Atul Gawande on the Secrets of a Puzzle-Filled Career

; Atul Gawande, MD, MPH


December 06, 2013

In This Article

"Cheesecake Factory Medicine"

Dr. Topol: I remember how shocked I was when I read some of the actual quotes that you got. You also invoked the Cheesecake Factory. Did you get a lot of flak for trying to make that analogy between the Cheesecake Factory and medicine?[2]

Dr. Gawande: I always get a certain amount of flak for the things I write, and it was a little bit provocative. I'm saying, here is this fast-food chain, medium-ly based fast food chain -- they serve you at a table. And I was saying that this place runs better than healthcare.

It is partly an unfair comparison, and I acknowledge that in the piece, that making a hospital work is far more complex than making the Cheesecake Factory work. But there was a puzzle to it in that they did not make premade food. They made food that was custom-made for every person in their restaurants and they'd learned something about how you make a place like that work. They have something new that everybody learns every 6 months. They have a kind of oversight and quality control that has sharpened their costs and improved their results. They're incredibly aware of what their customers think about what they do. I talked to management [at the Cheesecake Factory] and asked them about when they got sick and go to a doctor's clinic and whether it struck them how different that world is. Every one of them had terrible stories of how their families are treated and how they themselves would manage it differently. I could recognize real truth in what they had to say.

Dr. Topol: That was extraordinary. Another article you wrote that resonated was "The Hot Spotters,"[3] where you really zoomed in on these high costs. There's a limited number of people who are responsible for so much healthcare economic burden.

An Itch That Can't Be Scratched

Dr. Topol: How do you get the ideas for your pieces?

Dr. Gawande: I don't know. I'm interested in things that are confusing to me, so I write them down. I keep a little list on my phone, actually, and it's up to about 300 possible things to write about. Eighty percent of them are bad ideas.

Dr. Topol: But some of them are so unusual, like the woman who had an itch that just itched all the way, scratched to her skull.[4] Where do you find this kind of stuff?

Dr. Gawande: I happened to hear about this case. Massachusetts General Hospital published a case report of a woman who had an itch so terrible that she scratched through her own skull.

The interesting puzzle that immediately got me was, what the heck is itching? And why do we itch? And what's the relationship with scratching? What's it solving? And so here I am. I'm 10 years out of medical school. It's the kind of thing a doctor ought to know, right? And I can't even explain what an itch is.

Dr. Topol: Nobody knows.

Dr. Gawande: So then I unpeel and it turns out there is a whole story. There's a whole science and there's an annual meeting on the itch every year, and I could talk to the people who go to the meeting, and I could get the meeting proceedings, and there's science everywhere that's completely fascinating.

I could write about something deeper and more interesting. The itching story starts with that person scratching their skull, but what it gets you into it is, what's the current understanding of the brain and how consciousness works. And that's what ultimately made it a piece that would work. I was able to get it to that third layer. A lot of my ideas don't necessarily get that far, so I might have 300 ideas but there might only be 30 that work. But it doesn't matter. I'm doing surgery and research and everything else, so I only have time to write 3 or 4 of them a year. I try to pick the good ones.


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