Being Mortal by Atul Gawande

I’ve been a big fan of Atul Gawande ever since I read Complications, which is still one of my favorite books. Gawande is a surgeon at Brigham and Women’s Hospital in Boston, a professor at Harvard Medical School and the Harvard School of Public Health.  He’s also an acclaimed writer who welcomes his reader into his personal exploration of the assumptions he brought in to his surgical practice and where those assumptions have fallen short.  I enjoy Gawande’s skills as a writer and an observer, and I deeply respect his capacity for introspection, honest self-critique, and his willingness to take on medical orthodoxy even when (especially when) it’s uncomfortable.

Complications hooked me from the first page and helped me understand surgery, and the fallibility of surgeons, in a new way. I also devoured The Checklist Manifesto, which, while not nearly as enthralling as Complications, was so overwhelmingly useful that I couldn’t put it down. It explains, among other things, why they ask you seemingly stupid questions before operations (“which leg are we operating on today?” answer: because when they don’t ask this they often end up amputating or reconstructing the wrong legs) and why commercial flying is safer than driving (hint: checklists!).

I downloaded a free sample of Atul Gawande’s newest book, Being Mortal: Medicine and What Matters Most in the End, weeks ago, but I’d hesitated to start it because, on some level, I wanted to shy away from the topic. Who wants to read a book about end of life care?  Then last week a friend told me how profoundly the book had changed his thinking, and that I had to read it. I started reading it on Friday and I’d finished it by Sunday.

Being Mortal confronts head-on a reality that we all will face: how we manage dying and death, for ourselves and our loved ones. No, it’s not a fun topic, but it is a singularly universal topic, and I’m convinced that without reading this book we will not face death well.

The basic premise of the book is that, in the West, where families have become nuclear (rather than extended), illness, dying and death have been turned over to medical professionals and to end-of-life facilities, both of which are designed to treat illness and prioritize safety rather than care for people. This is why more than 85% of people in the US died in hospitals, not at home, in the 1990s; why we sign on for third-line chemotherapy treatments that have miniscule chances of success and very likely to worsen quality of life; and why we are surprised to learn that high-quality hospice care not only increases the quality of life, it often ends up extending life as well.

In summarizing his findings, Gawande argues:

I am leery of suggesting the idea that endings are controllable. No one ever really has control. Physics and biology and accident ultimately have their way in our lives. But the point is we are not helpless either. Courage is the strength to recognize both realities. We have room to act, to shape our stories, though as time goes on it is within narrower and narrower confines. A few conclusions become clear when we understand this: that our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one’s story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture, and our conversations in ways that transform the possibilities for the last chapters of everyone’s lives.

The story gets very personal at times, as Gawande weaves in the details of his own father’s illness and death.  He shares the excruciating choices that his father, his mother, and he had to make in the years following the discovery of his father’s rare spinal cancer; the important conversations they all had while navigating the nearly impossible decisions of whether and when to operate, and what sort of care to get in service of his fathers’ well-being and his father’s health in the years leading up to his death.

The book is both moving and overwhelmingly practical. It presents stories and facts and analysis and also gives us the tools to manage our own confrontation with serious illness and death. Most powerful, to me, are Gawande’s guidelines for the conversations we need to have when someone is very sick and near death. They must follow, in Gawande’s estimation, a clear path:

Whenever serious sickness or injury strikes and your body or mind breaks down, the vital questions are the same: What is your understanding of the situation and its potential outcomes? What are your fears and your hopes? What are the trade-offs you are willing to make and not willing to make? And what is the course of action that best serves this understanding?

These questions are powerful because they put the sick and dying person back in the driver’s seat, not just as someone making choices from an array of medical interventions – interventions that are, customarily, described incorrectly (doctors consistently overestimate the likelihood of success and consistently underplay risks to patients) – but as someone who knows best what they value in their own lives. It is these conversations that empower real choices and ensure self-determination even in the midst of declining physical and mental well-being.

The book is both sobering and empowering, giving us the tools to confront some of our most challenging moments with dignity. Gawande concludes with a simple reframing: “We’ve been wrong about what our job is in medicine. We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being. And well-being is about the reasons one wishes to be alive.”

I’ll be evangelizing this book for a while, to anyone who will listen – not because it’s a fun read or a good one, but because it’s real and because we are failing ourselves and our loved ones by handing over some of the most important decisions in our lives to professionals who are neither trained nor equipped to answer them without us.

Do Linchpins have Checklists?

Atul Gawande has convinced me that checklists are way more powerful than I’d ever realized.  I picked up The Checklist Manifesto because I love Gawande’s writing and I’m fascinated by ways to improve the practice of medicine.  While I wanted to learn more about improving surgical outcomes, I never expected that in so doing I’d learn why buildings don’t fall down, why planes are a safer way to travel than cars, and how some of the most successful VC firms beat their competitors: you guessed it, they all use of checklists.

Guwande leads with a deep look at the building trade, which used to rely on master builders who ran the show, until that stopped working.   What it takes to put up a building got too complex for any one person to handle in an improvisational way, and so the “master builder” model gave way to intensive use of checklists: checklists that describe who does what, the steps to follow, and, most importantly, how the groups interact with each other.  The parallel is to modern surgery which, until recently, has been dominated by the surgeon as “master builder;” Guwande’s compelling argument is that modern medicine, with all of its sub- sub- specialties and technology, has become so complex that this “master builder” mindset is hopelessly outdated.

As I’ve been digesting this, I’ve been trying to reconcile it with the idea – which I believe on a deep level – that to thrive in the modern economy and to be a happy and fulfilled person, what the world is asking of all of us is that we be linchpins, that we create our art and do the work that no one else can do.  And then the question arises: where are checklists in this picture?

And then it hit me that the point of intersection between checklists and linchpins grows out of the recognition that the most successful checklists define both the steps to take in a given situation AND the norms and expectations for how people are going to interact.  For example, something as simple as members of a surgical team introducing themselves to one another by name before the start of surgery, Gawande found, has a significant positive impact on surgical outcomes: people on the surgical team (nurses especially) are more likely to speak up when a step is skipped or a mistake is made if everyone knows each others’ names.

Last week at NextGen:Charity Seth Godin said that only the perfect problems are left today – because all the imperfect ones have already been solved.  What a great rallying cry!  As our teams get more virtual and more loosely connected, as roles begin to blend and the edges around our roles and responsibilities get softer, the answer Guwande points us towards is not to create a process for everything, to think that there’s a series of all-encompassing steps that will foresee each new situation and how we interact with it.   Instead, the onus is on us to increase our comfort with that place of uncertainty by defining two things: the steps we’re going to take in situations in which the steps can be defined; and how we’re going to interact with each other all of the time.

So it’s not about constantly improvising outside of all norms and best practices; nor about thinking that everything will go right if we can just systematize the process.  It’s about our orientation towards the world, and the knowledge that we can optimize how we solve the imperfect problems and, in so doing, free up the space in our minds and our lives so we can practice our art – and tackle the remaining, perfect problems.