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On the Record: ‘In medical school, we are taught how to fix a problem. But not enough time is spent on problems we cannot fix.

US-based doctor and writer has written his most recent book, ‘Being Mortal’.

In the latter part of the book, Gawande takes us on to the even more difficult emotional terrain of preparing for and meeting death in case of terminal illness. In the latter part of the book, Gawande takes us on to the even more difficult emotional terrain of preparing for and meeting death in case of terminal illness.

Atul Gawande, US-based doctor and writer, has written his most recent book, ‘Being Mortal’, on some very difficult questions — about mortality and medical science and care. He is also known for his “checklist manifesto”, where he advocates for a checklist to help create a system for individual doctors to deal with complex medical situations, and sometimes even seemingly simple ones. Gawande is also researching the ability of the checklist to improve the quality of care in public hospitals in Uttar Pradesh. He spoke to Seema Chishti:

How did you come up with the idea of checklists for health, an idea from the aviation industry?

It came out of my experience as a young surgeon trying to learn about effective surgery. I realised that while the last century was one of an immense number of discoveries, we needed something that allowed knowledge and complex skills to somehow come together into something that could make a large difference if you did it right. As I looked into other fields, I realised that one of the things people do when they are overwhelmed is create a checklist. So we devised a checklist for surgical care to capture the most complex moments, when even experts can get it wrong. We tested it in Delhi, Toronto, Seattle and Manila and in every hospital, complications and deaths fell by more than a third.

What about your experience with checklists in India ?

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We thought about how, in the lowest income groups, childbirth had emerged as a challenge. There are several things that could go wrong during childbirth, and though people were coming to hospitals, the mortality rate was not dropping. That was because of poor care. So we worked with the World Health Organisation and created a checklist of 30 important steps from the time a pregnant woman comes into the hospital to when she leaves with the baby. We started it in Belgaum in Karnataka, and found that it improved performance to up to 80 per cent. We then, under the better birth programme, applied it to UP on a much-bigger scale and interacted with different health centres there to identify problems and allow them to come up with their own solutions. Will it work? Give us some years, we will tell you if it does.
Healthcare became a big political issue in the US and you have a system now in place in your country. Does it help to make issues of healthcare political? Will that help it take off in India, in your opinion?

Two things in a person’s life really impact on it — healthcare and education. We in the US and you in India are always asking why it’s not top of the agenda. After many years and many unsuccessful attempts by several US presidents, we have a universal healthcare programme that could cover everybody. But it cost Barack Obama two elections to get here. Here, too, health and education are important. People’s experience of corruption is through their inability to access healthcare and education. In UP, what happened to the $2 billion that was to go towards securing rural child birth? In my father’s village in rural Maharashtra, a relative’s wife had to pay five years’ wages to secure a government teaching job. She then had to start charging kids to pay that back. So health and education have to be on the agenda when you fight corruption. There are many studies that indicate that the biggest predictor of survival in childbirth is the corruption index. Wherever it is low, more kids make it.

In your latest book, ‘Being Mortal’, how difficult was it to be a doctor and talk about death, rather than the prospect of avoiding it?

It was hard on one level, but at another level, I am attracted to problems that confuse me and which I keep encountering when I practise.


In medical school, we are taught how to fix a problem. But not enough time is spent on problems we cannot fix. When I first started practising, I found I was running into problems of frailty, chronic illness and old age, which I wouldn’t be able to fix. Our mode is always to have something more to offer, another operation we can do. But there comes a point when the key uncomfortable skill is to recognise that people have priorities in their life beyond just surviving another day. It requires us to ask them when treatments start to fail as to what they want from life. There are multiple studies that show that early treatments benefit people. But if and when they start failing, and you discussed it with them, they often choose to not take the aggressive course of action and spend more time at home or as active as possible.

We find that not only does their quality of life improve, but they live 25 per cent longer than those who continue to opt for the more aggressive course of treatment.

How much does your Indian past inform your philosophy in a way that you are conscious of and can recognise ?


I don’t know. I feel like someone who has become part of many worlds. I grew up in diverse settings — a small town in Ohio, a college education that let me go to Stanford, Oxford, I was based in the medical Mecca of Boston, married into an old southern family from the US, and my mum came from Gujarat, my father from rural Maharashtra, and they met in New York. Every bit of this feeds into me, who I am, what I write about. I love the ability to ask questions that move across all of this. I have had discussions about what dying meant in Boston, Ohio and Delhi — each remarkably different, but with patterns that are universal and bridge across them.

First published on: 15-12-2014 at 02:10:26 am
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