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 reform. 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. (LAUGHTER) 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 companies? 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 their cancer. CHARLIE ROSE: Two years -- every patient who had cancer who need coverage in Massachusetts who was a patient of yours has gotten insurance coverage? 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 routine. 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 package. 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 decisions. 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 improvement. 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 radiologic procedures. 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 quality care. 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, only because... CHARLIE ROSE: And that’s the highest percentage of any economy in the world? 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 works? ATUL GAWANDE: No. CHARLIE ROSE: No country, no city, state, no... ATUL GAWANDE: There’s not even an imperfect system that really works great. 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 these. 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 grandmother. 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 work. 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 system. 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... CHARLIE ROSE: What would you need if you had a private insurance, essentially a private insurance system to make sure that it worked? ATUL GAWANDE: In the countries that have private insurance as the dominant way that provide care, it’s heavily regulated. The insurers cannot just -- not only cannot provide preexisting condition exclusions, they also have to be public about the ways they spend their dollars. They have serious competition over whether the quality of care and the provision of care is up to snuff. And that kind of approach requires living with rules of the road. They make it so you can have genuine fairness and competition for driving better care. So will private insurers actually provide value-added by -- in a new system? That ball goes to their court. They either will be in a system of making care that’s better organized and better service for people, and they’ll be able to be part of making that solution... CHARLIE ROSE: Or? ATUL GAWANDE: Or they will just be an extra middleman taking money out of the system and not providing good for care. That test is going to be up to -- the ball’s in their court on this now. CHARLIE ROSE: What do you want to be? Do you want to be a writer? Do you want to be a doctor? Or do you want to be a teacher? ATUL GAWANDE: I hope I get to be all. Surgery and being in the operating room and helping people through cancers and other problems is fundamentally grounding. It’s my reality check. If I’m pontificating in the world, I can get this wrong unless I’m testing my theorizing against the reality of the world. And this is my advantage on reality. I don’t want to let go on that. At the same time, the chance to move from the micro the macro, to think about our deeper problems -- when I’ve written about health care it’s through the view of just understanding what the range is of our human experience. I write about policy and politics and health care reform, but I also write about a woman who scratched her way entirely through her skull. CHARLIE ROSE: You told me that story. Tell me about the B-17 story, about the checklist. ATUL GAWANDE: Well, this was part of what I get to think about by being this mixed role. I had a project for the World Health Organization where they asked me to lead a team trying to come up with ways to reduce deaths in surgery. And what we looked to is we weren’t finding answers in our part of the world, so we looked to the aviation world. And there was a moment where aviation changed. There was a request by the army for a new long-range bomber in 1935, and Boeing came up with a plan to put four engines on the plane. This was a massive breakthrough. That plane could fly higher, farther, faster. It was clearly the answer for the military. They did a test run, they actually had a flight competition, and the plane crashed, killing the crew onboard. And the investigation showed nothing wrong mechanically with the plane. The pilot had forgotten to release the elevator controls, and so the plane could climb and climb but couldn’t level out, and so it just lost air and crashed to the ground. And the reason he forgot was that putting four engines on the plane increased the complexity of how many things he had to remember so much that the army deemed it too much airplane for one man to fly. What did they do to try to solve that problem? When Boeing built the first production models and the pilot said "I think we can fly this," they did not make a three-year specialty fellowship in flying the B-17 airplane. They did not throw more and more technology into it. They just made a checklist. A, before takeoff a few checks on one page, and following those basic checks they were able to fly that plane over almost two million miles without a single mishap and ended up having 13,000 of these planes in World War II. It was the backbone of our air superiority. And what I realized following that story was that not only in surgery but all across medicine, we’ve hit our B-17 moment. Medicine has become more complex than one person can remember for themselves, too much airplane for one person to fly. CHARLIE ROSE: Go ahead. So who writes the checklist? ATUL GAWANDE: So what it almost has to be that the people at the front line write their own checklist. But what we had to do, we had to learn from Boeing, who has tons of experience on how to do this, how to make a good checklist instead of a bad checklist. Make a way that you are not distracting people, not making it so long that it’s impossible to deal with. And so they showed us. We ended up following their rules and conducted a two-minute checklist for operating rooms that when we implemented it in eight hospitals, just asking teams to follow this checklist every time, it reduced deaths 46 percent. CHARLIE ROSE: Forty-six percent? ATUL GAWANDE: Forty-six percent. CHARLIE ROSE: Reduced death in the operating room? ATUL GAWANDE: In 8,000 patients. I implemented it in my operating room not because I thought we needed it in my hospital. At the Brigham and Women’s hospital we know what we’re doing. I didn’t want to be a hypocrite because I was asking these other hospitals to implement it. And then, to my surprise, I have not gotten through a week where it has not caught problems that we would have missed. CHARLIE ROSE: Doesn’t that say something about how many people might have been killed because there was no checklist if these numbers are as astounding as they are? You haven’t gone a week in which you didn’t find you missed something or would have missed something? ATUL GAWANDE: Not that it would have killed people, but it would have harmed them. And the striking this is we haven’t taken these lessons elsewhere. I got a note from a patient who -- it was just heartrending. He had an merge spleenectomy. And when you lose your spleen, there’s certain vaccines you’re supposed to get. But we forgot to give the vaccines, meaning my profession, we surgeons. CHARLIE ROSE: He lost his spleen, and if you lose your spleen, you have to have vaccines, and somebody forgot that? ATUL GAWANDE: Right. And so the result was instead of getting this pneumococcal vaccine he got this infection which you need a spleen to fight off. He ended up losing nearly all of his fingers and toes from a completely preventable problem. And I’ve seen in my own hospital that we’ve forgotten this kind of a vaccine. We’ve seen these kinds of steps across the board, and we missed them because we think using a checklist is a sign of weakness. Experts don’t need checklists. You become an expert so you don’t have to have a checklist. But when complexity has exceeded the capability of our brains to handle it, it’s actually more important than technology and more important than any of the things that we fall back on. It’s this very simple, mundane thing. CHARLIE ROSE: How is it applicable to other areas beyond a surgeon? ATUL GAWANDE: The fascinating thing to me and the reason -- I never imagined I’d write a book about checklists. CHARLIE ROSE: And look at this little check here. ATUL GAWANDE: I know. The profound thing that I found was that as I looked for ideas outside of medicine to apply in medicine, I ran into people in multiple lines of work, whether it’s the skyscraper world or investment world or teaching, who are struggling with the fact that we’ve gone from a world where our main problem was ignorance, we didn’t know what to do, to a world where now we actually have a lot of knowledge, but it’s so voluminous and so complex you can’t keep up with it anymore. And people are struggling with understanding how do I make sure I do the right thing at the right time the right place. In pockets of areas, people have started applying the checklist, a handful of people in the investment world, a handful of people in restaurants and places like that. CHARLIE ROSE: A checklist in a restaurant, how would that work? ATUL GAWANDE: I spent a day in a gourmet kitchen with Jody Adams, a chef in Boston who runs a fabulous restaurant. And I was there because I wanted to see how people really make the art of cooking work when you have to do it for 150 people a night. And the answer to my surprise was that even for a gourmet chef, you’d think she would carry it in her head. She has a checklist called as recipe that she follows, even the 300th time she’s making a lobster dish, because she says "That’s the moment when I forget to add that crucial spice or ingredient." And to make that kitchen run like a symphony with all of its specialists -- it’s grill cook, it’s baker, and so on -- they have a check in process to make sure that nothing goes in or out, including a little check before the dish goes out the door where the souse chef looks at it before it leaves. I was thinking to myself, imagine if I do an operation, and before I’m done the chief of surgery or somebody with him actually wanted to double check and make sure before the patient left the door? CHARLIE ROSE: Can a I read this? There’s a checklist web site in ATUL GAWANDE: One of the key priorities I want to get to is we have 13,000 diagnoses. I can’t, or a few teams of people cannot generate the checklist. It really has to be the clinicians who know best. What are the half-dozen steps for the HIV patient? What are the half- dozen things that should also happen for the depression patient? What are the half-dozen things that should always happen for breast cancer patient? The real place we have to go is use web technology to have clinicians actually sharing this information and generating these ideas and then rating each other’s work. We have to create this. It’s a component of what we’ll need to map medicine and generate the knowledge we need for making things work better and lower cost. CHARLIE ROSE: Do you have a two-do list as well? ATUL GAWANDE: I should be the way down to the to do list level, but I barely get through me email. CHARLIE ROSE: This is for better and complications, a previous book. "The Checklist Manifesto, How to Get Things Right." It is as fascinating as Atul Gawande is. Thank you very much. ATUL GAWANDE: Thank you for having me. CHARLIE ROSE: Thank you for joining us. See you next time. END 12