Surgeon Atul Gawande wants everyone to have a coach (Transcript)

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Re:Thinking with Adam Grant
Surgeon Atul Gawande wants everyone to have a coach
Sept 27, 2022

[00:00:00] Adam Grant:
Hey everyone. It's Adam Grant. Welcome back to Rethinking: my podcast on the science of what makes us tick. I'm an organizational psychologist and I'm taking you inside the minds of fascinating people to explore how they think and what we should all rethink.

Today's guest is Atul Gawande: a surgeon, Harvard professor, New Yorker writer, and bestselling author of books like Complications and Being Mortal. I've long admired Atul's work on error, checklists, and coaching. And at a conference last year, I got to see his confidence and compassion firsthand, when he helped rescue me from a severe allergic reaction. Thanks, Atul. In January 2022, he started a new job in The White House as Assistant Administrator of USAID's Bureau for Global Health. So it's a perfect time to talk with him about leadership, learning from mistakes, and how he works with his coach.

I've never asked you this question and I've always wondered. What did you wanna be when you were growing up?

[00:01:07] Atul Gawande:
Oh, man. It was so many different things, but you know, I'm the son of two Indian immigrant doctors. So you can bet that the base plan was "become a doctor". All thoughts of anything else were rebellious pivots. And I'd say that the single most attractive thing was becoming a rockstar. It just wasn't in the cards. But I met my wife during my second year of college, when she ended up in the same dorm and I convinced her to teach me to play guitar, which is partly a way of getting more time with her. But then I did pick up the guitar and got to record music, started a band, and I love the way you can connect with people through music and have a child who now lives out that musical dream for me. But it, oddly enough, happened to be through writing and public health and surgery that I found ways to make that connection.

[00:02:06] Adam Grant:
You chose surgery, obviously, that's an enormously consuming career. Somehow you managed to find time to write for The New Yorker. How did your identity expand from "I'm just gonna be a surgeon and that could, that could take up all my time" to, "I'm actually gonna have a side gig as a, a prominent writer"?

[00:02:24] Atul Gawande:
The best advice I got which came late in life, but seemed to register was a colleague who said, "Just say yes until you're 40, and after 40, just say no." When you're young, you don't know what actually energizes you and what you will prove to be good at. You don't have a sample size to know. And I started with a base assumption that I grew up around medicine, so I could be comfortable in it. But even in medicine, you don't know what you're gonna be when you grow up, what kind of field do you wanna go into? Do you wanna lead people? Do you want to go deep in a technical area? Do you wanna be in a research lab? Do you want to do startups, do you wanna do public health? There's so many different directions to go. And I just said, yes. I hit college and found my mind was blown. I was from a rural town in Ohio, and there was incredible possibilities. I ended up going to a place like Stanford, where everything was open to me. It was too much choice. And so I just started saying yes to stuff. And then I paid attention to the things that actually energized me.

Just finding time flew when I did certain things. I was very into Steven J. Gould, the writer on evolution. I was very into health policy. And I was very into understanding clinical trials and how you create impact in science. That blossomed into saying yes to spending time on presidential campaigns around healthcare. And I worked for Gary Hart and Al Gore when he ran. Long story short, by the time I got outta college, I was ready to do several things that then took 10 years to fit together. I did a degree in politics and philosophy. I worked on the hill in Washington. I started my training in surgery. I would end up getting a degree in public health during my surgery training.

And when I put it all together, the thing that was totally unexpected was I had stuff to write about, and I began writing for Slate magazine, and that became The New Yorker magazine. I loved surgery and I found I could have technical skills in how to build public health interventions and make it work. And only later did I reach that point, my late thirties hitting 40, where I said no to everything, except how I could put together writing as a way of exploring what I was experiencing in day-to-day medicine and the failures of the system and how we cope with the fact that we now are in a world where we can live into our eighties on average. If we can access the capabilities of a science that has given us drugs, medical and surgical procedures, public health interventions, but only part of our population gets to have that advantage in the United States or around the world. And our job has become to deploy that capability town by town, to everybody alive. And I get to explore it through writing. I get to live it through my practical work as a surgeon. I did. And then I built a public health institution around starting to solve problems in making that work. And I found my life's purpose doing that.

[00:05:59] Adam Grant:
It's amazing. I'm so fascinated by this advice you got to say yes until you're 40, which on the one hand, I, I think you make a very compelling argument that it's a great way to discover what your passions are or develop those passions and also hone your skills. It also sounds like a recipe for indentured servitude and possibly burnout.

[00:06:20] Atul Gawande:
You also have to pay attention to what is exhausting you and you gotta pair that out, cuz that's the cause of burnout, right? You are finding your own balance. I found, for me, my personality, I was doing surgery and that energized me. Even though I was in the middle of surgery residency, even though at that time it was 110 hours a week, I still was fired up about it. I hated staying up all night. I couldn't stand that. I saw the light at the end of the tunnel that, that might end, but then I'd weirdly I'd get home. And a friend said, would you write for Slate on healthcare stuff? And I found, I was making time at nine o'clock at night to work for a couple of hours. And, I was doing it. Like that was a signal to me. I was not energized spending time in lab. So I stopped the stuff that I didn't have the energy to do. There was a lot of things that I quit, a lot of things that I quit so that I wasn't burning out. And even today, the work can be overwhelming at times, but I'm marshaling my energy around spending as much of it doing the things that I can value and enjoy. There's always crap. There's always a grind in everything. And that part is there. It's just, there has to be some saving grace that keeps you going.

[00:07:39] Adam Grant:
I was wondering if that's a technical term: crap.

[00:07:44] Atul Gawande:
Yes. You study that on this podcast. I think.

[00:07:47] Adam Grant:
We do. We do. I'm struck by, as you, as you talk about the energy you found early on for writing, it sounds a lot like what the psychologist Robert Vallerand has called "harmonious passion" as opposed to "obsessive passion". I think that a lot of people would push themselves to do that 9:00 PM writing and say, "I've got an end goal and I feel guilty if I'm not working on it. And I have a sense of obligation to do it." And that's the obsessive form, right? You, I think, are describing much more of the harmonious "I enjoy this. I think it's interesting and meaningful and maybe even fun."

Atul Gawande:
I'm gonna give you another framework that I work with on this. There are cycles of how the work works, and it's understanding those cycles. So surgery is a harmonious passion in a very straightforward way. I can go in to do a two or three-hour operation and I will get something done and I will lose sense of time. And it, I can't tell you what a great experience it is working with a team focused on doing something where everybody is skilled and, and working harmoniously together. But there is nothing creative about it. In fact, you're trying to be anti-creative. You're trying to do things the same way every time. What you accumulate are thousands of people you've taken care of and not necessarily something that builds something larger. Whereas writing or doing certain kinds of research work, that's six months of effort, not always harmonious. Painful. A learning curve every time, but at the end of it, incredibly gratifying. And I found my six month cycle of doing with the creativity added in is my sweet spot.

Public health is working on problems that will take minimum five to 10 years and you may never solve and will be handing it off to someone else to finish the job. And I find that as being a contribution to legacy in a way that really feeds me at my soul level, working on how do we address advancing global life expectancy and burden of disease, a generational task that we have not learned to do. And I wanna put my brick in the wall of building that edifice. And that is not harmonious every day, but it does provide gratifications in singular moments as you advance along so that, you know, you get there. I need to be fed about every three to six months with a victory that feels meaningful and transformative. And I find I can live in that space, that three to six months space and wanna see it adding up to that larger picture. It's why I took this job at USAID which required me to leave The New Yorker, leave the operating room. Leave the nonprofits I'd started in order to work on a set of problems at a crisis moment for the planet. And actually, I've found on a day-to-day basis has remained incredibly energizing, even though it's daunting.

[00:10:52] Adam Grant:
That's exactly where I wanted to go next. Way to anticipate my next question. I was gonna ask, as you were talking about surgery, then why in the world did you join the government, which is the opposite of this, sort of in a contained window, I know I'm gonna improve someone else's life, but the, the long term impact and the chance to solve problems at scale clearly is meaningful to you. Talk to me a little bit, Atul, about the short-term urgency versus long-term impact dilemma you're facing right now. I know, on the one hand, you're partially responsible for controlling COVID around the world. On the other hand, you're trying to prevent the next pandemic. How?!

[00:11:29] Atul Gawande:
Yes. So the traction of this job, you know, I took it as we were in the worst of the COVID crisis. This was one of the first times as a global society and as a country and as a body of professionals in all lots of different places that it wasn't good enough to have a breakthrough innovation for saving lives. We had vaccines. Then we had rapid tests. We also now have antiviral medications that can cut the death rate for high risk populations by 90%. We have the tools to turn this into an endemic respiratory illness that's manageable. And we said, "It's not good enough to have the tools."

Beyond the breakthrough innovations, we need the followthrough innovations that make sure that it can deploy and reach everybody. And that has been what I've been building in a variety of domains, whether it's been in surgery where we've cut the death rate by half through a set of tools around the world, around childbirth, around end-of-life care.

And here was this one thing where we said the United States and the richest people in the United States getting the vaccines isn't good enough. It had to get to all Americans and everybody around the world. This year, that's incredible. And so I said, "Sign me up." And I got to work at addressing the next pandemic and doing it in a better way than we did the last time. This pandemic has resulted, in the last two years, in the first reduction in global life expectancy in a century. We've had steady improvement year by year in the likelihood that women in childbirth, that children, and that people that crossed the age span would survive. And that declined in the last two years. And it wasn't just directly from the COVID infection. It was also from breakdowns in health systems, health workers getting sick. There's the indirect effects from food insecurity because supply chains break down, because inflation has gone up caused by the pandemic. And then it's compounded by climate disasters, by war. All of that plays into a destabilized core capability of just surviving in the world and our likelihood to survival, including maternal mortality, those have worsened for the first time in a century.

So goal is reverse and reclaim the gains that we'd had, which means needing to invest and focus on building the global primary care workforce. Cause it turns out when you respond to COVID, when you have people prepared to respond to the next outbreaks that are coming and they come on a almost weekly basis. We're dealing with monkeypox. We have had an Ebola outbreak this spring in the Democratic Republic of Congo. We had an even worse outbreak, Marburg virus going on when Ghana, like I learned from this job that the crises are coming all the time, but they work through the same people who also deliver the babies. Also address the annual malaria season. Also address prenatal care and routine immunizations. And all of those ended up breaking down and it depends on strengthening primary care in our core focus. So I came in for the crisis and I'm staying to be able to address the big picture of the primary care workforce.

[00:14:52] Adam Grant:
Given all the crises that are really in front of us at the same time. How have you maintained hope? It's gotta be devastating having worked in healthcare your whole life to see life expectancy, backtrack after a century of progress. How are you maintaining your sense of optimism?

[00:15:11] Atul Gawande:
Hadn't even occurred to me not to be optimistic.

[00:15:15] Adam Grant:
Okay. I want a dose of that. Tell me more.

[00:15:17] Atul Gawande:
I'm lucky. I get to have some agency. What gets me down is feeling I have nothing I can do. When I'm just doing surgery and I see the way that the system around me breaks, how people can't get access to see me and other colleagues because they don't have insurance or they never had a primary care doctor who recognized that they had an illness that required surgical attention in time for me to be able to address it, or the systems don't even exist for 5 billion of the people in the world. That's what gets me down.

The other thing that jumped to mind when you said this was in surgical training, you have a rotation on the plastic surgery team, but you can also get called for someone's heart stopped and you, you're part of the emergency team to do, you know, CPR and see if you can get them back. I was so much happier in the crisis because with a plastic surgery patient, I'm promising to make you more perfect. And I already know I'm going to fail for some significant portion of people. There's gonna be an infection. There's gonna be some, a bleed. Like, I hate that position. In the crisis situation someone's heart stopped the worst that happens is the likely thing that, that we will not succeed. And so, yes, we're in the middle of crisis. And it's devastating. It is a major setback. We've lost years of work in gains in life expectancy and burden of disease. But I also see a pathway that we can reclaim that within the next two to three years. And if we focus on recognizing we're overworking this core, primary care workforce, you know if you make sure that they're staffed well, they have the tools that they need, that they're plugged into good systems, including into good primary care clinics, right down to the frontline community health worker level.

We see the places that have been doing extraordinarily well, whether... I was in Ghana just a few weeks ago and our support enabled them to get COVID vaccines that are now abundant out into the remote areas so that they could go from where they've been under 5% vaccination in the fall to hitting 40 and 50% vaccination in a matter of a dozen weeks. We aren't doing that for enough of the world, but I can see the positive deviance. I see it's possible and what can be done.

[00:17:42] Adam Grant:
This makes me think about the stress and burnout challenges in healthcare. You're leading a mission-driven organization, which on the one hand is a tremendous source of purpose. On the other hand, I think it's, it's very easy to feel that the weight of the world is on your shoulders.

In this case quite literally, whenever I bring up burnout in healthcare, people talk about compassion fatigue, and I immediately wanna intervene and say, that's a misnomer. Neuroscientists have taught us for a decade and a half now that it's actually not expressing compassion that exhausts people, it's empathic distress. It's the feeling of concern, but being unable to help. And I know you are managing a whole team of people who are confronting that empathic distress right now. There are a lot of problems that you can't solve, at least in the short term. What are you doing to help protect your team from burnout?

[00:18:29] Atul Gawande:
I think this is really important, and it boils down to how do I enable people to feel effective in what they're doing? So number one is to set clear priorities and I named those priorities: we're going to control COVID, we're going to work to prevent the next pandemic, and we're going to strengthen our primary healthcare workforce as a means to drive global life expectancy. On COVID, we have had a frustrating period where since January, we've been telling Congress and the world that COVID is not over, that the U.S. and richer countries have access to vaccines, to rapid diagnostic tests, to antiviral pills, and the systems to get it to every part of our population. But that the bottom 2 billion don't have that and are not armed with that arsenal. We have been without funding now to extend that work, we are going to be having to fold down our COVID task force for doing a substantial part of that work while retaining as much of it as we can. That is depressing, but I'm not gonna make people try to do impossible things with no resources. We are scraping. We're finding every creative way we can to keep programs up and going and concentrate in a few parts of the world where we can make some victories. We had a presidential summit. We said, ":ook, we have no money from Congress. We're still gonna ask the world to help solve this problem and raise $3 billion to work towards these ends collectively." And so we can express leadership that way and bring other people to the table to do it. So we're gonna keep hammering away. After this podcast I'm going right back up on the hill and saying, "Hope springs eternal, this has to happen. We have to do this. We have to give this backing."

Now we have almost a billion dollars of investment, incredible, on preventing the next pandemic. The Republicans and Democrats actually came together and committed to the funding to say, "We've got to do this better." And so we have the teams that are actively getting better at driving response to outbreak and part of my lesson there is they're overwhelmed by having to build fast and being asked, like, "Why isn't this happening already? We've provided the funding, what, what the heck's happened?" And I'm trying to help people understand the story of how much gain we're providing, where we're able to do this.

So for example, in the Democratic Republic of Congo, Ebola broke out in west Africa where DRC is in 2014, 2015, 10,000 dead. And it was four months of circulating virus before it was recognized in the health system and an outbreak was declared. And so that's why it's spread everywhere. Spread invisibly. We have made investments over the last seven years to drive improvements in that system. So that by 2020, instead of four months, it was 15 days in the 2020 outbreak before the case was a case was identified in a hospital, diagnosed, and an outbreak declared, and a response mounted. And the result, it was 55 deaths and it was confined to the country. In April the systems we'd worked with the government to produce meant less than 48 hours for it to be detected, suspected by the clinician, the diagnostic test was right there. They ran the test. It confirmed the person had Ebola. They immediately called an outbreak, started tracing contacts, and the outbreak was declared over within weeks, only five deaths, and it was locally contained.

[00:22:11] Adam Grant:

[00:22:12] Atul Gawande:
That is now what we're replicating in 50 countries. And I can energize people by helping them celebrate. We can accomplish this in some of the most difficult environments in the world. We can replicate it at scale and Congress can understand that their investments are not going nowhere. They're actually making a difference. And Republicans and Democrats do respond to that.

And I'm now trying to win the case on the primary healthcare components. What's measurable? How do we know if we're gonna make victory and win? And I haven't got them there, but I'm getting more of an understanding. I know this will take chipping away at it, and, and our teams will be coming along together on the journey. We're all pulling in the same direction. You're not alone at doing this. You know, I have 2,500 people across a hundred countries and that's where energy and effectiveness I think comes from.

[00:23:06] Adam Grant:
Wow. That's incredible progress. It strikes me that it's, it's never possible right. To succeed in every single one of those efforts though. Right. So if you're gonna scale in 50 countries, you're probably gonna have a few where it doesn't go, as you hoped. And this, this reminds me of Complications. I remember reading it and thinking I could never do this job. I'm so grateful that there's someone with the, the scale and the patience to do it.

But one of the things I took away from that book was how important it is to be able to detach your ego from your mistakes and your failures. And you're now facing that at a much larger scale, knowing that if you fail to contain an outbreak, it could be thousands of people or hundreds of thousands of people who die. How do you navigate that? How are you helping people learn from those kinds of failures and setbacks and, and maybe even errors?

[00:24:02] Atul Gawande:
Yeah, my first book Complications, it was called"surgeon's notes on imperfection." My writing tends to be coming from the places of distress and confusion. Right. This was written during my training, where I had to learn on people how to do surgery. How do I claim that permission to have a learning curve? And the only way is by not pretending to be perfect, but instead to always be living up to the belief that I'm aiming for perfection and that I understand it's not just me, but a team of people that make it possible for me to learn effectively and safely and for a person who depends on the team to have confidence in the team in even if there is a learner on the team, right? Writing that book helped me come to accept a space where you can actually enjoy the learning curve. And I love the learning curve. I came into this job. I'm not an infectious disease expert and I haven't managed 2,500 people spread across a hundred countries. But I'd done work at one scale level down from that. And it felt like I could climb this next learning curve, and I could be cared for in some way by the team. The government is a ship that moves with an enormous amount of inertia, and I'm not gonna break the ship, and there's a certain amount of comfort in the fact that this is a team of people who have existed for decades who have successfully driven life expectancy and global mortality downward in measurable ways that our countries that we partnered with when matched against countries that we've not partnered with and looking back to the periods where we didn't partner with anybody, you can see a divergence at any given income level of the places that we have supported.

And so part of my goal coming in is do no harm. This team has incredible capability, watching them in disaster, know how to pull a rapid response together, and execute is a thing of beauty. And I see lots of ways in which these teams had no clear priorities. It was not aligned with where we were now and what resources we had, and we could mutually help each other. I could help people feel more effective and have purpose pulling together and they could help me climb the learning curve to get good at this work. Nothing is static. We're all on a learning curve. There are areas of development for each of us and for us as an organization and as a team to get better at what we do. And there will be setbacks because not everything will go our way.

[00:26:41] Adam Grant:
Expect a learning curve. I almost feel like that's a mantra we could take away when taking on any new challenge. All right. Are you up for a quick lightning round?

[00:26:50] Atul Gawande:
Yes. Okay.

[00:26:51] Adam Grant:
What music did you most love listening to in the OR?

[00:26:55] Atul Gawande:
Oh gosh, I made a playlist. You can find it on Spotify, by the way. It's under my name. I love indie rock. I'm also, was trying to have a playlist that would draw in the best nurses and anesthesiologists to wanna join me. And I found that I had a target profile and I figured out what music they liked. And I got some of their music in and learned like country isn't gonna fly with some of the people I was trying to get. And like, you know, industrial techno, no. Okay. That's not gonna happen. There was a strategy behind it. But a lot of it was also just getting stuff I loved into it, which still ranges from Andrew Bird to Arcade Fire. And that's just the A's .

[00:27:35] Adam Grant:
Wow. All right. Since we can't read you right now, who's a writer we should all be reading?

[00:27:40] Atul Gawande:
I barely get to read these days, but a writer we should be reading... I'll just say Patrick Radden Keefe has blown me away with two books back to back that are incredible. Say Nothing about the troubles in Ireland and then Empire of Pain: The Secret History of the Sackler Dynasty, a critical driver of the opioid epidemic, killing a hundred thousand people now, uh, a year. And both are just unbelievably well told as well as important and powerful and meaningful books.

[00:28:17] Adam Grant:
What is the biggest lesson you've learned from the work you've been doing in Ukraine?

[00:28:22] Atul Gawande:
The biggest lesson was that there's a space between disaster relief, where you solve the acute crises of the moment, and the system building we're used to doing in global health, where you plan in months and deliver years. In Ukraine, the week that the Russian government invaded the entire country, the pharmacy system shut down. 90% of pharmacies closed. Access to medicines. Supply chain disappeared. The trucks from Europe aren't gonna be driving through anymore. Cyber attacks from the Russians were trying to take down the electronic health record system. And we are used to addressing well, "Is there a risk of polio or a risk of measles?"

And the disaster relief folks focus on what's the trauma, what's the food needs, what's the shelter required on top of that. Probably the biggest chunk of time was filling in the space of keeping the system itself resilient and moving. And that enabled a supply chain to get reestablished within three weeks, move the electronic medical record system into cyberspace and into the cloud and, and protected against cyber attacks. Incredible, just that need. And it led to really building an entire team on the fly that now we're applying to these other areas where it could be an outbreak, it could be a health disaster and making that, um, team come together.

[00:29:42] Adam Grant:
Excellent. What's the worst advice you've ever gotten?

[00:29:45] Atul Gawande:
Well, it's the constant advice I got early on, which is "you have to pick one thing, Atul." And I just resisted it because some people will be brilliant and best diving deep into one thing, but there's lots of creativity at the edges of combining fields, combining approaches. And so I combined surgery and public health and then I combined in writing and that work, and that is where I'm successful. It may not be the same way other people are.

[00:30:23] Adam Grant:
Atul, one of my other favorite pieces of writing of yours was the article you wrote on, on having a coach. And I remember seeing this headline and thinking, of course it makes perfect sense. Athletes have coaches, musicians have coaches, everyone else should too. If they wanna be at the top of their game. You have a coach. So you're eating your own dog food or drinking your own champagne depending on how that's going. What's that been like, what are you learning? I think it's one thing to, to be coached in a profession like surgery, right, which is very task oriented. To be coached as a leader is much broader, much more ambiguous in many ways. I'd love to hear what that's been like and what you've learned about coaching through this experience.

[00:31:04] Atul Gawande:
You know, that piece was prompted by recognizing that I was paying like 125 bucks to have a tennis coach, and that Roger Federer, Rafael Nadal, Djokovic, the top players in the world all have coaches. But that is not our... In whole swaths of other professions, we have a, an educational paradigm you will put in your 10,000 hours of education, and then you will be a self-learner. Part of the education is how to train and advance yourself. And so which one was correct? Music was really interesting to me because in parts of music like voice, I got to speak to Renée Fleming, the opera singer. All singers have coaches. They follow the sports paradigm, but in things like violin, they don't have coaches. And I got to call up Itzhak Perlman, the greatest violinist of his generation, and ask him, "Did you think you need a coach?" And he said, "We don't have coaches in playing violin, but I always did." His wife, that he met when he was at Julliard after a period of time as a professional musician herself, she stopped playing to become his coach. Sit in the audience, observe his performances, give him feedback, and do it in effective enough ways that he could improve, set new goals and move onward. And that's what I learned is the pattern of coaching.

Effective coaching is different from teaching in that it involves an external view of your own reality. And then ideally it orients around the goals that you set for where you wanna advance. It can give you a framework for where you wanna advance. And so I tried it out and I'm so glad you asked me about this because I decided to bring a coach into my operating room. And it was a fellow surgeon who was one of my professors. And one of the surgeons I most wanted to be like named Bob Ostein. And he died just a couple weeks ago, a cancer surgeon, I just tremendously admire and was my coach in the operating room. And would observe and, and we would set goals. I'm gonna work on how my team worked in the, these next few months. I'm gonna work on my technical skills. I'm gonna work on, you know, the things we worked on most in the, until I stopped doing surgery in December, which was painful, teaching. And how I could be a more effective teacher.

Translating that into this atmosphere as I started building public health institutions, I had a executive coach that I engaged, guy named Allen Foster. He's terrific. And we've been together now for a decade and working on as I've started up multiple organizations, as I've advanced them along the way. And now in this role, and I, I actually think a lot of people have executive coaches and it has become a familiar thing, but the key to it has been not just my giving him my independent view of the world, but having him do a 360. And we actually just came through our 360 here with our team where he reviewed and talked to all of my leaders. And we got inputs from more than 30 people, including people reporting up to me, people above me, people that we have to work with as peers across the government and, you know, identified things that were going well, and the strengths I was building on, and the opposite things. In that variably it was the flip side of my strengths. So for example, I'm, I'm very energetic, as you might hear. And, and I'm also good at making decisions and making them quickly, but I'm moving so fast that I'm not communicating them and I'm not recognizing how to move them down into the organization and across to other people. I'm already moving on to my next thing. It's the rubber band theory of leadership. You want the rubber band to pull ahead enough that people are coming with you, not, not fall so far behind people are just swinging around behind you. I will tend to go so far that I can break the rubber band.

[00:35:19] Adam Grant:
Do you have strategies for making sure that you take that feedback seriously, as opposed to brushing it off and saying, "Well, that's just how I work. You better get with the program."

[00:35:28] Atul Gawande:
The main strategy is identify actions to take, which include informing people here is what I've heard and trying to set that model that you make feedback part of the culture of the place that you are advancing. One line of feedback, one of many lines of feedback was that I tended to interrupt people as they were talking, and that was really bad. And so, we came up with that I would owe $10 to the candy jar that we kept out for people walking through. And every time I interrupted people and so people could call me out, have permission, it's $10 in the candy jar. And my whole goal was to get rid of the candy jar. Like I wanted an empty candy jar. I definitely never had an empty candy jar and so I wasn't quite accepting it. It was recognizing that, you know, it was trying to diffuse it, trying to reduce it. I reduced it, but not eliminated it. And there's a certain degree of you wanna share the strengths so you're not sacrificing the strengths along the way. They're typically related, the strengths and the weaknesses.

[00:36:33] Adam Grant:
I think of Deborah Tannen's work on what she calls high consideration versus high involvement conversation styles. And for you to say, listen, when I interrupt that doesn't mean I'm intending to be rude or impolite. It means I'm really engaged. And it's a sign that I'm excited to jump in and build. But as a leader, I know that carries a lot of weight and it might silence people in the room. It seems like even being able to have that conversation right, is a helpful step, whether or not you make it to the candy jar.

[00:37:01] Atul Gawande:
Yes. You know, it's acceptable once in a while, but it can't be an acceptable pattern. The culture of a organization is the worst behavior you tolerate. We'd be in a wonderful place if the worst thing that happened is that the boss sometimes interrupts you. We have bigger problems to work on in every organization I've been part of, cuz it's not just about me. It's also getting the organizational feedback.

This I got out in surgery, right?. You cannot have a functional surgical world where you are not recognizing there are behaviors that can cost people's lives. And then address them. And we have an institution every Wednesday morning reviewing our deaths and major complications for the patterns that underlay them. And when you're doing that on a regular basis, it's recognizing failure occurs regularly. And then you are activating that we are going to look out for them and then address what are the worst things that happen. And then our plan for not tolerating them. And, uh, and I think that's absolutely crucial in public health work because of exactly the reasons you mentioned: the scale at which we do this work. We will have failures, we have risks. We absolutely have to take, and we have to drum out the worst behaviors that set us behind and identify where we can attack them.

[00:38:21] Adam Grant:
Music to my ears. Well, thank you, Atul, this has been just packed with insight, and I'm so grateful for the work that you're doing for not only the U.S. but for public health at scale around the world.

[00:38:31] Atul Gawande:
Well, I'm always delighted to talk to you Adam. Over the many years, we've known each other fantastic to get, to get to do it in the medium of your podcast, which I'm an avid listener to.

[00:38:40] Adam Grant:
Wow. Thank you. I'm glad we didn't end up in the ER this time. Cheers.

[00:38:44] Atul Gawande:
Cheers. We'll leave that story for, to be told later.

[00:38:49] Adam Grant:
Seriously. Thank you, Atul.

One of Atul's points builds on something that Danny Kahneman, the Nobel Laureate psychologist told me: that it's more important to reduce misery than promote happiness. I agree--in principle. But in practice, I've often felt that the circumstances with the greatest misery are the most difficult ones to helpen because it drags us down to be surrounded by so much pain. But Atul challenged me to rethink that with his comparison of plastic surgery and emergencies. In a true emergency, the worst-case scenario is that you don't succeed in making things better. Whereas when you're trying to improve something that's already good, the worst-case scenario isn't just failing to make progress. You can actually make things worse. Yeah. Being unable to help hurts, but causing harm hurts a lot more.

ReThinking is hosted by me, Adam Grant, and produced by TED with Cosmic Standard. Our team includes Colin Helms, Eliza Smith, Jacob Winick, Michelle Quint, Sammy Case, and Anna Phelan. This episode was produced in mixed by Cosmic Standard. Our fact checker is Paul Durbin. Original music by Hahnsdale Hsu and Allison Layton Brown.

[00:40:08] Adam Grant:
I think most of the world is glad that you chose medicine rather than music .

[00:40:13] Atul Gawande:
Well, if you heard that early music, you are definitely very glad. One song for example, was about the fall of Marxism and the rise of my love for my girlfriend.

[00:40:28] Adam Grant:
Well, we'll try to get a recording of that later.