Atul Gawande Quotations

As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.

Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination.

To become a doctor, you spend so much time in the tunnels of preparation - head down, trying not to screw up, trying to make it from one day to the next - that it is a shock to find yourself at the other end, with someone shaking your hand and asking how much money you want to make.

Our great struggle in medicine these days is not just with ignorance and uncertainty. It's also with complexity: how much you have to make sure you have in your head and think about. There are a thousand ways things can go wrong.

No one looks at your hands to see how much they shake when you are interviewed to be a surgeon. The physical skills required are no greater than for writing cursive script. If an operation requires so much skill only a few surgeons can do it, you modify the operation to make it simpler.

I write because it's my way of finding cool ideas, thinking through hard problems and things I don't understand, and getting better at something.

The damage that the human body can survive these days is as awesome as it is horrible: crushing, burning, bombing, a burst blood vessel in the brain, a ruptured colon, a massive heart attack, rampaging infection. These conditions had once been uniformly fatal.

You want to ensure people can do it right 99 percent of time. When we have to fire one of our surgical trainees, it is never because they dont have the physical skills but because they dont have the moral skills - to practise and admit failure.

Every country in the world is battling the rising cost of health care. No community anywhere has demonstrably lowered its health-care costs (not just slowed their rate of increase) by improving medical services. They've lowered costs only by cutting or rationing them.

I have always believed that there is nothing greater than a life in rock n' roll - it has to be good rock n' roll - and I still think it is true.

Human beings are social creatures. We are social not just in the trivial sense that we like company, and not just in the obvious sense that we each depend on others. We are social in a more elemental way: simply to exist as a normal human being requires interaction with other people.

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

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

The history of American agriculture suggests that you can have transformation without a master plan, without knowing all the answers up front.

Outsiders tend to be the first to recognize the inadequacies of our social institutions. But, precisely because they are outsiders, they are usually in a poor position to fix them.

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

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

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

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

No one teaches you how to think about money in medical school or residency. Yet, from the moment you start practicing, you must think about it. You must consider what is covered for a patient and what is not.

I'm floating between multiple media. I really wish you could buy the hardcover book and it would come with the digital download and audible version. I spend stupid amounts of money because I'm usually buying my books in at least two formats.

You know, 97 percent of the time, if you come into a hospital, everything goes well. But three percent of the time, we have major complications.

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

Oliver Sacks remains my hero to this day. He was one of the first medical writers I read. The other was Lewis Thomas, who is no longer alive but is just heroic to me.

I believe that one version of the good in life can be defined by the moments I sometimes had playing tennis as a sixteen-year-old. You'd be out on the court and for an hour, two hours, sometimes an entire roasting hot day, and every single thing you hit would go in. Hit that ball as hard as you wanted, wherever you wanted, and it went in.

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

We now live in the era of the super-specialist - of clinicians who have taken the time to practice at one narrow thing until they can do it better than anyone who hasn't.

Most people are squeamish about saying how much they earn, but in medicine the situation seems especially fraught. Doctors aren't supposed to be in it for the money, and the more concerned a doctor seems to be about making money the more suspicious people become about the care being provided.

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

George Orwell is a pinnacle writer, for his combination of moral insight and literary writing.

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

My vantage point on the world is the operating room where I see my patients.

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

Doctors quickly learn that how much they make has little to do with how good they are. It largely depends on how they handle the business side of their practice.

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

People say that the most expensive piece of medical equipment is the doctor's pen. It's not that we make all the money. It's that we order all the money.

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

The vast majority of doctors really do try to take the money out of their minds. But to provide the best possible care requires using resources in a way that keeps you viable but improves the quality of care.

The definition of what it means to be dying has changed radically. We are able to extend people's lives considerably, including sometimes, good days.

Man is fallible, but maybe men are less so.

These are folks that keep people out of hospitals, out of emergency rooms, out of nursing homes. And not only that, they help people achieve more fulfilling lives.

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

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

If I became just a brain in a jar - as long as I can communicate back and forth with people, that would be okay with me.

Our ideas of what our priorities are shift as we come face-to-face with some of the struggles.

Expertise is the mantra of modern medicine.

In one study, old people assigned to a geriatrics team stayed independent for far longer, and were admitted to the hospital less.

Writing lets you step back and think through a problem. Even the angriest rant forces the writer to achieve a degree of thoughtfulness.

If we took away the ability to put defibrillators in people in their last years, people would be shouting in the streets.

The battle of being mortal is the battle to maintain the integrity of one’s life,

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

And in stories, endings matter.

No travel ban or quarantine will seal a country completely. Even if travel could be reduced by eighty per cent-itself a feat-models predict that new transmissions would be delayed only a few weeks. Worse, it would only drive an increase in the number of cases at the source. Health-care workers who have fallen ill would not be able to get out for treatment, and the international health personnel needed to quell the outbreak would no longer be able to go in.

When [disease] can't be stopped, that's where we become lost.

Culture matters. Of course, if physicians are rewarded or penalized for their service and results, the culture will change. But the key values we doctors are being pressed to embrace are humility, teamwork, and discipline.

We recruit for attitude and train for skill,

We Have Medicalized Aging, and That Experiment Is Failing Us

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

The possibilities and probabilities are all we have to work with in medicine, though. What we are drawn to in this imperfect science, what we in fact covet in our way, is the alterable moment-the fragile but crystalline opportunity for one's know-how, ability, or just gut instinct to change the course of another's life for the better.

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

What is the alternative to understanding the complexity of the world?

Are doctors who make mistakes villains? No, because then we all are.

Making systems work is the great task of my generation of physicians and scientists. But I would go further and say that making systems work - whether in healthcare, education, climate change, making a pathway out of poverty - is the great task of our generation as a whole.

Practice is funny that way. For days and days, you make out only the fragments of what to do. And then one day you've got the thing whole. Conscious learning becomes unconscious knowledge, and you cannot say precisely how.

Having great components is not enough, and yet we've been obsessed in medicine with components. We want the best drugs, the best technologies, the best specialists, but we don't think too much about how it all comes together.

People underestimate the importance of dilligence as a virtue. No doubt it has something to do with how supremely mundane it seems. It is defined as "the constant and earnest effort to accomplish what is undertaken."... Understood, however, as the prerequisite of great accomplishment, diligence stands as one of the most difficult challenges facing any group of people who take on tasks of risk and consequence. It sets a high, seemingly impossible, expectation for performance and human behavior.

We've created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets - and have only the rudiments of a system to prepare patients for the near certainty that those tickets will not win. Hope is not a plan, but hope is our plan.

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

Don’t let yourself be. Find something new to try, something to change. Count how often it succeeds and how often it doesn’t. Write about it. Ask a patient or a colleague what they think about it. See if you can keep the conversation going.

I chose surgery because I thought that perhaps this would make me more like the kind of person I wanted to be.

People who reach certain levels of frailty, more important than getting their mammogram, more important than getting their blood pressure tweaked, they're at high risk of falling. If they fall and break their hip, they not only die sooner, they die miserably.

Good checklists, on the other hand are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything--a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps--the ones that even the highly skilled professional using them could miss. Good checklists are, above all, practical.

At times, in medicine, you feel you are inside a colossal and impossibly complex machine whose gears will turn for you only according to their own arbitrary rhythm. The notion that human caring, the effort to do better for people, might make a difference can seem hopelessly naive. But it isn't.

What about regular professionals, who just want to do what they do as well as they can?

Coaching done well may be the most effective intervention designed for human performance.

Human interaction is the key force in overcoming resistance and speeding change.

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

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

What is needed, however, isn't just that people working together be nice to each other. It is discipline. Discipline is hard--harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can't even keep from snacking between meals. We are not built for discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is something we have to work at.

Life is choices, and they are relentless. No sooner have you made one choice than another is upon you.

Arriving at an acceptance of one's mortality is a process, not an epiphany.

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

I said there are at least two kinds of satisfaction, however, and the other has nothing to do with skill. It comes from human connection. It comes from making others happy, understanding them, loving them.

A failure often does not have to be a failure at all. However, you have to be ready for it-will you admit when things go wrong? Will you take steps to set them right?-because the difference between triumph and defeat, you'll find, isn't about willingness to take risks. It's about mastery of rescue.

In psychology, there's something called the broken-leg problem. A statistical formula may be highly successful in predicting whether or not a person will go to a movie in the next week. But someone who knows that this person is laid up with a broken leg will beat the formula. No formula can take into account the infinite range of such exceptional events.

In the end, people don't view their life as merely the average of all its moments-which, after all, is mostly nothing much plus some sleep. For human beings, life is meaningful because it is a story. A story has a sense of a whole, and its arc is determined by the significant moments, the ones where something happens. Measurements of people's minute-by-minute levels of pleasure and pain miss this fundamental aspect of human existence. A seemingly happy life maybe empty. A seemingly difficult life may be devoted to a great cause. We have purposes larger than ourselves.

Sometimes we can offer a cure, sometimes only a salve, sometimes not even that. But whatever we can offer, our interventions, and the risks and sacrifices they entail, are justified only if they serve the larger aims of a person's life. When we forget that, the suffering we inflict can be barbaric. When we remember it the good we do can be breathtaking.

No matter what measures are taken, doctors will sometimes falter, and it isn't reasonable to ask that we achieve perfection. What is reasonable is to ask that we never cease to aim for it.

We always hope for the easy fix: the one simple change that will erase a problem in a stroke. But few things in life work this way. Instead, success requires making a hundred small steps go right - one after the other, no slipups, no goofs, everyone pitching in.

You can't make a recipe for something as complicated as surgery. Instead, you can make a recipe for how to have a team that's prepared for the unexpected.

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

Over time I learned that there are two very different satisfactions that you can have in your life. One is the satisfaction of becoming skilled at something. It almost doesn't matter what the terrain is. There is a deep, soul-feeding resonance in mastery itself, whether in teaching, writing a complicated software program, coaching a baseball team, or marshalling a group of people to start a new business...

We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line. There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing. The gap between what we know and what we aim for persists. And this gap complicates everything we do.

Developing a skill is painful, though. It is difficult. And that's part of the satisfaction. You will only find meaning in what you struggle with. What you struggle to get good at next may not seem the exact right thing for you at first. With time and effort, however, you will discover new possibilities in yourself-an ability to solve problems, for instance, or to communicate, or to create beauty...

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

Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and denied them the basic comforts they most need.

Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.