Summary

Better performance in medicine rests on diligence: the constant and earnest effort to complete what is undertaken. Hand washing, polio immunization, and falling gun assault mortality show the force of ordinary execution at scale: make a science of performance while weighing tradeoffs and doing right. To fix medicine: measure ourselves, compare, be open, and remain experimental, rebellious – the capacity to learn and change turns 1 → n.

Key Takeaways

• Diligence is the constant and earnest effort to complete what is undertaken, and routine execution can transform outcomes.
• Perfection of performance can mobilize millions with information and expertise, but eradication still demands a tradeoffs perspective.
• Make a science of performance: measurement and systematic practice.
• Doing right requires judgment across what is skillful, lawful, and moral rather than following rules and laws blindly.
• Piecework pays doctors for the amount of work involved, while making money has little to do with how good you are.
• Measures create a benchmark for improvement, but what is not measured can distort performance.
• Bell curve outcomes reveal outliers; identifying the best creates the capacity to learn and change.
• To fix medicine: measure ourselves, be more open, compare, and be experimental and rebellious.
• 1 → n medical research is the work of performance: scale what works beyond the lab despite limited resources.

Notes

1: Diligence

1: On washing hands

• 2 million infections at the hospital / yr
• 1/3-1/2 as much as they’re supposed to
• Eg. 20% → 1% childbirth death rate after washing hands during
• Dedicated individual to sterilize

2: The mop up

• Diligence: the constant and earnest effort to complete what is undertaken
• 1/6 of the world has hookworm (1B)
• Polio immunization: 4.2 million children in 3 days
• WHO: no real resources - just information and expertise
• Eradication a “monument to the perfection of performance”
• But is it worth it from a tradeoffs perspective?

3: Casualties of war

• Gun assault mortality rate 16% (1964) → 5% (2000s)
• Though, not better for war (weapons getting better, too)
• Make a science of performance

2: Doing right

4: Naked

• Physical exam best practices
• Chaperones
• Balance: tightening standards too much could be Taliban-esque

5: What doctors owe

• Medical malpractice
• Being sued is the cost of doing business
• No doctor tries to, but it’s inevitable
• “The system is fundamentally perverse”
• Eg. third baseman 2% error rate comp
• American vaccine fund: alternative to ↑ with known fixed rate of complications

6: Piecework

• Doctors “hard hard we work and how little we earn”
• Doctors paid by insurers on a piecework basis
• Commensurate with the amount of work involved
• Formula for work:
  • Time spent
  • Mental effort + judgement
  • Technical skill
  • Physical effort
  • Stress
• Rebalanced for 6k+ total options
• “Making money has little to do with how good you are - it’s about the business side”
• Study: ROI:
  • 16% for primary care
  • 18% in surgery
  • 23% law
  • 26% business
• Need to balance thriftiness + reward
• Moral hazard: principal agent problem

7: The doctors of the death chamber

• Doctors must assist executions in death chamber
• Skillfully vs lawfully vs morally
• Two rational ways to look at it: for and against
• He’s personally against: the patient doesn’t have right of choice
• “We have a duty to not to follow rules and laws blindly”

8: On fighting

• The border between what we can do and what we can’t
• We want doctors who fight

3: Ingenuity

9: The score

• Child birth used to be the most common cause of death
• History of life-saving techniques
• Importance of measures → benchmark for improvement (Apgar score)
• Medicine as an art vs industry
  • Need to pick more scalable options, not just absolute best
• No measure of mother’s wellbeing → more C sections
• Should have an Apgar score for all operations

10: The bell curve

• Patient outcomes among different hospitals follows a bell curve, not a shark fin
• Cystic fibrosis life expectancy shot up from 3y → 30y+ due to outlier identification
• To fix medicine:
  • Measure ourselves
  • Be more open about what we’re doing (total access)
• ↑ compare
• Be experimental, rebellious
  • Capacity to learn and change
• The best are breaking away - bell curve widening over time
• Grading should be mandatory across all professions

11: For performance

• 0 → 1 (lab) vs 1 → n medical research
• Lack of resources at Indian hospitals