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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.

-Atul Gawande

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Over Time I Learned

Atul Gawande

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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.

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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.

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.

Just Look At The List Of Who The Lowest-paid People Are. Pediatricians Are At The Bottom. You Would Also Look At Internists. You Would Look At Psychiatrists. You Would Look At Family Physicians, Hiv Specialists. People Who Take Care Of Chronic Illnesses By Seeing People Carefully Over Time, Those Are The People Who Get The Least Money. The People Who Have The Most Are People Like Orthopedic Surgeons, Interventional Cardiologists. And My Point Isn't That There Is Something Wrong With Heroism.

Human Interaction Is The Key Force In Overcoming Resistance And Speeding Change.

When We, Doctors, Ask Patients What Their Priorities Are If Time Is Short, What We Do Is We Use What Is Available To Us - Whether It's Geriatric Care Or Palliative Care Or Hospice Care - To Make Sure They're Living The Kind Of Life That They Want To Live.

Coaching Done Well May Be The Most Effective Intervention Designed For Human Performance.

I Talked To Over Two Hundred Patients And Family Members About Their Experiences With Aging, Serious Illnesses, And The Big Unfixables. But I Also Spoke With Scores Of Physicians, And Especially Geriatricians, Palliative Care Doctors, Hospice Nurses, And Nursing Home Workers. The Biggest Thing I Found Was That When These Clinicians Were At Their Best, They Were Recognizing That People Had Priorities Besides Merely Living Longer. The Most Important And Reliable Way That We Can Understand What People's Priorities Are, Besides Just Living Longer, Is To Simply Ask. And We Don't Ask.

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.

In Every Industrialized Nation, The Movement To Reform Health Care Has Begun With Stories About Cruelty.

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.

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.

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.

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.

Just Using A Checklist Requires [doctors] To Embrace Different Values From Ones We've Had, Like Humility, Discipline, Teamwork.

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.

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.

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.

We Have Medicalized Aging, And That Experiment Is Failing Us.

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.

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.

This Is The Reality Of Intensive Care: At Any Point, We Are As Apt To Harm As We Are To Heal.

In One Study, Old People Assigned To A Geriatrics Team Stayed Independent For Far Longer, And Were Admitted To The Hospital Less.

We Now Have 30 Percent, For Example, Of Medicare Patients Who Are Seeing Doctors Who Are Rewarded For Doing This Kind Of Work, Like High Blood Pressure Control. So, The Affordable Care Act Has Pushed This Direction Down The Road.

When [disease] Can't Be Stopped, That's Where We Become Lost.

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.

Go Back To The '30s, '40s, '50s, And It Was The Discovery Of Heroic Interventions, The Ability To Cure People With Penicillin Or Do An Operation To Stop Disease That Was What Saved The Day. Primary Care Physicians Couldn't Do All That Much That Really Demonstrated A Difference. The People Who Control And Work With You To Control Your Blood Pressure, They're Not Rewarded For Doing That Or To Be Innovative About Doing That. So, The Result Is Half Of Americans Have Uncontrolled High Blood Pressure, Despite Seeing Clinicians.

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.

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.

What Is The Alternative To Understanding The Complexity Of The World?

Expertise Is The Mantra Of Modern Medicine.

The Battle Of Being Mortal Is The Battle To Maintain The Integrity Of One's Life.

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.

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.

Are Doctors Who Make Mistakes Villains? No, Because Then We All Are.

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.

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.

If We Took Away The Ability To Put Defibrillators In People In Their Last Years, People Would Be Shouting In The Streets.

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.

We Recruit For Attitude And Train For Skill.

One Of The Reasons People Might Be Fallible, Why We Might Fail To Do What We Try To Do Isignorance, That We Have A Limited Understanding Of The Laws Of The World - The Physical Laws That Govern The World And Of All The Particulars Of The World Upon Which Those Laws Work. And Then There's Ineptitude, Meaning That The Knowledge Is Available, But Individuals Fail To Apply It Correctly. The Third Source Is "necessary Fallibility." That Is, We're Never Going To Be Omniscient, There Is Some Knowledge That We Will Simply Never Achieve, And There Are Limits To What We Will Be Able To Do.

I Chose Surgery Because I Thought That Perhaps This Would Make Me More Like The Kind Of Person I Wanted To Be.

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.

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.

In Many Ways, The Effort To Study Philosophy Was My Rebellion Away From Medicine. I'm The Son Of Two Indian Immigrant Physicians, So The Natural Path For Me Would Have Been To Become A Doctor. I Ended Up Doing The Master's Degree At Oxford In Politics, Philosophy, And Economics While Already Having A Seat In Medical School. I Was Keeping That As My Escape Hatch. But My Hope Was That I Might Become A Philosopher Or Something Else Entirely.

What About Regular Professionals, Who Just Want To Do What They Do As Well As They Can?

Courage Is Strength In The Face Of Knowledge Of What Is To Be Feared Or Hoped. Wisdom Is Prudent Strength.

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.

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.

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.

After Readinf Some Essay On The Nature Of Human Fallibility, I Was Very Aware That We Are The Recipients Of A Huge Amount Of Discovery Over The Last Century. Medicine Exemplifies This. And That Has Transitioned Us From A World In Which People's Lives Were Mostly Governed By Ignorance To One That's Constrained By Ineptitude. A Century Ago, We Didn't Know, For Instance, What Diseases Afflicted Us, What Their Nature Really Was, Or What To Do About Them. And That Has Changed.

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 Yearn For Frictionless, Technological Solutions. But People Talking To People Is Still The Way Norms And Standards Change.

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.

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.

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.

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.

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.

If The Conversation People Think Is Coming Is The 'death Panel' Conversation, That's A Total Failure.

And In Stories, Endings Matter.

Once You Start To Ask Patients About Their Priorities, You Discover What They're Living For. Once You Uncover That, It Helps You, As A Doctor, Decide What To Fight For. And When We Do That, We Often End Up Identifying Limits To The Kind Of Care That People Want. One's Assumption Is That These People Are Going To Live Shorter Lives, But What We're Doing Is Protecting Quality Of Life. In Doing So, You Sometimes End Up Helping People Live Longer. Certainly, You Help People Live Better Days And With More Purpose In Their Lives.

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.

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.

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.

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.

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.

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.

There Are Times When You Have Sharp Elbows, And People Are Trying To Muscle You Out Of Certain Meetings - Because Then People Could Leak To The Press That You Had A Role In Certain Decisions. I, At Twenty-six, Was Very Impatient And Didn't Know How To Keep My Powder Dry. I Was Running A Team Of Seventy-five People When I Had Never Been A Boss. I Was The Worst Boss Ever.

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.

Our Ideas Of What Our Priorities Are Shift As We Come Face-to-face With Some Of The Struggles.

One Of The Consequences Of If The Affordable Care Act Is Repealed, Is That All Of Us Now Are At Risk Of Being A Preexisting - Of Having A Preexisting Condition Waiting To Happen. Life, Increasingly, Is A Preexisting Condition Waiting To Happen, Now That We Have More And More Of This Data Available.

Man Is Fallible, But Maybe Men Are Less So.

The Big Thing That's Happened Is, In The Time Since The Affordable Care Act Has Been Going On, Our Medical Science Has Been Advancing. We Have Now Genomic Data. We Have The Power Of Big Data About What Your Living Patterns Are, What's Happening In Your Body. Even Your Smartphone Can Collect Data About Your Walking Or Your Pulse Or Other Things That Could Be Incredibly Meaningful In Being Able To Predict Whether You Have Disease Coming In The Future And Help Avert Those Problems.

The Affordable Care Act Also Offered Protections That Allow For Preexisting Conditions, As People Know, That You're Provided Coverage And You Can Maintain Steady Coverage. And That's An Important Part Of Being Able To Stay In Care And Do Better Over The Long Run.

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.

Difficult Situations

The Evidence Is That People Who Enter Hospice Don't Have Shorter Lives. In Many Cases They Are Longer.

I Learned About A Lot Of Things In Medical School, But Mortality Wasn't One Of Them.

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.

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.

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.

My Own Son Has A Congenital Heart Condition, Where His Life Was Saved By A Cardiac Surgeon Stepping In At 11 Days Of Life To Save His Life. But He Is Now 21 Years Old Because Of Constant Monitoring And Working With Him With A Primary Care Physician. That's The Only Reason Now That He's Getting To Live A Long And Healthy Life. That's What We're Not Rewarding. They Don't Have The Kind Of Resources And Commitment That We Are Giving To People Like Me. I Have Millions Of Dollars Of Equipment Available To Me When I Go To Work Every Day In An Operating Room.

Writing Lets You Step Back And Think Through A Problem. Even The Angriest Rant Forces The Writer To Achieve A Degree Of Thoughtfulness.

My Biggest Fear, That 27 Percent Of Americans Under 65 Have An Existing Health Condition That, Without The Protections Of The Affordable Care Act, Would Mean They Would - Could Be Automatically Excluded From Insurance Coverage. Before The Aca, They Wouldn't Have Been Able To Get Insurance Coverage On The Individual Market, You Know, If You're A Freelancer Or If You Had A Small Business Or The Like.

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