Atul Gawande 2024

Patrick:

Hi, welcome back. We couldn't be happier to welcome Dr. Atul Gawande to Behind the Knife. Dr. Gawande, welcome, and thank you for taking the time out of your extremely busy schedule. Thank you for having me on. So for those of you that may have been living under a rock, Dr. Gawande is the Assistant Administrator for Global Health at the U.

Patrick: S. Agency for International Development, where he oversees a bureau that manages more than 4 billion with a footprint of more than 900 staff committed to advancing equitable delivery of public health approaches. around the world. And the bureau of Global Health focuses on work that improves lives everywhere, from preventing child and maternal deaths to controlling the HIV and AIDS epidemic to combating infectious disease and, of course, preparing for future outbreaks.

Patrick: So prior to joining the Biden Harris administration, Dr Gawande was a practicing surgeon at Brigham. in Women's Hospital in Boston and a professor at the Harvard Medical School and the Harvard T. H. Chan School of Public Health. He is the founder and formerly chair of Ariadne

Labs, and of Lifebox, which is a nonprofit making surgery safer

Patrick: and from 2018 to 2020, he was CEO of Haven, In addition to that, Dr. Gawande is a long time staff writer for the New Yorker magazine and has written four New York Times bestselling books, Complications, Better, The Checklist Manifesto, and Being Mortal. Dr. Gawande, the arc of your career has been extremely impressive from surgeon to writer to entrepreneur and now a public health official at USAID.

Patrick: You are truly the renaissance man. You've recreated yourself multiple times over, and you published four popular books. And I would say that these books are really required reading for all surgeons. And I recently had an opportunity to listen to an interview you did with Adam Grant. And you said that writing is a harmonious passion, something that you do effortlessly and you do it with love.

Patrick: And conversely, you describe surgery as inherently anti creative because you're trying to do the same thing, every time the same way. And that from a big picture standpoint, this is not

the best way to build something truly impactful. So can you expand on that a little bit? I thought that was particularly interesting.

Patrick: Well, I was talking about the cycle of production of the three different blocks of what I do. There's surgery where you can do good in two to three hours,

Patrick: and I had a 97 percent chance That I was going to do real good while three percent of the time in the cases that I did someone would be left with a disability or death and the contrast with the, writing an article or a chapter of a book, which would take me four to six months. And I think I'd give it a 70 percent chance.

Patrick: It would go well. I think maybe a little higher, but all right, we'll go with 70. Well, I've had definitely articles and chapters that haven't landed, didn't have much impact. Like I'm trying to have, I'm very motivated by impact. I want to know that I'm making a difference that's going to last. It's not going to be momentary and

articles or a chapter or an idea like that 70 percent hit rate I'm very happy with because that can, that's increased over time likelihood that it will land and that, my target is five years later, will people still be reading it and thinking it makes, matters to them.

Patrick: And then I'll work on public health projects that, and I've worked on many. that the chances of success are 10 or 20%. Everything from the beginning of my career, trying to, I worked on the failed Clinton health reform initiative to right now, how do we advance surgery systems and public and private primary care systems to be, universally available in safe, reliable ways That's like making advances there is a big unknown and I'm only a brick in the wall.

Patrick: So when I talked about surgery as being fundamentally anti creative, when I'm going to the operating room, my goal is

to do the same thing every time and not to be like, winging it, trying new stuff every time I go in the operating room, I'm trying to reduce it. So every move is 99. 9 percent chance that every move is going to go extremely well.

Patrick: I don't want to be like, Shaq at the free throw line had a 50 percent chance of hitting the basket. Like I want to get 99 percent on every move I'm making. And there are often situations that are creative in the operating room, right? Every tumor is different. Every situation is different.

Patrick: And yet you're trying to assemble your moves so things are fairly predictable. Even in the 3 percent of cases where things go wrong, there's about 10 of them that are the dominant ones. And I'm, I've got my algorithms for how I'm prepared to handle those too. That's what being professional is.

Patrick: By contrast, writing, I have to make a new every time. It cannot come out as a formula. If I started

a book chapter or a New Yorker article with, a scene in the operating room and it's, it's the time is ticking. And it's a gruesome scene. I can't do that every time, right?

Patrick: I have to structure and I have to take a different approach the next time I'm writing. So that's what I'm meant by it. And there's what I love loved is getting build a career where I have that mix because Every Friday, either in Sonic or the operating room, I know I did something good.

Patrick: Yeah. And I have no idea in the rest of the work, whether I am. And it's also ironically the least stressful part of my week, because people can't be in a bad mood that day, right? You got to bring your best self every day. And the team is going to be that about that way.

Patrick: No phone calls, no email, you're protected, and I, the music's on, I've even controlled the playlist, it's like, it is amazing control, and the likelihood something goes wrong on any given day. In a management job is like in a serious way. It's probably 50

percent Somebody is bringing some really bad news that we gotta deal with.

Patrick: Yeah, let alone in your position. Yes. I think a lot of surgeons most all surgeons find the operating room to be a real special place in terms of that sense of zen and productivity without getting interrupted With that let's go on to talk about this entrepreneurial itch that you've scratched, you've been able to have a career that has been impactful in so many different realms.

Patrick: You also founded Lifebox and Ariadne Labs, which are organizations that focus on patient safety through process improvement and At the system level, but you also led a joint health care venture with Amazon, Berkshire Hathaway and JPMorgan Chase with the goal of providing employees in the U. S.

Patrick: and their families simplified and reasonable health care, which is an impressive endeavor. And so before we jump into your work at USAID, I'd love to hear what lessons you've learned from time spent in the private sector. How did these lessons inform your approach to institutional leadership, especially with what you're doing now?

Patrick: And if you have any recommendations for the

entrepreneurial surgeon who's looking to branch out , I'll boil this down to saying that the fundamental decision that I had to make early on if I wanted to get scale and impact was how much am I willing to only do things individually myself.

Patrick: And how much am I going to work at building and executing through teams and man, that's managing people and I'm not someone who loves managing people, right? You're only as happy as your unhappiest child and as I managed larger and larger organizations. That always was the stress me out thing, right?

Patrick: The person or the team who are not happy, not doing well. And that's the cost. And that's an emotional cost. , the opportunity is the magic. We all know it in the operating room. Everybody's clear on the priorities, you have the right people for those priorities and they're pulling together in the same

direction.

Patrick: Incredible things can happen. And if you can say, here's the hill we're going to climb, one of the things I got to do with building a team and working with W. H. O. was early on was, let's see if we can reduce mortality in surgery and do it through quality improvement, do it through a safety approach.

Patrick: And we hired a Boeing engineer and came up with a safe surgery checklist that W. H. O. ultimately embraced. And that took years of work and then just getting to the clinical trial. Was step one, and we found it outpaced our results, our expectations by far 47 percent reduction of mortality across eight eight cities around the world from Seattle to rural Tanzania and then had to work to get it deployed over the next decade at scale.

Patrick: So my entrepreneurial bent has been, it's not particular to whether it's private sector, it's academics or it's government. I think the thing I learned early on. By having a

role 30 years ago in the Clinton administration leading health reform for the campaign and then one of the task forces that didn't work.

Patrick: Was a, I was a terrible manager and I drove people crazy who were working for me and I had to work on that. I had to work on how do I truly support people under high pressure, get the right people, everybody agree on the direction we're going and then navigate that process of pulling in the same direction that took me a very long time and by the time I built Ariadne labs, that was 15 people coming together eventually became 200 faculty and 110 staff.

Patrick: And you got to keep everybody paid and doing and progressing and driving impact every day and at what you do. And that just carried over into what we did at Haven with Amazon Berkshire Hathaway, JP Morgan. And everywhere I learned something new there, I learned how to build technology, how to work with

engineers.

Patrick: and create solutions. And then applied that during the pandemic. When I started a public benefit corporation called C. I. C. Health that grew to 3000 people when we didn't have enough diagnostic texts for the country. This doubled the amount of capacity the U. S. Had for testing volume.

Patrick: I don't know. Yeah, and got to do that over a couple of years. And then I couldn't have, if I hadn't had that experience, I couldn't have taken this role where I've got 900 people in Washington. We have 1700 people around the world and in 65 countries. And the aim again is reduce, premature mortality at large scale.

Patrick: And and it's been incredibly exciting. And I just go back to the same principles again and again of the building blocks of making an operating room successful are pulling everybody together around clear priorities and directions. Yeah, and you've been a proponent of coaching. Certainly. I think we as surgeons recognize that at the surgeon specific level .

Patrick:

Did you get coached up at all when it came to these major leadership roles 100%. It was a real revelation to me. I got to write this article in the New Yorker called personal best about why do we think so differently in medicine than in athletics, for example, or, in music, like, Opera singers have voice coaches and started having a surgeon a colleague that I really admired come to the operator and watch me.

Patrick: And I was 10 years into my career. I'd flattened out on the curve of performance and, Bob Osteen 20 minutes of chatting after a single operation and he had all these things he'd noticed that I could do better Now people have embraced that much more around executive roles like the idea of an executive coach, right?

Patrick: And I really hadn't heard about that until I'd led my first team that started to , have a couple of faculty on It was about 15 people total

and I really frustrated people because I was a typical surgeon, micromanager in the extreme and I was the chief resident who would do this computer check, at noon, have you got the x rays in?

Patrick: If you didn't, I would fire in the order. Instead of figuring out how do I coach this person? So the next time this doesn't happen and take the time to really do that. And that took coaching. I ended up hiring a a leadership coach on how I developed my teams and how I progressed with them. And I've actually had him now as my coach for, I think 13 or 14 years and talk every Friday at 6 AM.

Patrick: And go through. You know what the struggles of the week are for creating impact and It's remarkable. And and I feel extremely lucky. I've never gotten there without that. Yeah that's fascinating. That's a whole nother in and of itself, but I do want to discuss the work you're doing currently as the assistant administrator for the global health agency at USAID.

Patrick: So this is obviously a massive job

and I really have enjoyed watching the work you're doing. It's been spectacular. So I congratulate you and your team on this and the areas of focus are many. But some of the primaries have included looking at lead poisoning, primary care and health outreach capacity building and the development of a global immune system is what you've called it to detect and contain epidemics.

Patrick: Can you expand on one or more of these projects and why USAID decided to tackle these initiatives among, a list that has to be so long? How did you prioritize these particular areas? First, you gotta understand, like, I've got the best job in medicine in government that nobody's ever heard of.

Patrick: The task of USAID, founded by John F. Kennedy in 1963, is to work with other countries around the world. To do two things address health threats to the United States before they get here and number to advance

the systems of care so that you are actively reducing premature mortality and the inequities and survival around the world.

Patrick: And so it's primarily focused on the low and middle income countries around the world. When I came in, one of the things I did was say, we have. All of these vertical programs, like the ones you named, 100 percent of the funds we get from Congress have an earmark. It's sort of like the NIH.

Patrick: It's always named to a disease or a condition and you have to it's an HIV or it's TB or it's malaria or it's child health or it's maternal Pregnancy outcomes, etc But there was never a roll up of like what are we doing as a whole Bureau all these people working together? Are we actually advancing not just the system for HIV care, but overall survival?

Patrick: And so the metric that I adopted was that we should be reducing the percentage of deaths that occur in any given country before the age of

50. When USAID started in 1963, 50 percent of deaths around the world were in children under age 5. So it was, forget 50, like, 70 80 percent of deaths around the world were before the age of 50.

Patrick: A lot of what USAID did was reduce child mortality. 60 percent of the reduction around the world in child mortality and the lengthening of life expectancy has been from vaccines. And really driving that out and USAID is the engine behind. Smallpox eradication around the world and has been a major driver of getting routine immunization in childhood.

Patrick: around the world, et cetera. . But now, as you go around the world U. S. Has dropped to only 10 percent of deaths occur before the age of 50, like deaths in the country are there. Now, if you're in Europe, it's less than 5%.

Patrick: If it's Japan or Korea, they're down below 2%. That's an indicator of what the potential like we've discovered so much in public health, And in health

care that people can live on average well over 80 years Korea, Japan are at 85 years. If we can deploy that capability town by town to everybody alive, the first job, the biggest gains come from helping not just children, but young and middle age adults, because those are the economic engine of your future.

Patrick: Yeah. Not to mention, say more years of life. The single most important thing that I've found in this work is that if we just. Deploy HIV medicines or TB, but you don't strengthen an overall system of care. You don't get anywhere. The foundation of that is primary health care.

Patrick: When I came in their single most important thing was. Covid was raging, and we had plans in the US. But we needed to make it into a manageable endemic respiratory illness globally. And so USAID, our team that I led oversaw the coordination of deploying. We became, U. S.

became the largest contributor of vaccines to the world.

Patrick: We deployed 700 million vaccines to 120 countries. And. Carried out support programs that boosted the percentage of their populations that got vaccinated by 25 percent just from U. S. Contributions and then sat on the board of global organizations that could get that moving a second big area.

Patrick: You talked about, the I called it. I've called it the immune system for the world. As you said, it is everything we know. That's in Yeah. In surgery and in emergencies, speed is everything and outbreaks have to be recognized within seven days. Of hitting a a health center, you need to have an emergency response once you've recognized that you have a deadly outbreak within a day.

Patrick: And then there are 7 things that have to happen in the 1st week that are employed. It's called 717 and I just made that a targeted focus where we now built a network of

50 countries around the world that haven't had these capacities and it's. Relatively small investments to make sure they have an emergency operating center in their government that they have frontline workers who know how to report when they have unusual deaths and then get teams that actually feel that work.

Patrick: an example is that in the Congo democratic Congo, they had an Ebola outbreak in 2018 rage for 4 months. Killed 2500 people and spread across borders took 2 years and a billion dollars to stop with our investments last year. They had in the bowl outbreak was, or was April 2022.

Patrick: This time, and it's, this has happened several times the family turned up with a relative who was extremely sick, died of a viral hemorrhagic fever. It was recognized to be dangerous. The health workers are usually the ones that get infected, protected themselves, knew how to protect themselves,

diagnosed it because they had the diagnostic unit there, and then reported it, and within a day, 250 contacts were identified, isolated, and the family was the lone people to die from that outbreak with just five deaths, and no emergency resources needed to go in at all.

Patrick: At the present time, we're dealing with. half a dozen major outbreaks going on right now. I didn't know a damn thing about doing this kind of stuff. I couldn't have told you Ebola from Gang. Standard surgeon level. Okay. Yeah, but I knew how to operate processes and drive speed.

Patrick: And that has been like one of many super exciting things to me. I love the learning curve and then that chance for. Mobilizing impact. What would you say is your biggest win in the years spent at USAID so far? There's many but is there something that sticks

out to you that was particularly successful that you want to share?

Patrick: Well, I would say that one we've created what I call the global health emergency management system and a win to me is one that I think is going to last beyond me. Like, will this actually matter? Like, I could say the COVID vaccines, , I was a part of that. Getting both vaccines moving around the world was thousands and thousands of people building the global health emergency management system that we have now, where almost every week there CDC is recognizing issues.

Patrick: We're a huge part of the operational capacity of the U. S. government to get it going. Responses out there. And , it's turning up by getting the systematic approach in place. It's like in trauma. It's like the abc's like to here are the steps that we all follow and take\

Patrick: there's a Marburg virus outbreak in Rwanda right now. And Marburg is a cousin of Ebola. And there's no vaccine. There's no test. Unlike for Ebola.

And we were prepared enough that this time within nine days working with HHS and CDC, not only was their response, but we deployed an experimental vaccine in a trial.

Patrick: that now has vaccinated a thousand people and we will have results in the next couple of months so that we are likely to have a Marburg vaccine coming out of that. It's just one example of the outcomes that, feel like a real win. That Has to be super exciting and really gratifying

Patrick: and there was no system before covert, right? We got to see that kind of laid bare. Can you describe how you put this into action How do you build? How do you scale that? Yeah. The goal was build local capacity to be able to solve problems. And create that ownership and capacity at that front line.

Patrick: What worked about it being in the DRC, despite it being one of the poorest, the entire budget for their health system is less than 50 per person per year. Compared to the US firm, with the current spending. 12, 000 year for health,

right? Their Ability to recognize illness means that you're working not with doctors, but community health workers whose job is to recognize.

Patrick: Hey, if you have two deaths in a family under circumstances where, you know, you just shouldn't see two deaths, right? Report that. Maybe it's malaria. A lot of malaria, causes stuff but then you can escalate and bring that upward. So the lessons to me are number one making priorities super clear and the priorities have to be very tangible and concrete.

Patrick: Like, here are the, here are, it's the surgery checklist is here 18 things an operating room can do that can cut death by half. In an outbreak. Here is the cascade of Do you have the ability to diagnose? Well, if less than 10 percent of your people who have symptoms will have access to a diagnostic test, you got to get the diagnostic tests out there.

Patrick: So what's the simplest way and cheapest way we can get that going? And then when you have the

diagnosis, who do you call? How do you react? How do you protect yourself? And how do you get that call in? And then will someone answer that phone? It's just like, it's that really basic, break it down, step by step kind of stuff.

Patrick: I'm often learning new things , like, in TB, what's the most critical steps that really matter? Why are we not executing on it? It still continues to be the biggest infectious killer around the world, but we discovered 50 years ago how to stop it. So 100 years ago it's breaking those things down and then aligning everybody, having the talent around being able to solve it.

Patrick: And the hardest part is getting them all pulling the same direction. You can have the priority, you can have the talent, and you can still have people grow like. No, I don't. That's not what I want to do. I want to do it this way.

Patrick: With that, many of the initiatives that you have been involved in have become political and cultural flashpoints of sorts, for example, you mentioned life expectancy in the U. S. It's recently decreased.

And it's now less than at least in 2022, I believe Cuba and Lebanon, for example.

Patrick: And I recently came across a post on X that was from a high profile person shaming the U S government for abandoning its citizens to focus on healthcare infrastructure building around the globe. And, in this time of an America first approach, something that rings so true to so many U S citizens.

Patrick: How do you explain the important work USA does globally? Yeah, I think there's 2 things. Number 1, that's the easiest part for people to understand is stopping health threats before they hit the U. S. borders and being able to have the relationships and the networks and the capacity to make that happen.

Patrick: I think the 2nd part which is a little harder for people to recognize is that working with countries for them to build successful systems and investing in their strength and ability to do that ends up paying off in ways that also create friends when you need them

and enables them to get to stability and economic growth.

Patrick: Prosperity, which is overall better for the world. I focus on people under the age of 50 because people intuitively understand if you have people die before the age of 50, you've lost their ability to contribute just as they're starting to reach an age where they can be leaders, where they can create new enterprises and foster a future for a country.

Patrick: Reduce dependence. Yeah. innovate and contribute to the world and everywhere we've enabled that to happen. Those places have become our friends right after World War Two. We invested in Germany and Japan recovering their capabilities, recovering their systems and had long term partners and friends in a friendlier world.

Patrick: We've doing that in places that have been really left behind,

much of Africa Latin America has really progressed a great deal, right? 80 percent of Latin America is now middle income because of support the U. S. has had and Latin America. It's been markedly less violent than other places around the world.

Patrick: We still have clear sections where there's much more to be done. Asia has also advanced and really Africa is the one place where, it's 40 percent low income. And half of the deaths that occur are in people under the age of 50.

Patrick: And so the focus has been on enabling that capacity and I can tell a story of actually making a difference. So 20 years ago, Thailand they have 35 percent of their population dying before the age of 50.

Patrick: We not only help them address HIV and TB in partnerships that were very generous in many ways but also use that support to enable them to build. Universal health coverage, and

they didn't have enough money to cover everything. But they had choices they could make, and they made choices to invest in universal primary care.

Patrick: So every community had a primary health care center. It would be have enough, as they climb to middle income level, they were investing. Small amounts of our money, big amounts of their own money in staffing them with enough nurses and eventually doctors that and, pretty big panel size that their panel size would be like 4000 people.

Patrick: Our primary care doctors have about 1500 everybody had a primary care and they had community health outreach workers who would knock on every door in the community at least once every month to see. Are there children with malnutrition? Are there children who didn't have vaccines? Are there adults whose blood pressure has not been recognized and get that under control?

Patrick: And The combination of that outreach to bring people into the system led to where Thailand's today matches U. S. life

expectancy, their deaths below 50 or about where we are. And they have progressed to upper middle income. They are a partner in helping detect.

Patrick: Outbreaks where we don't have that line of sight in China and everywhere. Thailand's been an important regional partner so we can know when diseases are happening. And and they have shown us that on 300 dollars per person per year. You can match us life expectancy that we actually know how to do this and don't have to cost that much.

Patrick: There are lessons we can learn from that. And success abroad is not mutually exclusive when it comes to success in the United States, but not everyone in the United States has a primary care physician and our primary care network is quite weak and the way the system works with insurance and all that, it's so extraordinarily complicated.

Patrick: So again, how do you square that and. If it can be done in Thailand, can it be done here? Yes, so I'm going to speak from my prior experience

where for example, at Haven,

Patrick: this was the startup that Amazon Berkshire Hathaway, JP Morgan started. And I was lucky enough to lead for three years. They had almost 2 million workers who are primarily lower wage workers. These are the workers who, made, above minimum wage, too much money to qualify for Medicaid.

Patrick: So they're paying the taxes for people who get Medicaid, where there's no, no insurance premiums, no deductibles, no co pays. And it's comprehensive coverage. You remind us really quick. What is that level of income again? Roughly? Oh, the the level of income for, well, if you're making 20 bucks an hour, you're probably not qualifying for Medicaid, right?

Patrick: And it's like 40, 000 a year. That's not a lot of money and hard to get by. And at that point you have. That 1, 500, 2, 000 deductible before you can even access care. Even with more generous benefits than the average American gets in those companies they saw,

routine opportunity.

Patrick: What drove them crazy as CEOs was these are some of the top CEOs in the world who have squeezed the value out of every part of their balance sheet. Except the healthcare, which keeps growing and they don't, they're not trying to make money on it. They just want, they want to see that I'm getting value from it.

Patrick: And so one of the things we recognized was I deployed a health plan. Was able to build it in two months that got rid of deductibles, got rid of co insurance, just made copays, and then used medical know how to say, let's redesign it. So we reward the things. That actually make you healthier.

Patrick: So we made primary care 15 a visit and and preventive care was free for a visit, but you know, just go in if you're feeling sick, you have a fever going to the primary care doctor would be 15 bucks. Now the ambulance ride, cause the cost of that plan had to stay the same. The ambulance ride to go to the ER is going to be

500 getting the hospitals a thousand and we didn't know how people would look at that, whether the sticker shock would turn them away.

Patrick: The second thing we did is we made 60 medicines free because if you're hypertensive medication or your insulin or your HIV meds are missed for months on end, then the 3 to 5 years. The model seemed to suggest that you would have hospital expenses that would outpace that. Common drugs we made, common essential drugs we made free. These were just no brainers can't afford your statin can't afford your, cholesterol your hypertensive med can't afford your insulin like this is dumb.

Patrick: This is undermining ourselves. And so we designed that and it became rapidly the most popular plan. Even though it showed you right off the bat your hospital admission is going to be 1000. because people were able to get the things that were causing them the most pain. And it was very similar to what I ended up seeing in this work abroad, that these are pathways that

are, within our reach.

Patrick: The second thing we saw this in COVID and I saw it when I was a bunch of work for during the COVID crisis where we needed to get to Greater than 95 percent vaccination of the elderly. We couldn't get over about 70 or 75 percent in most places until you hired community health workers whose job was, yeah, knock on doors and make sure people knew they had an offer of a vaccine.

Patrick: Knew how to get it got you got your schedule for appointment or delivered it if you were disabled and not able to get out of your home. And that was what got us to over 95 percent vaccination for over 65, 150, 000 community health workers who, you know. Or hired from the community known in their neighborhoods and could be trusted going door to door.

Patrick: Sure. Did a lot of people not answer the door? Yes. Once the word got around that these were people who could help Republicans and Democrats, it was over 95

percent vaccination for the high risk groups. And I that's the kind of system I've. Seen around the world in the current administration for the 1st time.

Patrick: Now pays for community health workers. If a primary care physician wants to hire them onto their team or they can also directly bill for services for community health outreach. If an organization employs them to reach out to the elderly, and I think. We have the beginnings of some of that to become possible at large scale.

Patrick: We have many examples where this is working at state level and city level around the country. How has that played out at Haven is one question. The second is, when it comes to, these community health workers, it seems like that could be the glue, right? It seems like just common sense, relatively cheap.

Patrick: So why aren't we employing that at a large level, making that investment? We already spend so much on healthcare. Is there a

cynical aspect to it where healthcare drives so much of our GDP and , the more healthcare that's consumed, the more money large swaths of the economy make, what's the way to frame that and think about it for someone who's on an uninformed on this kind of stuff like myself.

Patrick: Yeah. In the end, Haven ended up different parts of the company, different companies who participated were interested in different parts of the portfolio. So J. P. Morgan was really interested in scaling the insurance functions.

Patrick: They started something called Morgan Health and the venture capital components. Amazon got really interested in the primary care work and they have ended up taking on our team. They built a big primary care enterprise now that has millions of people participating. They bought one health. , they offer with prime membership and things like and I think that the challenge is that these are still bits and pieces.

Patrick: The core thing is we don't build our system with intention to get results. And that's, The thing I took away from this experience in public health in USAID

is we don't purposely look around and say, I'm trying to reduce the percentage of deaths that occur before the age of 50 or, probably in the United States, you say before the age of 70, right?

Patrick: And what are the biggest killers in my community? And I, as a clinician, I'm responsible for that. And, as a system that, That we're all doing that. We've had this massive debate for decades about is France the best system is UK the best system without asking what outcomes do they get?

Patrick: Like, do they get you a better life expectancy per dollar? Costa Rica and Chile right now in North and South America have the highest life expectancy and they're doing it for a fraction of U. S. dollars. And, the common theme is really this strong primary care system with community level outreach, but , that's the means the goal.

Patrick: They actually have a goal, right? They have a goal to reduce their premature mortality. They measure that goal in different ways. But that intentionality and then having an operating arm where clinicians are responsible

for that. And by the way, I think it's so motivating for people.

Patrick: Like, this is why we went into the profession. You want to feel like you're part of it. And I do think that very little of the world has fully adopted this, right? We have these examples around the world and, as, Riven and as painful as and cataclysmic as our political debates are underneath the surface.

Patrick: I feel like there's this. incredible opportunity of progression because, we know how to give people an average 90 or life expectancy. And we have in front of us an opportunity to bring that to an entire country in the world. Yeah. This transition to COVID, you've been at USA through the height of the COVID pandemic. And there's no greater flashpoint in culture right now than the epidemic itself when it comes to the origination theories to vaccine mandates to acquisitions of government overreach.

Patrick: Now, the epidemic is not fully over, right? But we've

settled into it and looking back, how do you frame the chaos

Patrick: yeah, so I'll boil it down by saying on the one hand, we had. Tremendous public health response and the fastest, of bringing a respiratory illness under control. Fastest speed to a vaccine, fastest speed to getting that to be deployed and yet it's still moved too slow. And it was extremely messy and I don't think it ever is going to not be messy being able to move forward.

Patrick: I think the big lesson that I took away walking through the process. I've written a book about, being mortal, about the fact that people have purposes in their life that we are not serving in our individual care at the end of life. And I came to realize that this was true more broadly around any kind of chronic and serious illness that people have purposes in their life besides just survival.

Patrick: They have goals that they're willing to

even sacrifice their health for and in those priorities in their life change over time. And you have, as a clinician, your job is to not just assume that. You know that I'm just there to control the disease. I'm there to help them serve their priorities and their goals, which include may include living longer, but also include these other things and being able to figure out to learn those parties.

Patrick: You have to ask people and we don't ask. We asked less than 25 percent of the time when somebody has a serious illness. What are your goals besides just living longer? And when we don't ask, the result is suffering because the treatment and the care we provide is often out of sync with what matters most in their life.

Patrick: Yes, I want to live long. My mother has metastatic ovarian cancer, and for her priorities were at 80, now 88, her birthday just this week. She's four years, four years with stage four ovarian cancer, took chemotherapy, major goals included

being able to stay independent in her home.

Patrick: And she had a oncologist who understood that goal. And when Taxol caused her to have a neuropathy that led to some falls at home, we stopped the Taxol. And they made that plan from the beginning and understood, like, it was not worth it to her to lose her independence. And that became a goal. That ability as clinicians was so important.

Patrick: Now, public health and the COVID, this was the experience we had as well, where the public health officials only spoke to survival. In many ways, it was a misunderstanding of the political figures really are the ones who have to tap into that. What the priorities are of a community and there are many different parties and people have different risk tolerances, but at the end of the day, there are lots of families who are slowly going crazy at home and their kids were losing education and at a certain point.

Patrick: We were willing to say survival is not the only goal that we

also need to be able to enable kids to get back to schools and take some risks for the sake of it. Being able to have that intelligent dialogue and regular recognizes public health officials that it is not a crime to, care, even at the cost of lives, in the same way.

Patrick: That I just talked about end of life care. We have priorities in our communities besides just surviving and living longer, and we're constantly balancing the tradeoffs and need to offer in public health. The choices for navigating the tradeoffs, but then ultimately rely on the political figures who represent the community to channel the choices that are going to be made.

Patrick: And and, bit by bit, we got there. But it was that failure to recognize. That this is how we have to do public health.

Patrick: So one last question for you is what's next? You've done so many truly incredible things and you have a long future ahead of you.

Patrick: So what are you

thinking? Yep. I, I will be leaving with the change in the presidency. I'm in a Senate confirmed position, so January 20, I'm out of my job. I was lucky enough to be on leave from the Brigham and Women's Hospital, and they'll welcome me back thankfully. I'm not immediately going to return to the operating room.

Patrick: I had a book that was I just started about a quarter of the way when I accepted this job. And, sworn in early 2022. And and so that's the 1st thing I'll do. I know that I. Will always want this mix of getting to communicate to the public, but also to drive scale and.

Patrick: In implementing through teams and management and so it'll take me a year or more for this book to get finished. By then I'll figure it out. What's the mix going to be? That lets me get the pieces that that make me happy. But I'm not worried I'm looking forward to the next projects to come.

Patrick: Yeah, well, we are too. thank you so much. for

your time. And perhaps in the future, we can snag some more of it. Would you do us the favor by signing off

Patrick: right. This is Atul Gawande signing off now and saying dominate the day.