regional differences and will
this bill, this health reform package, impact them?
ATUL GAWANDE: The regional differences have to do with — in some
communities they're demonstrably lower costs and higher quality than
average. And in other communities they're not.
I pointed to two counties in Texas that are almost identical public
health statistics, both poor countries, both high rates of immigration,
both high rates of diabetes and cardiac disease, but one community costs
twice as much per person for health care than the other.
And the answer was the care was more disorganized in that other
community, medicine was more about a business, there was — people had
chased the incentives where they say you should follow them. But that had
resulted in less preventative care, less primary care, less mental health
care and then twice as many operations, twice as many certain kinds of
CHARLIE ROSE: Fee for service and stuff?
ATUL GAWANDE: Yes.
And the interesting part is that not all communities have taken
incentives and run this way. We picked out ten communities that ranged
from Sacramento, California, to Tallahassee, Florida, that were finding
ways to lower costs and have higher quality of care.
And the answers were they were starting to pay their doctors
differently. They were looking at answering questions like why are we
doing so many CT scans when we know that the radiation actually increases
risks of certain cancers and we have not been smart about making sure we're
using them at the right time and the right place?
And they were tackling these problems even though it could mean that
they would make less money.
Now changing incentive can accelerate that process and there are
components in the bill to drive that.
But the part that troubles me and actually led to my writing the book
is that on a clinical level we in medicine have said making care go well
and making it so that you have higher cost and lower cost, that's for
somebody else to deal with. It's for us to deal with.
When we have these questions about what's the right way to provide
surgical care, we'd see over and over we haven't provided antibiotics to
prevent infections at the right time and the right place. We've missed
making sure blood is available at key times.
Or we had to have people on the team who actually knew each other's
name and who were prepared to work as a team together to solve this
problem. We found there are simple things you can do. You can make a
checklist — take an idea like from aviation and implement it.
CHARLIE ROSE: People at the Mayo Clinic and the Cleveland Clinic, the
leaders of those two institutions were vocal in terms of talking about
health care reform. Are they satisfied with this bill or do they think
this bill will do more harm than good?
ATUL GAWANDE: I don't know the answer to that. And I don't think
that's the litmus test here.
CHARLIE ROSE: Because their reputation — they have reputations of
ATUL GAWANDE: Yes. What I had read recently is that both Mayo Clinic
and Cleveland Clinic had backed the packages coming out. But this isn't
about whether one hospital clinic or another is able…
CHARLIE ROSE: Believes it's the right way to go.
ATUL GAWANDE: Exactly. We are all incredibly invested in our own
perspectives on this.
What is much more interesting though is whether the group of places
that are achieving higher quality and lower cost, whether we are learning
from them and have the components in this kind of health care bill to drive
more doctors to try those lessons, to —
Here's the way I would put it. Are we ready in any county in America
to take on a project as a community of doctors and hospitals to say, you
know what, we can make health care lower cost and higher quality? I think
all we need is one county this will take on that task. I know we can do
it. We have seen many countries around the world…
CHARLIE ROSE: Wait a minute, you're saying today at this moment if
there's one county this will take on the fact and has the commitment and
the will that we can have better care at lower cost, it can be done and it
will be a role model for the rest of the country?
ATUL GAWANDE: Absolutely.
CHARLIE ROSE: Well, how hard is that to do?
ATUL GAWANDE: The reform bill has the tools for a county to do it.
We are in a system that leads doctors into hospitals to be completely — we
pay everybody completely separate bills, and the result is nobody gets
together to say — I grew up in Athens County, Ohio, a small county in
southeastern, Ohio. We know in that county that there are human beings
like everybody else, which means there are 13,000 diagnoses, 13,000 ways
that the people of that county's bodies will fail.
And can we organize the care in our county to say we know what we'll
do at least to make sure the half dozen key things go right for each of the
key problems that people are going to hit?
CHARLIE ROSE: Why is this such a volatile issue?
ATUL GAWANDE: Well, only because it's 18 percent of our economy now,
CHARLIE ROSE: And that's the highest percentage of any economy in the
ATUL GAWANDE: Right, by several percentage points.
CHARLIE ROSE: More than several, five or six or seven or eight.
ATUL GAWANDE: Yes. Also because this employs almost 20 percent of
our work force indirectly or directly, so everybody working has a stake in
it. And because we all get sick and we all worry. What our greatest
sphere is not — we fear losing what we've got, and that when that moment
comes that we need it to be there, it won't be done right.
CHARLIE ROSE: When push comes to shove, everybody's health is the
most important thing they have, and they worry that somehow somebody's
going to tamper with something for them, for them, that's going to make
health care less good.
ATUL GAWANDE: Here's the thing. We've got a used car, and we
consider it pretty clunky and we're not entirely happy with it, and it's
breaking down. Are we willing to trade in for the next car?
Whatever the problem that car has, we're going to blame it on the guy
who sold it to us — Obama and the Democrats. But we are — the choices
are a hard one, because we are afraid of losing what we've got, we're
watching this thing go down the tubes, harm our economy. None of us are
entirely happy with the way care unfolds for us, and we will only begin
tackling the problem if we begin trying that next car.
CHARLIE ROSE: Is there a perfect system somewhere where it really
ATUL GAWANDE: No.
CHARLIE ROSE: No country, no city, state, no…
ATUL GAWANDE: There's not even an imperfect system that really works
CHARLIE ROSE: Anywhere in the world?
ATUL GAWANDE: The strange thing to me — I've been doing work with
the World Health Organization on how we improve surgical care anywhere, not
just in the United States. I've seen care in Britain, in Canada, in
Jordan, in Manila, all over, in India. The amazing thing is everybody's
struggling over these same questions. They're having trouble controlling
the costs. They're having trouble making the care go right.
And at the center of why it's so hard, science has discovered 6,000
drugs, 4,000 medical and surgical procedures. We're trying to deploy them
town by town to get the right thing to the right place. And as individual
clinicians, we find it incredibly hard because it is more complex than we
are currently able to handle.
CHARLIE ROSE: Because you're a voice that people wanted to hear this
question — would the president have been better off if he'd done other
things, made other arguments, been more passionate about his own opinions
and his own decisions from early?
ATUL GAWANDE: It is hard for me — here's the thing. Results speak.
Nobody has taken the health care bill this far along. I was one of those
people who was critical about the idea that Obama was going to be the lone
spokesperson behind this bill, because he's distracted by many, many other
things, terrorism, foreign affairs, a lot of problems, the economy, and
there wouldn't be enough focus.
I also worried putting it in the pit of Congress it would just become
— it is a mess in some ways. And yet each iteration of the bill — we've
been arguing about every single provision, mandates on employers and
individuals, abortion coverage. We've fought our way through each of
I keep thinking you need him in there battling away because we'll
never solve these problems without someone there. And the public solves
these problems. We keep moving on.
We had people screaming about death panels in August. I thought it
was the end of the bill. Instead the American people didn't change one
iota. They continued to say “I don't think this is a bill that's going to
put death panels in place.” They recognized…
CHARLIE ROSE: No bureaucrat is going to make decisions about
ATUL GAWANDE: They recognized it was a joke.
And they said — the debate was how are we seriously going to solve
these problems? And I've been fascinated that we have as a country
continued to be putting one foot in front of the other, saying yes, it's
messy. This is not the prettiest way to solve problems, but we actually at
CHARLIE ROSE: But in the end are you satisfied that in the end you
come up with a solution that's better than what we had before?
ATUL GAWANDE: Yes, I think that's without question.
CHARLIE ROSE: If you had to start all over and you could design a
system, what would it look like? Would it be a single payer system?
ATUL GAWANDE: Well…
CHARLIE ROSE: What would be the essential ingredients for a system
that worked best from all that you know?
ATUL GAWANDE: Part of it — part of my reluctance to answer that
question is that I don't think any system gets cooked up that way. We
don't — when I looked at how other countries adopted their health care
systems, no one sat in a committee room and decided that Britain would be a
government takeover of healthcare and that France would be run by unions
and employer organized care.
CHARLIE ROSE: Or that Canada would have a single payer.
ATUL GAWANDE: Yes. Instead it was that the historical moment was, in
Britain, in World War — they had a private, entirely privately run,
largely privately run system. In World War II the blitz emptied London out
of millions of people. They went into the countryside and there was no
health care there. The government had to do something.
So they started building hospitals and employing doctors to staff
them. And so when the war ended you suddenly had a largely government-run
And then when Churchill started addressing the question, “Now, how do
we organize health care after the war?” Churchill, a conservative, ended up
being on the side of “Let's go with the system we've got,” which was
largely government run there.
So my answer to you is I — if we were in a system where we had
Medicare for everybody, I think that would be a great system. If we had a
system we where we had private insurance plans for everybody, I think it
could be a great system, too. The devil is in the details. You can make a
terrible system under either one of those…