Atul Gawande on What it Takes to Change Ineffective Practices

The article: “Slow Ideas: Some Innovations Spread Fast. How Do You Speed the Ones That Don’t?” by Atul Gawande in The New Yorker, 29 July 2013;

http://www.newyorker.com/reporting/2013/07/29/130729fa_fact_gawande. See also a summary of Dr. Gawande’s article on agricultural extension in Marshall Memo 315.

In this thoughtful article in The New Yorker, Boston surgeon/author Atul Gawande analyzes why some worthwhile innovations spread like wildfire while others incubate for decades before gaining acceptance. For example, the idea of using ether for anesthesia was suggested to a Boston surgeon in 1846 and within six months, it was being used all over the world. But it was a full generation before doctors accepted the idea of using antiseptics to kill and prevent germs.

What was the difference between these two changes? “First,” says Dr. Gawande, “one combatted a visible and immediate problem (pain); the other combatted an invisible problem (germs) whose effects would not be manifest until well after the operation. Second, although both made life better for patients, only one made life better for doctors. Anesthesia changed surgery from a brutal, time-pressured assault on a shrieking patient to a quiet, considered procedure.” Keeping germs from infecting patients, on the other hand, was a cumbersome, tedious, and uncomfortable process for doctors.

For similar reasons, says Dr. Gawande, America is not implementing known solutions to a number of contemporary problems – climate change, an over-sugared diet, a trillion dollars in unpaid student debt – because we cannot see immediate results and they require individual sacrifice and inconvenience.

Is there a way to speed up the adoption of good ideas?

“In the era of the iPhone, Facebook, and Twitter,” says Dr. Gawande, “we have become enamored of ideas that spread as effortlessly as ether. We want frictionless, ‘turnkey’ solutions to the major difficulties of the world – hunger, disease, poverty. We prefer instructional videos to teachers, drones to troops, incentives to institutions. People and institutions can feel messy and anachronistic. They introduce, as engineers put it, uncontrolled variability.”

But, as innovation scholar Everett Rogers said, “Diffusion is essentially a social process through which people talking to people spread an innovation.” People follow the lead of those they know and trust. Change requires letting go of what we are used to, and deciding to make the effort to change often stems from a social process.

Dr. Gawande tells the story of a rural hospital in one of the poorest states in India where nurses in the delivery room were not washing their hands or getting mothers to put their newborn babies skin-to-skin on their chests to maintain the baby’s body temperature (hypothermia is a major reason for complications and even death among newborns). There are several possible ways to get nurses in the hospital to change their practices:

- Please do X. “This is what we say in the classroom, in instructional videos, and in public-service campaigns,” says Dr. Gawande, “and it works, but only up to a point.”

- You must do X. This involves establishing standards and regulations and threatening to punish noncompliance with fines, suspensions, and revocation of licenses. “Punishment can work,” says Dr. Gawande, but it’s also possible that it will result in nurses quitting their already-difficult jobs.

- I will reward you if you do X. But paying a bonus for every healthy child who makes it past a week of life would be impossibly complicated: you would have to track babies’ health back in their villages, make sure people were not gaming the system, factor in prior risk factors, and decide how to divvy up the reward among all the other staff involved.

None of these accomplish the real goal, says Dr. Gawande, which is “a system and a culture where X is what people do, day in and day out, even when no one is watching… Getting to ‘X is what people do’ means establishing X as the norm. And that is what we want: for skin-to-skin warming, hand washing, and all the other lifesaving practices of childbirth to be, quite simply, the norm. To create new norms, you have to understand people’s existing norms and barriers to change. You have to understand what is getting in their way.”

So Dr. Gawande and his colleagues in the BetterBirth Project hired a cadre of childbirth-improvement mentors to visit nurses and hospital leaders, walk them through a checklist of better practices, listen to their objections, and tenaciously work with them until they did things differently. Gawande tells how a young nurse, Sister Seema Yadav, worked with a nurse who was much older and more experienced but was using a number of ineffective practices. When Sister Seema pointed out the problems, the attendant was annoyed and made excuses for everything she was doing wrong – there was not the time, the hospital was swamped with deliveries, the thermometer was not handy, the cleaners never did their job.

Sister Seema – “a cheerful, bubbly, fast talker” says Dr. Gawande – kept at it, and on her fourth and fifth visit, the tone began to change. She and the nurse began to chat over cups of chai, and Sister Seema explained why it was important to wash hands even when wearing gloves and why checking blood pressure really mattered. The two women also learned about each other – their children, the long bus ride to get to work – and exchanged phone numbers. The nurse began making all the changes her mentor had been recommending.

Weeks after Sister Seema moved on to a new placement, Dr. Gawande spoke to the nurse to see if the changes were sticking. They had. “Why did you listen to her?” he asked. “She was nice,” said the nurse. “She smiled a lot. It wasn’t like talking to someone who was trying to find mistakes. It was like talking to a friend.” And do the mothers who come into the birthing room listen to what she tells them to do? asked Dr. Gawande. “Sometimes they don’t,” said the nurse. “Usually they do.”

Impressive, but can this kind of low-tech, person-to-person approach be taken to scale? Absolutely, says Dr. Gawande. “Think about the creation of anesthesiology: it meant doubling the number of doctors in every operation, and we went ahead and did so. To reduce illiteracy, countries, starting with our own, built schools, trained professional teachers, and made education free and compulsory for all children. To improve farming, governments have sent hundreds of thousands of agricultural extension agents to visit farmers across America and every corner of the world and teach them up-to-date methods for increasing their crop yields. Such programs have been extraordinarily effective. They have cut the global illiteracy rate from one in three adults in 1970 to one in six today, and helped give us a Green Revolution that saved more than a billion people from starvation.”

[What does this have to do with schools today? Picture a mediocre classroom practice like only calling on students who raise their hands or moving on after a test on which 40 percent of students scored below mastery. The role of an instructional coach, peer mentor, or principal is exactly analogous to that of Sister Seema. Ineffective practices are hard to change, and it will happen only with patient, understanding, cheerful face-to-face work day after day, week after week, month after month until new practices are “the way we do things.” K.M.]

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