Welcome to Sentivia

Alright, let me tell you a bit about myself and how I got here. My journey started not in some ivory tower of academia, but as a surgical trainee. I was knee-deep in the trenches, learning the ropes of a world where I was, frankly, far from being an expert at anything. That experience really forced me to confront a fundamental question: How do you actually become good at something, *anything*? It’s a question that resonated not just for me as a fledgling surgeon, but I think for all of us in the human experience.

It’s hard enough to simply master the technical skills of any craft, the sheer amount of information you need to absorb can be overwhelming. As a surgeon, I had to master the physical acts of sewing and cutting, but beyond that, I also had to grapple with the incredibly complex task of determining who exactly was the right candidate for a surgery, whose health and circumstance were best suited for the procedure at hand. This process naturally led to reflections on what it really meant to be good at the job, which was something different from just being technically adept at cutting and sewing.

But then, in the midst of all of that, came a new understanding. Over the last several years, we’ve come to realize that medicine is facing what might be its deepest crisis ever, and it’s not about some new disease, but something you don’t often think about when you're a doctor. It's about the cost of healthcare. Every single country on this planet is now wrestling with the question of whether they can actually afford the kind of medical care that doctors provide.

And that led to a big political showdown. We're all pointing fingers - some say it's the government’s fault, others blame the insurance companies. But the truth is, it's much deeper than that. The core of our problem lies in the sheer complexity that science has given us. To illustrate this point, I like to take people back a few generations to a time when Lewis Thomas was writing “The Youngest Science.” Thomas, one of my favorite authors, was a physician who described what it was like to be a medical intern back in 1937, the era before penicillin.

At that point in time, medicine was inexpensive, and frankly, not very effective. If you were in the hospital, you were going to be comfortable because they’d give you warmth, food, a bed, and caring nurses. However, doctors and medical treatments at that time were pretty ineffective and rarely made a real difference. Despite their limitations, doctors were incredibly busy, tirelessly trying to determine if a patient had one of the few conditions for which they could actually do something. They might give you an antiserum for lobar pneumonia, a bloodletting for congestive heart failure or a cocktail of mercury and arsenic for syphilis. Beyond that, however, there wasn't a whole lot doctors could do.

This era, though, shaped the very foundation of medicine and the values we built our medical system on. It was a time where a single doctor could hold all of the essential medical knowledge in their head and could execute all parts of patient care by themselves. A doctor with a prescription pad, a nurse, and a hospital to convalesce, could effectively manage a patient's care from start to finish. They set the fractures, drew blood, examined it under the microscope, plated cultures, and injected serums. It was the life of a true craftsman.

This naturally led to a culture built around values of daring, courage, independence, and self-sufficiency. Autonomy became our highest value.

But fast forward a couple of generations, and the world of medicine is unrecognizable. We now have treatment options for nearly all of the tens of thousands of conditions a human being can suffer from. We can't cure everything and we can't guarantee that everyone will live a long and healthy life but we can certainly improve outcomes for most. However, with this advancement has come a level of complexity previously unimagined. There are over 4,000 medical and surgical procedures and about 6,000 drugs that I am licensed to prescribe, and the effort to deploy these options effectively is a massive undertaking, town by town, to every human being alive.

And this is where we've reached a critical juncture. As doctors, we've realized that we simply can't know it all. And we certainly can't do it all by ourselves. A recent study showed that in 1970, it took about two full-time clinicians to care for the average hospital patient. By the end of the 20th century, that number had jumped to over 15 clinicians – specialists, physical therapists, nurses; we are all specialists now, even primary care physicians. Each person has just a little piece of the pie.

But we are holding on to that old structure, that old mindset, of independence and self-sufficiency in each of these individual specialists. And the result has been, in no uncertain terms, a disaster. We’ve trained, hired, and rewarded people to be cowboys, when what we actually need are pit crews for our patients. We have 40 percent of our heart disease patients receiving incomplete or inappropriate care. 60 percent of asthma and stroke patients receiving incomplete or inappropriate care. Two million patients a year in hospitals pick up preventable infections because someone didn’t follow basic hygiene practices. The experience of getting sick in our world, despite having amazing, well-trained and hardworking clinicians, along with access to incredible technologies, we don’t have a sense that we can rely on these systems to work well for us every time.

And it's this lack of cohesiveness that contributes to our unmanageable healthcare costs. We tend to say that the high cost of care is just "the way it is,” as a result of advancements. But in my view, we are ignoring the data. We are finding that the most expensive care is not always the best care, and in fact the best care often turns out to be the least expensive, with fewer complications, and more efficiency. That fact gives me hope.

If the best outcomes needed the most expensive care in the country, then we would be talking about rationing, but when we look at the positive deviants, the places that are seeing the best outcomes at the lowest cost, we find that the most successful practices are those that function as systems. They find ways to get all of the different pieces and components working together in unison. We’ve been too obsessed with components: the best drugs, the best specialists, the best technologies. But we fail to consider how these components fit together. That is a terrible design strategy!

I often reference the thought experiment, “what if you built a car from all of the best car parts?” Well, you’d have Porsche brakes, a Ferrari engine, a Volvo body, and a BMW chassis. You would end up with a very expensive pile of junk that couldn’t go anywhere. And that’s what medicine often feels like. It's not a system.

I believe that systems have three key skills. The first is recognizing success and failure. As a specialist, it’s hard to see the entire arc of patient experience. Therefore, you need to become intensely interested in data. It may not seem sexy, but it is essential. Take one of my colleagues, a surgeon in Iowa. He decided to find out how many CT scans they were doing in their community. It took him 3 months to get that data, because no one had asked it before. They found they had done 52,000 CT scans for a community of 300,000 people and he found there was a problem that needed fixing.

The second skill of a system is to devise solutions. I became interested in this problem when the World Health Organization asked my team for help reducing deaths in surgery. Surgery had spread across the world, but safety had not. Our usual methods for tackling these kinds of problems is more training, more specialization, and more technology. However, in surgery, it's difficult to imagine more specialization and more training. And yet, we see unacceptable rates of death and disability that could have been avoided.

So we looked at other high-risk industries – skyscraper construction and aviation. They have technology, they have training, and they also have checklists. I never expected to spend my time as a Harvard surgeon worrying about checklists. But they were an incredibly effective tool in helping experts to get better. We partnered with an engineer from Boeing to help us develop a surgical checklist, not for the least experienced among us, but for the whole team, including the surgeons. Developing a checklist involves a lot of work. You have to think about pause points and key places where you can identify and catch problems before they get too dangerous. You need to identify the specific killer items that can get overlooked or missed. It's not a recipe for the whole process, but a reminder of the things that must be done.

We designed a 19 item, two minute surgical checklist. It included “dumb stuff,” like ensuring that antibiotics were given at the right time frame (which cuts the infection rate in half!), and more complex items, like ensuring everyone in the room had introduced themselves at the beginning of the day. We implemented this checklist in 8 hospitals across the globe, and the complication rates fell by 35 percent. The death rates fell by 47 percent. And this improvement was bigger than any drug that has come on the market.

And that brings us to the third essential skill – the ability to actually implement these changes, and get everyone on board. It’s been incredibly slow to spread because the use of these tools forces us to confront that we aren’t a system, and to behave with a different set of values. Using a checklist requires humility, teamwork, and discipline. It's the opposite of the independence and self-sufficiency that medicine was built on. I met a real cowboy once and he explained that even they are now using checklists and protocols for herding their cattle. Even the cowboys are pit crews now.

I believe that making systems work is the great task of my generation of physicians and scientists, but I’d go further and say it’s the great task of this entire generation. Whether it’s in healthcare, education, climate change, or poverty reduction. Knowledge has expanded in every field, bringing with it increasing complexity and specialization. We’ve come to a point where we have no choice but to acknowledge that as individualistic as we want to be, complexity requires group success. We all need to be pit crews now.