Dr. Atul Gawande
In any given week, Dr. Atul Gawande might perform thyroid cancer surgery, write a sprawling piece for The New Yorker, meet with the White House about public health or talk with his medical students at Harvard about the role of a physician in the art of dying. In this episode, he reflects on his personal and professional experiences with dying patients.
People have priorities for their lives
besides just living longer.
our most effective way of learning
what your priorities are is to ask people,
and we don't ask.
Dying is hard work.
So is growing old,
though there are ways to make both meaningful
and even beautiful.
The problem is that medicine is meant to fix,
and health care is usually measured
in costs, not moments of grace.
Perhaps our country's best thinker on this tension
that ultimately involves us all is Atul Gawande.
Any given week, Dr. Gawande might perform
thyroid cancer surgery,
write a sprawling piece for "The New Yorker,"
meet with the White House about public health,
or talk with his medical students at Harvard
about the role of a physician in the art of dying.
He's also the author of several very important bestsellers,
most recently "Being Mortal."
I'm Kelly Corrigan.
This is "Tell Me More," and here is my conversation
with writer, thinker, and doctor Atul Gawande.
So we used to lie about being older,
and now we lie about being younger.
When this country was founded,
people would make themselves look older.
You see the wigs that people wore.
They would wear powder in order to make themselves
look older and wiser because being old was rare,
so the old were revered.
And what does that mean
that we have decided that old age
is something to hide or disguise?
A reality of living in the 21st century
is that dying before the age of, say, 65
is extremely uncommon.
As a result, there's almost this divide
between that part of your life
where you really don't think about the notion
that when you're older, life might be limited,
and that has put us in a place
where we value youth for the idea
that you have no limits.
The other part is, you know,
the losses of life as it goes on.
You lose a little bit of your vision.
You lose a little bit of your...
Hair. your hair, you know?
We don't see any of the other side
of the value that comes along with that.
We so easily discard
what seems even faintly old.
Your grandfather lived to be 110.
Yeah, or thereabouts.
You know, he's aged
according to when there was a famous flood,
but we know he was at least 108 years old.
On the flipside, my father's mother
died by the age of 30 from malaria at a time
where there were malaria pills available,
couldn't get it, and so, you know,
my grandfather's living until 108
in the bosom of the family,
riding his horse around his farm every day
because he still wanted to be the one to check the crops.
So what's the difference between the way
that your grandfather grew old
and the way that maybe our parents
have or will grow old?
We tend to be incredibly nostalgic
about the way that someone like my grandfather died.
You have multigenerational families living together.
He sat at the head of the table.
They came to him still for advice.
There was always someone there to take care of him.
We're nostalgic about it, but the reality of it was,
it was also young women were more or less
enslaved to the elder parents in the family.
Part of what came as we developed cities,
better economies was freedom for young people.
They didn't have to become farmers
or enslaved to the family,
and the current generation in India
or in the United States or elsewhere
are people who can dream
of leading a life of their own.
That's the funniest thing to me,
is that the research shows that
we have this idea that all the aging parents
would just love to go live with her children.
My mom doesn't want to live with me,
and neither do any of the other moms.
Like, if you have an ounce
of financial security,
what you want is independence.
One of my favorite phrases from the sociologists
is that people like to have an intimate distance,
and a parent doesn't want to move into the home
of a child and follow their rules.
The child doesn't want to be living in the home
of their parent and still following their rules,
and people end up wanting to have their own space.
My grandfather died falling off a bus
because he was insisting on still managing his own way,
hit his head, and had a brain bleed.
That's part of the other story, too, though--
being able to take risks in your life...
getting to choose, and they aren't always
the ones my kids will agree with
or my doctors will agree with,
and that's part of living, too.
Right, and that's really the rub
because if you're a diabetic
your whole life and you have a feeling
that your time is limited
and you'd like to have a cookie every day,
like, part of us wants to say,
"Well, God bless you. Like, do it."
The other problem, though, is that
if you fall and break your hip
and you have all these tremendous new set
of needs that have costs associated with them,
then is it self-centered?
Like, whose life is it?
On one hand, it is clearly the case
that being in a place
where you get to make the choices
is what defines being in your own home.
I remember visiting my wife's grandmother
when she was living in a nursing home
the last year of her life,
and whenever we went to see her,
she would just say, "When do I get to go home?"
and you'd have to eat at certain time
and you had to go to bed at a certain time,
and, you know, she loved wearing high heels,
and she wasn't allowed to wear heels anymore.
Now, I think about it as a doctor, right?
I'm gonna have an argument with you about the heels.
I'm gonna have an argument with you about cigarettes.
I'm gonna have an argument with you about the seatbelt,
but if we can have a conversation
about what ultimately matters to you
and what really is most important,
those might be more important than survival.
At some point, someone in your book said,
"It's almost like an orphanage in reverse
where we've been pulled away from society
"and housed in these 10-by-10 rooms
until we disappear,"
and then you told the story
of the Eden Alternative.
A guy named Bill Thomas,
this was his first experiment.
He's a geriatrician and a kind of crazy guy
because he became the medical director
at a nursing home and decided
these people didn't seem to have life.
You just saw the people slumped over
in their wheelchairs parked in front of a TV,
and he said, "I'm gonna make it
so everybody can have a pet if they want a pet,"
got a hundred parakeets in,
got dogs, got cats, and the staff
would help you with managing having a pet.
Having something to care for
allowed people to feel they had life.
As a result of the Eden Alternative,
they had a marked reduction
in use of antipsychotics,
of antidepressants, and saw people,
you know, literally come to life
who had been almost catatonic
but now had created a bond with their animal
and were being brought back to life again.
In 1900, the average American,
we died in our mid 40s.
Fast-forward to where we are today,
we're practically at double our lifespan.
It's because we intervened.
It's because we interviewed,
so we created the medical capability
to help people live that length of time.
How do I make life worth living,
that extra life worth living?
And that has depended on the creation
of specialties like geriatric medicine,
palliative care, and other fields
where you're not focused on the heroics
when the geriatricians
were incredibly fascinating to me
because they understood that people
have goals besides just living longer,
and the irony of making sure
that we give you your best possible day every day
is that people don't live shorter.
They live longer, on average.
There's a great trial, for example,
that was done at the Mass. General Hospital here
with stage-4 lung cancer patients.
They lived, on average, in the trial 11 months,
and half of them got the standard oncology care,
and the other half got the standard oncology care
and a visit with a palliative care specialist
who focuses on how to make sure you feel better...
Mm-hmm. over time,
and those who saw
the palliative care clinician
in addition to their chemotherapy
lived 25% longer than those who didn't.
If it was a drug, it'd be
a multibillion-dollar blockbuster.
So it's always framed as less time,
but higher quality,
and that's not correct.
It could be more time.
It's very easy for me to imagine
a doctor in the room saying,
"Your prognosis is grim,
and I want you to be comfortable,"
and then feeling the disappointment
in the room and saying,
"I mean, there is this one trial,"
you know, or some little thing,
and you've had moments like that
where you really regretted
opening up a line of hope for a patient.
Well, I always think there is
some line of hope to offer to people,
but there's a difference between offering
a false hope and a true hope.
It's the difference between learning
to be a technician and being a counselor.
The counselor is really good at being able
to say, "What really matters to you?
Tell me about your life."
That makes a huge difference.
One man said, "Minimum quality of life,
"if I can eat chocolate ice cream
"and watch football on television,
that'd be good enough for me."
Ha ha ha!
That is the best living will ever.
There's usually multiple people involved,
so when my father was dying, he had my mom
and my two brothers and me,
so there were 4 of us on one side
and this guy over here,
and, blessedly, all 5 people agreed,
but I thought it would have only taken
one person in that scenario to say,
"We have to give him everything there is,"
to disrupt what was
a really peaceful, beautiful exit.
We have a word for this.
We call it the seagull syndrome.
The relative who lives furthest away
flies into town and craps all over the plan.
Ha ha ha!
Oh, my God, that's incredible.
Is that, like, a known thing?
It's a thing.
You see it all the time, right,
that people hadn't been there in the conversation,
and it's out of love, right?
Giving chemotherapy in the last two weeks of life
only makes them worse instead of better
and so being able to say,
"What really matters to this person?
"What matters in their life,
"and can we restore that?
"Can we can we rescue that,
"and if that isn't possible anymore,
now what can we shoot for?"
My youngest child's piano teacher
was admitted to the hospital here
and just sick, incontinent, in pain
with a tumor in her pelvis that couldn't be cured,
and the question was, does she want to do
an experimental bone marrow transplant
with very little evidence of whether it would be
even remotely be imagined to work
or go to hospice?
And she went home on hospice, and she--
First day, it was all about just get pain under control.
They gave her more morphine,
and within 3 days, she had lifted her sights and said,
"You know what I really wanted?
I want to teach again."
My child got to have piano lessons
the last 6 weeks of Peg's life,
and Hunter just graduated
from Berklee School of Music
last month because of Peg.
That was what Peg got to make possible.
So you and I have shared an experience.
We were both with our fathers when they died,
and one of the last things that a parent can do
is teach you how to die,
so what did your father teach you?
It was hard. He was quadriplegic.
He was in a lot of pain
at various points along the way,
but what I learned is, it is possible
to have clarity,
even if it changes from week to week,
about what was he gonna care about today
and could I make something happen today
that would make that day worthwhile.
My guess is that everyone watching
is gonna want to know, like,
"What is the question--
"the two questions, 3 questions--
"that I should ask my parent
the next time we're together?"
What's hard is, it's hard to ask
the questions like, you know,
"What's your understanding
"of where you are with your health?
"What are your fears?
"What are you willing to endure?
What are you not willing to endure?"
Much easier was telling my dad,
"Hey, I met this guy, and he said,
"If I can watch football on television,
"eat chocolate ice cream,
that'll be good enough for me."
What would be good enough for you?"
That's become, like,
my favorite dinner-party conversation.
So what would be good enough for you?
What are your non-negotiables?
So my wife and I find
we are in different places on this.
You know, my body doesn't have to work,
but if I can interact, that's what really matters.
If I can't have a conversation,
if I can't remember the past
and connect it to the future,
let me go,
but if I can be a brain in a jar
and if I can communicate with you,
Mm-hmm. keep it going,
and my wife says, "That is so dumb."
Ha! Ha ha!
She's like, "Look.
"I don't have to remember you.
"I don't have to, like, be able to tell the story
"and, like, all that.
"You know me.
"You know when I have joy,
"and you know when I don't,
"and if I can still have joy,
keep me going."
We have this segment called "Plus One"
where we ask our main guest
to introduce us to someone special
who's really affected their thinking
and their work.
Sarah Creed taught you a lot
about great palliative care.
Talk a little bit about her.
She was a hospice nurse.
I realized in the course
of my starting to do the research
for what became "Being Mortal," my book,
that I really had no understanding
of what hospice was.
I went on--
you know, was able to arrange to spend
a couple days with a hospice nurse,
and what I got was Sarah Creed,
a 27-year-old nurse,
who'd been a former ICU nurse.
I didn't put how old she was in the book
because she was so wise...
I didn't think anybody would believe
it was coming from a 27-year-old,
and what I learned from Sarah was that
she had gotten such wisdom
from a few years of really spending time
with people at this moment in their lives
and being able to articulate,
the goal is not fight or give up.
It is, "We've got this incredible arsenal.
What are we gonna use it to fight for for you?"
I wanted to show you
something she said about you.
Creed: Working in the hospital
was not my favorite part of my career.
I started working in the hospital
right out of nursing school.
I worked in cardiology, and I wasn't able
to really spend the time with my patients
and getting to know my patients the way that I wanted to.
The patients, they were just so sick,
we would be keeping them alive to get their organ
until the brink of death,
and I started to really wonder,
"You know, should we be doing all of this?"
A friend told me, you know, I should think about hospice.
I loved the job.
I used to say, I couldn't believe
that they paid me to do this job.
I first met Atul Gawande
when we went out on hospice rounds together.
We talked about this concept of making each day count.
That was a aha moment, I think, for him
where he realized that this was not
so much about getting better.
This was about what is important to a person.
It's not about hastening death. It's not about extending life.
It's about making life as good as it can be
for the time that we have left.
I have had people who are just so sick
and just have, you know, very little time left,
but they have a smile on their face when I come to their door,
and they are happy to see me.
They're happy for the time that they have.
They're happy for the life that they've led,
and I try my hardest
in my day-to-day life to take some of that with me.
I've learned from my patients
that life is incredibly precious
and it's incredibly short
and that in the time that we have here,
we need to make it count.
Well, you can see why I was so moved by her.
Yeah. Yeah, for sure.
We saw some really sick people,
and she found some way to make them better...
Mm. Right, right.
To my mind, it goes
to who's attracted to medicine.
I think the people
who are good at organic chemistry--
which is, like, kind of the gateway
to being a pre-med--
Is the person who's really good
at organic chemistry also likely
to be good at thinking about this kind
of soft skill, empathetic,
It's the worst process
for picking who should be our doctors.
A weed-out in your freshman year
based on your grade in a chemistry class
is no indication
of who's gonna be a really good doctor,
and then there's this whole other part
of medicine which is about your ability
to connect and empathize with other people
and your ability to lead a group of people
that's a team and being able to work effectively on teams.
I call it the difference between cowboys and pit crews.
We have hired, trained, and rewarded people
to be cowboys in medicine,
but what people really need--
Or cowgirls. or cowgirls--
and what people really need are the pit crews.
And you teach at Harvard Medical School...
and are you finding ways
to bake into your classes this kind of learning?
I am a founder of a research center
called Ariadne Labs, which is
for planting better systems of health care delivery.
Out of that, we made a partnership
with a group of different folks,
including our local insurer here,
Blue Cross Blue Shield of Massachusetts,
to create a whole coalition
around how we teach medicine
not just for the doctors, but even nurses,
social workers in the state,
so we're trying to become the first state
where everybody is developing your skills
as you go through your training
for how to have these conversations,
and it takes years of work.
The first level is just how do I ask people,
"What's your understanding
"of what your prognosis is?
"What are you willing to go through
and not willing to go through?"
So you were born to two Indian doctors
who emigrated to, I think,
the poorest county in Ohio,
like, right on the Appalachian.
They met in New York City,
and then when they got jobs,
they ended up locating.
My mom was a pediatrician.
My father was a urologist in Athens County, Ohio,
the poorest county in Ohio,
And interestingly, like, those are two topics
that people love to opine on--
immigrants and rural poverty,
and the case for you was that
your parents were really respected.
You had the only Mercedes in town.
Like, it's not the story that everybody thinks,
and I wonder if you being somebody
who isn't who people think you're gonna be
has helped you be
a little bit more of a free thinker.
You know, 70% of the country does not go to college,
and I got to have both.
I got to have the opportunity to go to Stanford
and the opportunity to grow up in Appalachia,
and yet I think I've spent most of my career
really trying to figure out how to belong
because I wasn't quite of either place,
and my way of belonging
was try to achieve stuff people valued.
I definitely don't have original ideas.
What I have are, "Ooh, that looked cool.
"They did that over there in airplanes.
"What if we took that and brought it
over here in medicine?"
Part of my work has been around
how we make our systems just better,
and in surgery, it had been bringing
the introduction of basically a pilot's checklist.
The critical element of that
is everybody having a chance to speak
and hear their name.
It's like having a meeting.
You always start by going
around the conference room and saying, you know,
"Everybody introduce themselves,"
because once you've heard your voice in the room,
you are willing to say something.
We also asked people to think,
"Who are you?
What should I know about this patient?"
and the result of that has been--
in our original trial in 8 cities
was a 47% reduction in death
because of a team having a conversation.
You know, what I like about the checklist is,
I feel like it inserts a moment of humility.
Humility isn't always associated with heroes.
You put your finger on actually what has been
the hardest part of the transition.
The values of an operating room
before we brought the system in
was that the autonomy of the surgeon
was number one-- what they said goes--
and the shift was to saying
that we are gonna value humility--
no matter how experienced you are, your pedigree,
you can make a mistake--
the recognition of doing certain things
the same way every time,
including the conversation we're gonna have,
helps save people against their own errors--
and third is teamwork, that anybody in the room
can turn out to have information
or something to say that will make a difference.
So everybody who's watching this
and thinking about their parents or themselves,
some massive percentage of them say things like,
"I'll tell you what.
"That's not gonna happen to me.
"Nobody's gonna change my diaper.
I'm gonna take the pill."
How do you think about euthanasia?
I find the urge understandable, right,
to say, "I want to control what happens here."
It's become a rising form
of ways in which people die.
It's 3% or 4% of the population in--
I think it's the Netherlands
that it's up to, and, you know,
it's more common among women than men,
and the most common reason cited
by the women would be,
"I don't want to be a burden on my family."
That's troubling to me.
The bottom line is,
I think we're in a place where we have not
been able to give people confidence
that their pain,
their ability to express their wishes
and to have the ability to manage
under circumstances where you don't have control,
whatever is worth living through,
we should be able to make that happen,
and so I'm reassured by the fact
that at present in the states that have it,
it's less than 1% who choose the option.
They get the pill jar,
and half of them never use it,
which means it was comfort enough
that they have choice if it gets that bad...
and that 99%, we really just have to--
we really have to work on this fundamental thing,
which is making a system that actually
serves people's priorities.
Are you ready for the speed round,
OK. I'll try.
What's your go-to mantra for hard times?
"This will pass."
When was last time you cried?
Last time I cried. I tear up very easily.
So do I.
I was tearing up when we were talking.
I think the last time was, like, last week
watching the first episode of "Sweet Tooth."
Ha ha ha!
If I looked at your Spotify playlist,
What song would be the most listened to?
I actually looked this up because of this thing,
and it was "Ringside" by Julien Baker.
All right. I didn't know you were so hip.
What's your guilty pleasure?
I think my main guilty pleasure,
it's music... Yeah.
going to concerts.
If your mother wrote a book about you,
what would it be called?
"I'm So Proud." Ha ha ha!
She is that kind of Indian mom.
Yeah. Well, she's a lot to be proud of.