Big Think Interview With Atul Gawande
Atul Gawande is a general surgeon at Brigham and Women’s Hospital and, since 1998, a staff writer for The New Yorker. In 2006, he received the MacArthur Award for his research and writing. His book "Complications: A Surgeon’s Notes On An Imperfect Science" was a finalist for the National Book Award in 2002 and is published in more than a hundred countries. His newest book, "The Checklist Manifesto," is one of Amazon’s best books of the month: December 2009. He and his wife, Kathleen Hobson, live outside Boston and have three children: Walker, Hattie, and Hunter.
Atul Gawande: So I'm Atul Gawande. I'm a surgeon at the Brigham and Women's Hospital in Boston, associate professor at the Harvard School of Public Health, and a writer for The New Yorker magazine.
Question: Does emotion ever come into play in the operating room?
Atul Gawande: You know, I think they -- I think emotions were from the very beginning. Your biggest emotion is fear. I remember that first time I got handed a knife, and you know, the surgeon opposite me had drawn the dotted line where I was to use the knife. And I pressed down on the skin, and half of my thinking was, oh my God, what if I cut too deep? And instead I found that skin is springy, it's tough, it's rubbery, and drawing the knife through that very first time, I didn't go nearly deep enough. I had to cut a couple of times in order just to get through. So fear and learning not to be paralyzed was fundamental to what it was to get good at surgery, grappling with it in ways that you weren't ignoring the fear. I think the worst surgeons are the ones who have no fear, and therefore can become almost cavalier and not learn from inevitable errors. But I've also seen folks who can become paralyzed by the fear and the choices and the proliferating complexities as a case goes on. And all of that fascinated me, and I was trying to get a handle on how do you temper yourself in ways that you can be effective individually? And then later on, as I grasped that there are whole teams involved, it got more and more complicated.
Question: What was your greatest difficulty in becoming a surgeon?
Atul Gawande: You know, I don't know that they were issues that were unique to me personally, but my experience going through surgical training was tempered by an unusual set of experiences. My fifth day of surgical training, the fifth day of July in that first internship year, my son was born. And then 10 days later at home, he went into congestive heart failure. And I was in the operating room, doing -- assisting in my first gall bladder operation, when I got called to -- that my son was in the emergency room at Children's Hospital and I needed to go over. When that happened, I left the operation, walked over still in my scrubs, and walking over the bridge between the Brigham and Women's Hospital, which is an adult hospital, and the Children's Hospital, which was right next door, I felt myself transforming from doctor to father, and arrived in time to see my son failing to breathe, everybody scrambling, and the nurse saying they weren't sure he'd make it. He did pull through. They got him intubated, they got him into an intensive care unit, they slowly figured out what was going on. It was a -- part of the arch of his aorta was missing and needed to be reconstructed. He was in the hospital for two weeks. He left still quite ill. It was two months before he really was on the mend, and during that whole time I got two days off, and then needed to be seeing my patients, and then walking back and forth between the hospital where I was a surgical trainee and the hospital where I was a dad.
And that sense of being in the middle of my training, trying to talk to people about, well, I'll be assisting you in your case today, and then walking over to the other side, seeing one of my own fellow interns come to me and say, I'll be assisting the surgeon in your son's case today -- it was revealing; it gave me a kind of double sense of what it meant to be on both sides of the scalpel. And I think that has pervaded the way in which I've tried to think. What does it mean for us to be good at what we do in medicine? It's also been personal because, growing up in a small town where my parents were local doctors, where everybody knew them, where people would call on the phone and have medical emergencies or minor problems, and trying to sort through it all as a kid picking up the phone, my parents saying, ah, tell them to go to the emergency room -- that sense of seeing it from afar and from up close, the micro and the macro, has been a way that fed into my training and my writing.
Question: What did this experience with your son teach you about medicine?
Atul Gawande: Well, I think that there -- one of the things that surprised me was that there was an art to being not just a doctor that I had to learn, but an art to being a patient. We are in a realm where there is constant awareness of the ways in which we're no longer assumed to be gods. We are fallible in medicine, and I understood that extremely well. My son had his fair share of complications, bleeding that forced them to rush him back into the operating room within an hour after his operation. And yet his heart problem was one that they couldn't repair 15 years before. They used a new procedure on him that still hadn't -- they didn't have all the data on. And as a patient, as a family member of a patient being on the other side, I was trying to grapple with when do you ask for second opinions? When do you push the team? And when do you just back off and say, okay, I understand they're fallible human beings, but the best thing for me now is to trust in them as a team?
And so what I came away with was two things: a sense that our relationship with medicine has changed enormously since the days when we could just believe that everybody was infallible in medicine; and second, that none of this was in our textbooks, none of this was in any of what I was being taught about, that there was a kind of second education going on in the course of my training. And I wanted to identify it and describe it and show what was good about it and show what was not so good, what needed to change.
Question: What happens when a potential patient lacks health insurance and won’t be able to pay for treatment?
Atul Gawande: Well, there's lots of things you do from a practical point of view. Your secretary learns how to say questions like, well, maybe you should call the social work department first, before we book this appointment; or hmm, the schedule looks really full. All of those things are honestly practical things doctors do. Second, many of the larger hospitals, like my own, have a free care pool, and will have people apply to it so that they can get their care, but there are delays built into that, and you see that happen. The next thing, though, is that when you're committed to the idea that look, I want to help anybody I can coming in the door, you still have the questions of how to arrange for their care and manage it.
I can't tell you how dramatically my practice changed when the Massachusetts health reform went through. We went from being a state with about 12 percent uninsured -- and that was about the percentage of my patients who could not pay for my treatments, and I would forgo the surgery costs, and the hospital would eat the medical bills, but you'd still have to figure out how are they going to pay for outpatient chemotherapy, certain kinds of radiation treatments, things like that. And it was a nightmare over and over again. And when the reform bill came through -- well, let me put it this way: it's been two years, and I've not had a patient in those circumstances from my state since then. And it's -- you almost don't notice that you used to grapple with these issues all the time.
Question: What ethical dilemmas have you faced as a doctor?
Atul Gawande: I face ethical dilemmas all the time. They're routine. The 19-year-old patient who sticks in my mind because right before the Massachusetts health reform came through, I'd seen her, and she had a metastatic thyroid cancer. Her cancer had really spread widely. We did the surgery, and then it turned out that she needed chemotherapy and radiation, but her insurance coverage ran out. She only had a -- she had a $75,000 cap on her policy, and she didn't want me to tell her parents about her condition, because she knew they would try to find a way to pay for all of this. That is a kind of ethical dilemma. It seemed to me a no-brainer; I called her parents. And sure enough, you know, they got a second mortgage on their house, they found a way to make damn well sure their daughter got the treatment she needed.
But you have everything ranging from someone who doesn't want to leave the hospital; they are in the hospital, and they're better, but you know, they're just -- they -- things are kind of a mess at home, and they'd love a couple extra days in the hospital even though it's $2,000 a day. How do you grapple with that? Do you kick them out? How do you kick them out? Or do you just say, well, you know, this is my patient. What they -- they're the customer; what they say goes. And you can't -- you find moral questions are a daily part of what you do as a physician, and part of what makes it so interesting.
Question: Is it possible to maintain a normal friendship with somebody you’ve operated on?
Atul Gawande: Well, you're not really friends. And what's unusual is that I've even operated on some friends, and it's changed our relationship because they've gone from being friends to being friends I operated on, and I almost am their doctor now more than their friend. And it's different. You -- my father operated on folks in town and had an interesting perspective on this. Because we're from a small town, he usually knew people he was operating on, and he often found it odd to not know a person he was operating on. He liked it better when he knew because he felt more invested, even though he had complications and things go wrong like anybody else; whereas in a big city practice -- I’m in Boston -- you know, I always end up thinking twice. You know, one of my colleagues operated on his girlfriend's boyfriend -- I mean, sorry, his daughter's boyfriend. And it was -- you know, we all kind of scratched our heads, and he said, well, you know, who better to take a look at this guy? So I think there is a necessary, though, professional line where people are relying on you to be something more than a friend. They're relying on you to be a professional. And by being a professional, that means really thinking through how to do things optimally for them, give them their best chance, work with other people as a team, and that goes beyond what friendship requires. It's just different.
Question: How has it changed the nature of the friendship?
Atul Gawande: Well, in some ways it deepens it because you understand their issues. I'm a cancer surgeon; most of my -- I mean, I do general surgery, but most of the patients I take care of are cancer patients. And it changes it in the sense that -- well, let me put it this way: for example, I mean, I haven't ever operated on someone who's really my best friend, and I'm not sure I would do that. But folks who are friends, colleagues from work, for example, who are the same age as me, and we find, for example, that they're not sure what to call me any more. They always called me Atul before, and then they almost want to call me Dr. Gawande because they see me that way. And I would say to them, no, no, no; call me Atul. And it is that discomfort. You see them deciding, well, I won't call him anything. I'll just say hi. The friendship can become both deeper and yet a little more formal. We end up talking about, you know, life and death and their fears. Will this cancer come back is often very high in their minds. It makes it hard to just talk about, you know, boy, that movie Avatar was not that good, was it?
Question: Whom do you think the relationship changes more for, doctor or patient?
Atul Gawande: I don't think gratitude's the right word. You know, the -- we're getting so good at doing what we do in medicine -- not good enough -- but when it goes well there's enormous relief, but there's an expectation that, you know, that's the way it should have gone. Instead, I think what they feel like is, there's this person here who's a source of information for me, who can tell me something about what's going on that I don't really understand. And so when we run into each other, you know, on the one hand we might be sharing CD recommendations; but you know inevitably they can't get out of the room and meeting up without just wanting to take you aside and say, hey, you know, I've been having this going on or that going on, and is that anything I should be worried about? And that discussion is very different. In some ways, you know, I want to be able to escape it. You know, let's just have a regular old friendship. But in other ways it is special. I like that connection, being able to be helpful.
Question: Does the fear of being sued ever affect a doctor's judgment?
Atul Gawande: I'm sure. I'm sure it does. Less so in the operating room. I think the place where it affects your decision-making is often in the office, where someone comes to you with a problem, it doesn't seem like a big deal, but then you get the what if? We had a meeting, for example, with -- a surgical meeting where I met a surgeon who was from Cedar Rapids, Iowa, and he was talking about some data they'd collected on how many CT scans they'd gotten in his hometown. This is a town of 300,000 people, and when they pulled out the numbers they found they'd done over 50,000 CT scans for the population in the previous year. The vast majority were normal scans that were probably unnecessary. On the other hand, what do we mean by unnecessary? So, 10,000 were largely for head scans, head CT scans, for people with headaches. Only a dozen found any abnormality. And most of those were unusual headaches. They probably could have followed guidelines that said that you don't need the head CT for nearly anything like the percentage of people who got them. But the fear of a lawsuit if you should miss something led to lots of scans. The irony here is, there is probably even more risk from the scans themselves. They have high doses of radiation. And the number of scans Americans are getting nowadays, we know they're generating hundreds if not potentially thousands of cancers down the road.
Question: How does it feel to make a mistake while operating on another person?
Atul Gawande: I still make them. You know, I operate on about 250 to 300 people in a year. I have a 3 percent major complication rate. At least half I can look back on and see that there were things we should have and could have done differently. And when you recognize that situation -- I wrote in my most recent book of a patient who nearly died on the operating table because I ended up making a wrong move that led to a tear in his vena cava, the major blood vessel going back to the heart, and he lost his entire blood volume into his belly in 60 seconds and arrested on the table. And it was just fabulous teamwork that saved him; that I got lucky. And what it feels like is shame. You know, there's guilt, which means you feel badly for what you've done; and then there's shame, where you feel that you are what was wrong. And because we are in a system where we want to convey to people that we are infallible, we have a hard time grappling with our own fallibility. And in a sense, I don't want that shame to go away. But we've got to use that sense of shame more productively. When that sense of shame leads us to clam up and not want to talk to even the patient about the situation, have a hard time being willing to let the public see our results because of fear of what the data might say about us, that's when it has paralyzed us and kept us from solving problems. Where it's good is **** feel responsible. And the culture of surgery has fundamental components that are driven in ways that make every surgeon recognize that they're fundamentally responsible, they're responsible for the results of their patients, even when it isn't necessarily their own hand that's slipping here. Things can go wrong in lots of ways.
Question: How can a person be a better patient?
Atul Gawande: It's a good question, because I think it is -- there are two things about it. Number one is there's no straightforward recipe. But there are things that we recognize we can do. I think number one is to understand that making the system work well is something that we're only starting to grapple with. Medicine has been about parts; it's been about having a great drug, a great doctor. It has only in the last few years started to become about making all of that fit together as well as possible. And the most important role, I think, that patients play is, they're the only ones that see when things are falling through the cracks. You see one specialist and then another specialist, but they don't talk to each other, and what they're telling you doesn't make sense or fit together. A third of patients by the end of their life have 10 or more specialists in their care. And we're not very good at knitting all of that together.
And so I think the most important part the patient plays is not being passive about their part on the team. They are -- we're not great at drawing out the patient; we've wanted the patient to be passive and not so involved, just do what we say. But the more we have different people involved, what we tell people is contradictory. It doesn't always help them the way it should. And as we get our act together, I think what we're learning is, the patients play a key role.
Question: How can family members help?
Atul Gawande : One thing that I tell people is, if you have a sick family member, don't leave them alone in the hospital. Even when there are visiting hours where you're supposed to go home, I'll tell people, find any way you can to stay anyway, because when you're sick is the last moment when, as a patient, you're able to fend for yourself.
And the family member is often the person, as shifts change and different people come and go, who will be the ones to convey, you know, my dad actually seems sicker than he did yesterday. You'll be surprised about the extent to which just having those kinds of eyes and ears are missing with the slew of people coming and going. So I know it can be unnerving. It's sort of like when the effort to trap terrorists falls through, and the passenger has to be the one to tackle the terrorist trying to light the bomb on the plane. In a certain sense, for an extremely complex system of care to work well, we all have to be part of the equation. We in medicine have to be willing to hear from patients who have challenges. We sometimes have to be willing to push back and say, actually on that one, here's the reason why we're doing it this way. But it's becoming a group effort in order to get things right.
Question: Why are checklists important?
Atul Gawande: Yeah, I mean, I wrote a whole book on checklists. You'd be -- you know, why in the world would anybody write a whole book on checklists? And it was the last thing I thought I would be writing about. But I've been fascinated by how we grapple with risk and complexity in medicine, and I got assigned a project to try to find a way to reduce deaths in surgery. We have been struggling with our performance, and so I started looking at how people in other fields grapple with the enormously increasing complexity that people in professional worlds are dealing with. And what I found was -- in aviation, in skyscraper building and other lines of work -- that there was something really fundamental going on; we had transformed from a world where ignorance was our biggest struggle as human beings -- this is the way it was for millennia; we didn't understand why the human body fails, how to build things really well, how to do many, many kinds of tasks in the right way; that knowledge was missing.
Today, however, our biggest struggle is with what people call ineptitude, meaning the knowledge is there, but somebody's not doing it right. And in surgery, in other parts of medicine, what we're finding is that the amount of knowledge, the volume, the complexity, the tons of papers coming across the transom, the technologies that are proliferating -- that all of it has exceeded our abilities as individuals to hold it all in our head and do it right. And there are lots of fields, it turns out, where this has been happening: constructing buildings well, making good investment decisions with our hedge funds. And when I looked to see how people who actually are solving these problems were solving it, I thought you'd find that they had just trained in a different way, or they were training longer and harder, or they had a different kind of use of technology. Instead, what I found over and over again was, they used checklists, as simple and mundane as it sounds; that the checklists in a way filled in for weaknesses in people's brains, things that they forgot. It also filled in for weaknesses in making teams work. Teams constantly drop stuff between the cracks, and so we made a checklist based on what I learned. Actually, I got folks from Boeing to help us out. How do you make a checklist? I didn't think that that would be all that hard. It turned out to be hard.
And one of the things they showed us was how to really focus on making it swift and usable. We made a two-minute surgery checklist; it had just 19 items. Some of them were just make sure you don't forget dumb stuff: make sure you gave antibiotics, make sure you have blood ready for a high-blood-loss case. And then there were other interesting parts: make sure everybody in the room has been introduced by name and role; make sure the surgeon actually explained to the team what their goals for the operation are; make sure the anesthesiologist and nurses had a chance to explain their plans for the operation. We put that checklist in eight hospitals around the world, ranging from rural Tanzania to Toronto and Seattle, and every single hospital we put it in had a double-digit reduction in complications. The average reduction in death was 46 percent. That made me realize there was something much deeper and more important going on here about this set of problems we're grappling with in the modern world.
Question: What percentage of American hospitals currently employ a checklist system?
Atul Gawande: Well, on the one hand, you'd say zero percent. When you look at -- we have about 13,000 diagnoses we've recognized the human body to have. We have 6,000 drugs, 4,000 different kinds of medical and surgical procedures, and we know for each of them there's anywhere from half a dozen to many dozen steps that we should make sure are done correctly. And we just rely on human memory, the person in the office that you go to, to just remember what that stuff is. And we drop stuff all the time. A friend of mine went in for depression; she was just becoming really low. The doctor put her on an antidepressant, and for the next three years they're changing antidepressants, trying to get it right. And it was only much later, three years, that they realized, oh, we didn't check your thyroid hormone level. And she just had low thyroid hormone levels. Two weeks of thyroid hormone and she was better. She lost three years because of that.
So the surgery checklist is in place in about 20 percent of American hospitals. Some countries have implemented it nationwide; France, the United Kingdom, places like Ecuador are adopting it nationwide. But are people really using it? In their heart of hearts, are they in there? Well, in the surgery world we are adopting it. But have we recognized the lesson that maybe this is the way we ought to think about -- that we ought to have -- literally pick up a checklist when you come in with a new problem? That we're not there with. Every time you get on an airplane, someone picks up a checklist.
Question: Are there any institutional obstacles in hospitals adopting this?
Atul Gawande: Well, there are -- there's a cultural obstacle: we see checklists as a weakness as individual practitioners. You know, if you were in seeing a surgeon, and they said, hmm, I'd better check a textbook on this, or I want to check my checklist -- we're not there yet culturally. We're starting to be. The second obstacle is, any old checklist is not the story here. I mean, we could end up just creating a bunch of paper work and tick boxes that just get ignored and aren't really valuable. So the institutional obstacle is, we have to recognize this is science. In the aviation world we have a National Transportation Safety Board that goes in and investigates accidents and shows the lessons that a Boeing or an Airbus then can adopt into checklists, into making the lessons usable. We need the same thing, a kind of medical safety board -- a national institute for health systems innovation is what I would call it -- that would recognize for being discharge to go home from the hospital, there are six key components to a checklist that every hospital should have that we know make a difference in reducing the likelihood that you're going to bounce back into the hospital. We print two-inch-thick guidelines saying what you should do for cardiac care. But we haven't boiled it down to here are the six things one should never forget when you're in there with that patient complaining of chest pain.
Question: Is there enough room for medical experimentation in the current health reform bill?
Atul Gawande: Yes and no. So if this health reform bill goes through, and I think it's looking like every sign will, it is about health reform, but not reforming health care, which is what we really need; meaning redesigning health care to be better quality, better safety, lower cost, getting rid of wasted, unnecessary steps and moves and the harmful components of care. It has the experiments in it to be able to start having us try to innovate on that systems level. So when we've talked about innovation in medicine, what we've usually meant is, will there be a new drug? Will we have a cure for cancer? And we are on our way, with or without reform, to spending 18, 19, perhaps even 20 percent of our whole economy on health care. There's no shortage of money for those kinds of innovations, and I think those fields will prosper. But to take advantage of them and be sure we're using them in every community in the right way, at the right time, we have not been innovating. I think if health reform doesn't pass that we will be very slow to innovate.
But there are components in the health reform package that include innovations both at that front end, trying to design, say, the checklists for the right kind of care, and also on the incentives end. That is, one of the reasons we don't come up with these kinds of checklists is that hospitals and doctors don't do better financially when they put in these kinds of tools. For example, Children's Hospital in Boston came up with a checklist for asthma patients, children who are severely asthmatic enough to end up admitted to the hospital. And they recognized that a couple of components were key: making phone calls to the families to make sure the children were taking their inhalers, and having a look at their apartments to make sure that -- or homes -- to make sure that dust and mites were not a problem in the homes. By tackling just those two things, they reduced admissions for kids with asthma by 87 percent. But asthma was their number one admission to Children's Hospital. And the found this experiment lost them millions of dollars. And so they suddenly were face to face with, well, maybe we need to shut down this program in order to survive as a hospital. That's when you know there's just something wrong with the way we are designing our system.
And the reform bill -- we don't know what is the best way to pay that hospital so that it does the right thing, but we have some good ideas about the experiments to try. One is, for example, paying the doctors and hospital together, whether that kid is admitted to the hospital or not, so that they're on the same page about taking care of this kid with asthma. The kid with asthma might get -- I don't know; I'm pulling a number out of the hat -- $5,000 for that diagnosis and care in that year. And so let's simply give that money and then have them work to try to make the best of that financial situation, which I think leads -- can lead -- to better care.
Question: Is the Massachusetts health care system working?
Atul Gawande: What's right about the Massachusetts system is coverage. We went from 12 percent uninsured to 2 percent uninsured, and that's very impressive. European countries are at 98 to 99 percent coverage of their populations, and Massachusetts did it without -- with most of the people in the population not even noticing. It was through private coverage; basically, if you are uninsured or can't afford insurance coverage, you can go on the Web and get subsidized insurance policies that limit your costs to about 8 percent of your income. Not everybody's happy about that. If you're only earning $30,000 a year and have $2400 -- that's 8 percent -- to have to pay, that seems like a lot. But insurance premiums are typically 15 or 16 percent of people's income, so it's heavily subsidized.
The down side: cost. There was nothing in the Massachusetts plan to deal with costs. Now, the costs have not -- contrary to many of the news reports -- have not outstripped the budget. The Massachusetts health care costs have continued to rise about 8 percent or so per year, which is right in the middle of where the country's costs have been rising. And the program for the uninsured actually came in under budget. If the recession hadn't dropped the bottom out of tax revenues, then this would have gone on as if there were no issues at all. But the pressure of the loss of that tax revenue led the hospitals and doctors and insurers to actually be serious about cost controls. And I'd say in the state we're a couple years ahead of other places in starting to try innovations, paying doctors and hospitals differently. Instead of fee-for-service, just being paid for every time you do an operation, for example, there's a shift towards saying, let's pay for results, and let's figure out how to do it. So that kind of pay-for-results system is now being tested and experimented with, though it's still not easy to figure out.
Question: What are the biggest advantages being proposed in the current healthcare reform package?
Atul Gawande: The national reform package actually looks a lot like the Massachusetts package. It has coverage through private insurers that people would get to choose from -- go on the Web and sign up for a health plan if you don't have coverage or can't afford it. There's more in the bill to do with trying to control the costs, and that is also a plus. There's more in there than we see in Massachusetts by far. Some of it is to try to really drive insurance competition by, for example, having insurers pay a premium tax if their insurance plans comes to cost more than $23,000 a year. Most plans are far from costing that much right now, but they're on their way to doing it if they don't figure out how to organize better.
Second, though, is whether it's private insurance or federal programs like Medicare, there are very interesting experiments, pilot programs, to test out paying doctors in different ways from the way we've done it; for example, paying a hospital system that actually encompasses both hospital care and outpatient care -- what they call gain sharing. If they bring their costs down, the Medicare program would let them keep half of the reduction in costs, to try to provide an incentive for controlling costs, as long as they meet basic quality control measures and have good access to primary care. Can hospitals actually learn to do this? Can we organize to get our act together? I think the answer is going to depend on their adopting things like checklists for the most costly and harmful conditions, where we see a lot of mistakes and waste. But this is tough stuff. Doctors and hospitals are quite fragmented, very disorganized, and learning how to really work as a system of people is going to take us -- it's not going to be a matter of two or three years; this is going to be a generational effort. But I think the clear signs are, we can first end up reducing just the rate of inflation, but then over time if we are able to learn and use the lessons, we could even bring the cost down, which has been feasible in other lines of work.
Question: Are we seeing any efforts to cut down the rate of infections in hospitals?
Atul Gawande: Yeah. Yes. So we have 100,000 people a year who pick up infections at hospitals, all because somebody didn't wash their hands. And it is a -- it has become a kind of emblematic sign of how much difficulty we're having in medicine in grappling with our complexity. This is not about how great your doctor is or how great your nurse is; this is about how great the system is in making sure everybody does the right thing. And you would think that this we could do: just make sure everybody washes their hands. And -- sorry, I got the number wrong: 2,000,000 people pick up infections in hospitals, but 100,000 die from those infections. So when you're talking about that kind of public health impact, the fact that we hadn't solved it is a serious indictment of where we are.
The first experiments to begin to show something that worked was out of Johns Hopkins, where they developed a checklist. They took the aviation idea and said, okay, one of the most deadly infections that you pick up in hospitals is an infection of an intravenous line that you get in the intensive care unit called central lines. They go in the neck or in the shoulder, and go all the way down into the heart to put powerful drugs in and to monitor pressures inside the vena cava going to the heart. Five percent of the time they would get infected. And when they get infected, you'd have high death rates because these would be infections in the bloodstream. What they found was, a checklist just making sure people washed their hands, put on a sterile hat, mask, gown gloves, put a sterile drape over the patients' entire body, use soap on the site -- they found that when they didn't have the checklist in place, doctors skipped one of those steps 30 percent of the time.
Then they implemented the checklist, and it was tricky. It actually meant giving nurses the power to stop a doctor, to say, here are the five things we're supposed to make sure are done on the checklist; you haven't done one of these. And the very first day that a doctor bites off a nurse's head for saying that, and then the nurse is not backed up by the administration, the checklist is dead. The whole success is based on the idea that those in charge will back up the nurse. Well, they implemented this project in the state of Michigan. They made it work, and they reduced infections in the entire state by two-thirds. They saved 1500 lives in the first year that this was in. The worst hospital in Michigan has a lower rate of infections of these central lines than 90 percent of American hospitals. Saved $200 million too, by the way. And now it's three years later. Have we adopted this in all American hospitals? No. We're getting there, but it's moving way too slowly.
Recorded on: January 4, 2010
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China has reached a new record for nuclear fusion at 120 million degrees Celsius.
This article was originally published on our sister site, Freethink.
China wants to build a mini-star on Earth and house it in a reactor. Many teams across the globe have this same bold goal --- which would create unlimited clean energy via nuclear fusion.
But according to Chinese state media, New Atlas reports, the team at the Experimental Advanced Superconducting Tokamak (EAST) has set a new world record: temperatures of 120 million degrees Celsius for 101 seconds.
Yeah, that's hot. So what? Nuclear fusion reactions require an insane amount of heat and pressure --- a temperature environment similar to the sun, which is approximately 150 million degrees C.
If scientists can essentially build a sun on Earth, they can create endless energy by mimicking how the sun does it.
If scientists can essentially build a sun on Earth, they can create endless energy by mimicking how the sun does it. In nuclear fusion, the extreme heat and pressure create a plasma. Then, within that plasma, two or more hydrogen nuclei crash together, merge into a heavier atom, and release a ton of energy in the process.
Nuclear fusion milestones: The team at EAST built a giant metal torus (similar in shape to a giant donut) with a series of magnetic coils. The coils hold hot plasma where the reactions occur. They've reached many milestones along the way.
According to New Atlas, in 2016, the scientists at EAST could heat hydrogen plasma to roughly 50 million degrees C for 102 seconds. Two years later, they reached 100 million degrees for 10 seconds.
The temperatures are impressive, but the short reaction times, and lack of pressure are another obstacle. Fusion is simple for the sun, because stars are massive and gravity provides even pressure all over the surface. The pressure squeezes hydrogen gas in the sun's core so immensely that several nuclei combine to form one atom, releasing energy.
But on Earth, we have to supply all of the pressure to keep the reaction going, and it has to be perfectly even. It's hard to do this for any length of time, and it uses a ton of energy. So the reactions usually fizzle out in minutes or seconds.
Still, the latest record of 120 million degrees and 101 seconds is one more step toward sustaining longer and hotter reactions.
Why does this matter? No one denies that humankind needs a clean, unlimited source of energy.
We all recognize that oil and gas are limited resources. But even wind and solar power --- renewable energies --- are fundamentally limited. They are dependent upon a breezy day or a cloudless sky, which we can't always count on.
Nuclear fusion is clean, safe, and environmentally sustainable --- its fuel is a nearly limitless resource since it is simply hydrogen (which can be easily made from water).
With each new milestone, we are creeping closer and closer to a breakthrough for unlimited, clean energy.
The symbol for love is the heart, but the brain may be more accurate.
- How love makes us feel can only be defined on an individual basis, but what it does to the body, specifically the brain, is now less abstract thanks to science.
- One of the problems with early-stage attraction, according to anthropologist Helen Fisher, is that it activates parts of the brain that are linked to drive, craving, obsession, and motivation, while other regions that deal with decision-making shut down.
- Dr. Fisher, professor Ted Fischer, and psychiatrist Gail Saltz explain the different types of love, explore the neuroscience of love and attraction, and share tips for sustaining relationships that are healthy and mutually beneficial.
We explore the history of blood types and how they are classified to find out what makes the Rh-null type important to science and dangerous for those who live with it.
- Fewer than 50 people worldwide have 'golden blood' — or Rh-null.
- Blood is considered Rh-null if it lacks all of the 61 possible antigens in the Rh system.
- It's also very dangerous to live with this blood type, as so few people have it.
Golden blood sounds like the latest in medical quackery. As in, get a golden blood transfusion to balance your tantric midichlorians and receive a free charcoal ice cream cleanse. Don't let the New-Agey moniker throw you. Golden blood is actually the nickname for Rh-null, the world's rarest blood type.
As Mosaic reports, the type is so rare that only about 43 people have been reported to have it worldwide, and until 1961, when it was first identified in an Aboriginal Australian woman, doctors assumed embryos with Rh-null blood would simply die in utero.
But what makes Rh-null so rare, and why is it so dangerous to live with? To answer that, we'll first have to explore why hematologists classify blood types the way they do.
A (brief) bloody history
Our ancestors understood little about blood. Even the most basic of blood knowledge — blood inside the body is good, blood outside is not ideal, too much blood outside is cause for concern — escaped humanity's grasp for an embarrassing number of centuries.
Absence this knowledge, our ancestors devised less-than-scientific theories as to what blood was, theories that varied wildly across time and culture. To pick just one, the physicians of Shakespeare's day believed blood to be one of four bodily fluids or "humors" (the others being black bile, yellow bile, and phlegm).
Handed down from ancient Greek physicians, humorism stated that these bodily fluids determined someone's personality. Blood was considered hot and moist, resulting in a sanguine temperament. The more blood people had in their systems, the more passionate, charismatic, and impulsive they would be. Teenagers were considered to have a natural abundance of blood, and men had more than women.
Humorism lead to all sorts of poor medical advice. Most famously, Galen of Pergamum used it as the basis for his prescription of bloodletting. Sporting a "when in doubt, let it out" mentality, Galen declared blood the dominant humor, and bloodletting an excellent way to balance the body. Blood's relation to heat also made it a go-to for fever reduction.
While bloodletting remained common until well into the 19th century, William Harvey's discovery of the circulation of blood in 1628 would put medicine on its path to modern hematology.
Soon after Harvey's discovery, the earliest blood transfusions were attempted, but it wasn't until 1665 that first successful transfusion was performed by British physician Richard Lower. Lower's operation was between dogs, and his success prompted physicians like Jean-Baptiste Denis to try to transfuse blood from animals to humans, a process called xenotransfusion. The death of human patients ultimately led to the practice being outlawed.4
The first successful human-to-human transfusion wouldn't be performed until 1818, when British obstetrician James Blundell managed it to treat postpartum hemorrhage. But even with a proven technique in place, in the following decades many blood-transfusion patients continued to die mysteriously.
Enter Austrian physician Karl Landsteiner. In 1901 he began his work to classify blood groups. Exploring the work of Leonard Landois — the physiologist who showed that when the red blood cells of one animal are introduced to a different animal's, they clump together — Landsteiner thought a similar reaction may occur in intra-human transfusions, which would explain why transfusion success was so spotty. In 1909, he classified the A, B, AB, and O blood groups, and for his work he received the 1930 Nobel Prize for Physiology or Medicine.
What causes blood types?
It took us a while to grasp the intricacies of blood, but today, we know that this life-sustaining substance consists of:
- Red blood cells — cells that carry oxygen and remove carbon dioxide throughout the body;
- White blood cells — immune cells that protect the body against infection and foreign agents;
- Platelets — cells that help blood clot; and
- Plasma — a liquid that carries salts and enzymes.6,7
Each component has a part to play in blood's function, but the red blood cells are responsible for our differing blood types. These cells have proteins* covering their surface called antigens, and the presence or absence of particular antigens determines blood type — type A blood has only A antigens, type B only B, type AB both, and type O neither. Red blood cells sport another antigen called the RhD protein. When it is present, a blood type is said to be positive; when it is absent, it is said to be negative. The typical combinations of A, B, and RhD antigens give us the eight common blood types (A+, A-, B+, B-, AB+, AB-, O+, and O-).
Blood antigen proteins play a variety of cellular roles, but recognizing foreign cells in the blood is the most important for this discussion.
Think of antigens as backstage passes to the bloodstream, while our immune system is the doorman. If the immune system recognizes an antigen, it lets the cell pass. If it does not recognize an antigen, it initiates the body's defense systems and destroys the invader. So, a very aggressive doorman.
While our immune systems are thorough, they are not too bright. If a person with type A blood receives a transfusion of type B blood, the immune system won't recognize the new substance as a life-saving necessity. Instead, it will consider the red blood cells invaders and attack. This is why so many people either grew ill or died during transfusions before Landsteiner's brilliant discovery.
This is also why people with O negative blood are considered "universal donors." Since their red blood cells lack A, B, and RhD antigens, immune systems don't have a way to recognize these cells as foreign and so leaves them well enough alone.
How is Rh-null the rarest blood type?
Let's return to golden blood. In truth, the eight common blood types are an oversimplification of how blood types actually work. As Smithsonian.com points out, "[e]ach of these eight types can be subdivided into many distinct varieties," resulting in millions of different blood types, each classified on a multitude of antigens combinations.
Here is where things get tricky. The RhD protein previously mentioned only refers to one of 61 potential proteins in the Rh system. Blood is considered Rh-null if it lacks all of the 61 possible antigens in the Rh system. This not only makes it rare, but this also means it can be accepted by anyone with a rare blood type within the Rh system.
This is why it is considered "golden blood." It is worth its weight in gold.
As Mosaic reports, golden blood is incredibly important to medicine, but also very dangerous to live with. If a Rh-null carrier needs a blood transfusion, they can find it difficult to locate a donor, and blood is notoriously difficult to transport internationally. Rh-null carriers are encouraged to donate blood as insurance for themselves, but with so few donors spread out over the world and limits on how often they can donate, this can also put an altruistic burden on those select few who agree to donate for others.
Some bloody good questions about blood types
A nurse takes blood samples from a pregnant woman at the North Hospital (Hopital Nord) in Marseille, southern France.
Photo by BERTRAND LANGLOIS / AFP
There remain many mysteries regarding blood types. For example, we still don't know why humans evolved the A and B antigens. Some theories point to these antigens as a byproduct of the diseases various populations contacted throughout history. But we can't say for sure.
In this absence of knowledge, various myths and questions have grown around the concept of blood types in the popular consciousness. Here are some of the most common and their answers.
Do blood types affect personality?
Japan's blood type personality theory is a contemporary resurrection of humorism. The idea states that your blood type directly affects your personality, so type A blood carriers are kind and fastidious, while type B carriers are optimistic and do their own thing. However, a 2003 study sampling 180 men and 180 women found no relationship between blood type and personality.
The theory makes for a fun question on a Cosmopolitan quiz, but that's as accurate as it gets.
Should you alter your diet based on your blood type?
Remember Galen of Pergamon? In addition to bloodletting, he also prescribed his patients to eat certain foods depending on which humors needed to be balanced. Wine, for example, was considered a hot and dry drink, so it would be prescribed to treat a cold. In other words, belief that your diet should complement your blood type is yet another holdover of humorism theory.
Created by Peter J. D'Adamo, the Blood Type Diet argues that one's diet should match one's blood type. Type A carriers should eat a meat-free diet of whole grains, legumes, fruits, and vegetables; type B carriers should eat green vegetables, certain meats, and low-fat dairy; and so on.
However, a study from the University of Toronto analyzed the data from 1,455 participants and found no evidence to support the theory. While people can lose weight and become healthier on the diet, it probably has more to do with eating all those leafy greens than blood type.
Are there links between blood types and certain diseases?
There is evidence to suggest that different blood types may increase the risk of certain diseases. One analysis suggested that type O blood decreases the risk of having a stroke or heart attack, while AB blood appears to increase it. With that said, type O carriers have a greater chance of developing peptic ulcers and skin cancer.
None of this is to say that your blood type will foredoom your medical future. Many factors, such as diet and exercise, hold influence over your health and likely to a greater extent than blood type.
What is the most common blood type?
In the United States, the most common blood type is O+. Roughly one in three people sports this type of blood. Of the eight well-known blood types, the least common is AB-. Only one in 167 people in the U.S. have it.
Do animals have blood types?
They most certainly do, but they are not the same as ours. This difference is why those 17th-century patients who thought, "Animal blood, now that's the ticket!" ultimately had their tickets punched. In fact, blood types are distinct between species. Unhelpfully, scientists sometimes use the same nomenclature to describe these different types. Cats, for example, have A and B antigens, but these are not the same A and B antigens found in humans.
Interestingly, xenotransfusion is making a comeback. Scientists are working to genetically engineer the blood of pigs to potentially produce human compatible blood.
Scientists are also looking into creating synthetic blood. If they succeed, they may be able to ease the current blood shortage, while also devising a way to create blood for rare blood type carriers. While this may make golden blood less golden, it would certainly make it easier to live with.* While antigens are typically proteins, they can be other molecules as well, such as polysaccharides.
A new study suggests that reports of the impending infertility of the human male are greatly exaggerated.
- A new review of a famous study on declining sperm counts finds several flaws.
- The old report makes unfounded assumptions, has faulty data, and tends toward panic.
- The new report does not rule out that sperm counts are going down, only that this could be quite normal.
Several years ago, a meta-analysis of studies on human fertility came out warning us about the declining sperm counts of Western men. It was widely shared, and its findings were featured on the covers of popular magazines. Indeed, its findings were alarming: a nearly 60 percent decline in sperm per milliliter since 1973 with no end in sight. It was only a matter of time, the authors argued, until men were firing blanks, literally.
Well… never mind.
It turns out that the impending demise of humanity was greatly exaggerated. As the predicted infertility wave crashed upon us, there was neither a great rush of men to fertility clinics nor a sudden dearth of new babies. The only discussions about population decline focus on urbanization and the fact that people choose not to have kids rather than not being able to have them.
Now, a new analysis of the 2017 study says that lower sperm counts is nothing to be surprised by. Published in Human Fertility, its authors point to flaws in the original paper's data and interpretation. They suggest a better and smarter reanalysis.
Counting tiny things is difficult
The original 2017 report analyzed 185 studies on 43,000 men and their reproductive health. Its findings were clear: "a significant decline in sperm counts… between 1973 and 2011, driven by a 50-60 percent decline among men unselected by fertility from North America, Europe, Australia and New Zealand."
However, the new analysis points out flaws in the data. As many as a third of the men in the studies were of unknown age, an important factor in reproductive health. In 45 percent of cases, the year of the sample collection was unknown- a big detail to miss in a study measuring change over time. The quality controls and conditions for sample collection and analysis vary widely from study to study, which likely influenced the measured sperm counts in the samples.
Another study from 2013 also points out that the methods for determining sperm count were only standardized in the 1980s, which occurred after some of the data points were collected for the original study. It is entirely possible that the early studies gave inaccurately high sperm counts.
This is not to say that the 2017 paper is entirely useless; it had a much more rigorous methodology than previous studies on the subject, which also claimed to identify a decline in sperm counts. However, the original study had more problems.
Garbage in, garbage out
Predictable as always, the media went crazy. Discussions of the decline of masculinity took off, both in mainstream and less-than-reputable forums; concerns about the imagined feminizing traits of soy products continued to increase; and the authors of the original study were called upon to discuss the findings themselves in a number of articles.
However, as this new review points out, some of the findings of that meta-analysis are debatable at best. For example, the 2017 report suggests that "declining mean [sperm count] implies that an increasing proportion of men have sperm counts below any given threshold for sub-fertility or infertility," despite little empirical evidence that this is the case.
The WHO offers a large range for what it considers to be a healthy sperm count, from 15 to 250 million sperm per milliliter. The benefits to fertility above a count of 40 million are seen as minimal, and the original study found a mean sperm concentration of 47 million sperm per milliliter.
Healthy sperm, healthy man?
The claim that sperm count is evidence of larger health problems is also scrutinized in this new article. While it is true that many major health problems can impact reproductive health, there is little evidence that it is the "canary in the coal mine" for overall well-being. A number of studies suggest that any relation between lifestyle choices and this part of reproductive health is limited at best.
Lastly, ideas that environmental factors could be at play have been debunked since 2017. While the original paper considered the idea that pollutants, especially from plastics, could be at fault, it is now known that this kind of pollution is worse in the parts of the world that the original paper observed higher sperm counts in (i.e., non-Western nations).
There never was a male fertility crisis
The authors of the new review do not deny that some measurements are showing lower sperm counts, but they do question the claim that this is catastrophic or part of a larger pathological issue. They propose a new interpretation of the data. Dubbed the "Sperm Count Biovariability hypothesis," it is summarized as:
"Sperm count varies within a wide range, much of which can be considered non-pathological and species-typical. Above a critical threshold, more is not necessarily an indicator of better health or higher probability of fertility relative to less. Sperm count varies across bodies, ecologies, and time periods. Knowledge about the relationship between individual and population sperm count and life-historical and ecological factors is critical to interpreting trends in average sperm counts and their relationships to human health and fertility."
Still, the authors note that lower sperm counts "could decline due to negative environmental exposures, or that this may carry implications for men's health and fertility."
However, they disagree that the decline in absolute sperm count is necessarily a bad sign for men's health and fertility. We aren't at civilization ending catastrophe just yet.