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Surgeon Atul Gawande selected as CEO of new health care company from Amazon (statnews.com)
291 points by uptown on June 20, 2018 | hide | past | web | favorite | 139 comments

Atul Gawande is a brilliant person with interesting ideas on how to make healthcare more humane and robust. This is still probably a terrible choice of CEO.

To my knowledge he has never run a large organization or dealt directly with the complex backend of the healthcare system. The was healthcare is delivered and paid for is full of independent, semi monopolistic players that have often conflicting incentives. Oh and lets not forget that we have 50 states and 50 different sets of regulations.

Unless the plan is to create a brand new completely vertically integrated system, you’re gonna have to deal with the existing infrastructure, and I’d be much more confident in success if the person leading that effort had experience there. Having worked with many physicians and insurance companies, I can say from experience those skill sets are not the same.

Even if the idea is to be vertically integrated, someone like the CEO of the Mayo Clinic or Kaiser would have been a better choice.

I’d say hire that person as the COO. This will be a big organization. I think the person at the top needs to have a strong ideals about the direction of the organization

Healthcare/biotech companies typically have a CMO position (chief medical officer) which carries a lot of weight. I'm surprised that's not the way they went with a surgeon.

In an insurance context a CMO would be someone orchestrating coverage policy rather than serving in an advisory capacity iirc. It's a different role for the title.

Yeah that's fair. To be perfectly honest, everything being equal, I'll defer to Bezos and the like in choosing people for high level management positions.

I agree, this is exactly where I’d have hired him. He’s be perfect as the soul and conscience of this company.

They probably offered that to him.

The CEO cannot be a figurehead.

I really agree with the top commenter and am totally flumoxed as to how Buffet et. al. can back this.

Not only is this going to require 'CEO abilities' - it's also kind of a 'mega corporate startup' - which is another thing very difficult to achieve.

Amazon is ruthlessly operational, by the numbers etc. - this will collide with medical bureaucracy pretty hard ... it's almost as though you want an outsider ...

Or, to buy a small company or two and combine them, a small team with the 'right chops' and then back them with scale, financing etc..

Agreed – there's so much complexity that wrangling it is it's own effort, worthy of delegation to a supremely skilled and experienced operator.

If _all_ this company did was wrangle the complexity of the healthcare system, however, they wouldn't be a step function better than anything else.

For the deeper, more radical changes, you need a visionary at the helm.

Of course, Atul will need to be able to effectively recruit & work with a stellar team to fill the gaps you mention.

I know appeal to authority is obviously a bad way to support an argument, but I would imagine one thing the most senior people at Amazon, Berkshire Hathaway and JPM are fairly decent @ is picking management talent. So if all 3 sides agreed on a pick I would imaging there was pretty compelling case.

Jeff bezos mentioned they were looking for someone with expert knowledge, a beginner's mind, and a long-term perspective. Any leader of a current large healthcare organization would probably fail the 2nd and potentially 3rd criteria. In light of these criteria, the choice of Atul Gawande makes sense

That’s actually my point, I would argue Gawande doesn’t have expert knowledge. Being an expert surgeon is a very different skill set than an expert in healthcare delivery and management.

Let’s take the checklist manifesto, a fantastic idea that unfortunately isn’t as widely applied as it should be. Why? Because if you ask most surgeons they’ll say, “yeah it’s a great idea, I do it already/I don’t need to do it though because I’m that good”. In practice it doesn’t get applied because humans have ego and incentives get misaligned. It’s not actually that beneficial to reduce complications in surgery for the hospital as long as the patient is insured. And it’s not that beneficial for the insurance company to reduce costs because fundamentally as long as the insurance company can accurately predict how much costs will rise next year, they still make money. They just need to know how much premiums will go up.

Healthcare is full of great ideas and ways to make things better, but they often just don’t get implemented because the whole system is so poorly set up. I don’t see any evidence that Gawande for all his talents has a good approach or the expertise to break through all that.

Your point seems true regarding that particular article, though I dont think that is sufficient to demonstrate that he doesnt understand the system. As a surgeon, I'm sure he knows the barriers to adoption of such a tool, and being the head of a large buying consortium for health insurance (Amazon / berk / jpm) could give him the market power to "wag the dog" and push payers to implement such policies. But i agree that the checklist manifesto is prob not the best / most practical way to reduce spend

I'd point to another article, his "cost conundrum" article actually was a pretty insightful piece that I think gets at the core of one of the main drivers of high HC spend: local monopolies [1]

Another article of his, the "hot spotters" [2], was very influential among providers, administrators and even VCs as well. However, I dont think he's right that addressing frequent fliers is the solution -- you see the same cost concentration among a few patients in all countries, and even across time, so it doesnt appear that that phenomenon is the cause of the US' unique expensiveness

i dont know of many other people who have ideas that demonstrate the same combination of independent thinking, reach / visibility and understanding of the system as atul gawande (i actually dont think there are many great ideas to improve healthcare, most dont even diagnose the problems accurately). some of his ideas will be wrong, but he has new and solid hypotheses, and being able to test those and learn is a great way to make progress

[1] https://www.newyorker.com/magazine/2009/06/01/the-cost-conun...

[2] https://www.newyorker.com/magazine/2011/01/24/the-hot-spotte...

Your point is an excellent positive case for his appointment :).

I fully agree with you on monopolies and hot spotters. The monopolies are a pernicious issue that's incredibly hard to solve, and targeting hot spotters is not likely to be the silver bullet people hope it will be.

I hope he succeeds given his perspective, I'm just skeptical that he can given the scale and structure of the problem. In particular the monopolies issue seems utterly intractable. Maybe some combination of remote care and creating vertically integrated treatment centers can help? I don't know, healthcare is really hard. I just hope this isn't a flash/vision over nitty gritty execution appointment.

I agree that lack of ops / execution experience is a potential concern, but for me the characteristics that make me most positive are 1) ability to connect with a wide audience of physicians and 2) courage: a willingness to fight the "powers that be" and try things that probably won't work, as long as you get enough shots on goal to do something that does (not sure how courageous he is but his willingness to put himself out there in ways that most docs dont do is encouraging). Rushika Fernandopoulle at Iora has these qualities and they seem to make up for his lack of healthcare ops experience (though I dont know that his model is sustainable / scalable enough)

I think these are important because my hypothesis is that the way to tackle the monopoly issue is by reversing the trend of hospital consolidation and purchasing of independent providers, and putting more power in the hands of physicians rather than health systems or payers. But to do that you need to make being an independent physician feasible again, and to learn how to do that you need to connect with a lot of physicians and then be in a position to create services and products to help them become independent (probably by getting payers to pay independent docs more / reducing auth and other burdens; maybe this company has the heft to do so). I don't know that Atul Gawande's the perfect person for that, but I know that anyone who has run a hospital or payer is probably not right

I think Gawande is a good choice. He’s obviously a smart, visionary-type who lacked the power to implement his vision. Now he will have that power.

And he’s neither a fraud (e.g. Scott Thompson) nor a finger-on-the-trigger egoist (e.g. Elon Musk)

Surgeons don't get to play God as much anymore. Checklists dominate and are the hallmark of a good institution. One of the biggest risks in hospitals are central lines and infection. So cleaning protocols / enforcement and as much automation as possible are ways forward. The ACA imposes financial penalties on hospitals if they don't reduce infection rates and readmission rates. You can only do that if you improve quality. A hotshot with an ego is bad for business.

Also, I think Gawande _wrote_ "The Checklist Manifesto"!

After having worked with some A&Ps (aircraft mechanics) I was shocked that surgeons didn't operate with checklists. Doesn't matter how skilled you are, mistakes happen, especially when you are in a hurry. Aircraft mechanics also typically 'shadow' their toolboxes, which is where every drawer has individual cutouts for each tool to make it easy to verify that all tools are back in their place. And apparently instruments being left in a patient isn't that uncommon:

"According to the U.S. Department of Health and Human Services, it is anywhere between 1 in 100 to 1 in 5000.[1] However a study done in 2008 reported to the Annals of Surgery that mistakes in tool and sponge counts happened in 12.5% of surgeries.[8]"

Why are aircraft mechanics taking better precautions against this type of low hanging fruit than surgeons, aside from ego?


> Why are aircraft mechanics taking better precautions against this type of low hanging fruit than surgeons, aside from ego?

Nothing new under the sun. A guy who found that doctors should wash hands between autopsies and deliveries was ostracized by colleagues and died in asylum. [1]

[1] https://www.npr.org/sections/health-shots/2015/01/12/3756639...

Yes, that's correct - a very worthwhile read, regardless of your profession.

>doesn’t have expert knowledge ... very different skill set than an expert in healthcare delivery and management.

He's kind of celebrated for an article he wrote in the New Yorker on healthcare delivery and management. (see 'This magazine article saved $500M in unnecessary Rx spending' https://www.cnbc.com/2015/05/08/this-magazine-article-saved-...)

It impressed Munger, Buffett's partner sufficiently that he sent a cheque for $20,000 to Gawande at the time as a gift without knowing the guy. https://www.cnbc.com/2018/06/20/charlie-munger-once-wrote-at...

Yes, but you still need someone with startupy hustle, and with a CEO mindset, as well as a knack for ops.

In light of this, I'm truly perplexed by this choice.

This is not a 'resarch organization' or something like 'doctors without borders' for whom this guy would be a great choice.

Living outside of 'revenue' and 'products/services' all of one's career makes this a difficult choice.

I think one of the reasons tech startups haven't made a bigger dent in healthcare / biotech is bc they overweight startup hustle and underweight experience and domain expertise. Better to walk towards the right target than run really fast to the wrong one, and in fields like healthcare you can't pivot as quickly once you realize you're going in the wrong direction

Basically all successful biotech CEOs are old, former big pharma execs or academics -- two fields not known for their hustle. And they can grow big, fast: look at CEOs of Juno, avexis, kite; those companies were bought for $9-12B cash just 5ish years post series a

The biggest health tech companies are Cerner and Epic. They were founded in the 1970s I think. Have avoided disruption bc they know the system. Many other successful health tech companies are founded by dyed in the wool industry veterans or doctors with a good understanding of the field who work 9-5

Plus Atul probably has some hustle. He became a best selling author while being a surgeon and prof at Harvard. Takes initiative to decide to write books and actually pull off getting them sold. He sure knows how to build an audience -- probably has a bigger audience than any health tech startup CEO

I agree with all of what you are saying but I just don't buy that this is the guy. A prof, surgeon and 'successful author' is just not the right mix for this.

I would say: ex-surgeon Hospital administrator of a progressive hospital. Ex-director of technology and services for a healthcare provider or insurer. Head of a prestigious applied research centre.

'Prof' and 'author' are intellectual, non-leadership, non-outcome, non-operational, non-managerial positions. He's imminently qualified to be the spokesperson and possibly 'Chief Medical Officer', but not CEO.

Does he even have a history of doing in-depth research on the operational and cost challenges of running a healthcare system?

The 'innovation' required here will not be medical - it will be political, operational ... fighting incumbent structures.

Someone with a kind-of relevant background who is also an ex-physician. There are many of those.

I'm still perplexed.

Amazon was hugely successful with AWS because it was an outgrowth of their business. They bought their way into groceries.

They will use their deep distribution and warehousing advantage to move into delivery. All of that makes sense.

But taking on incumbent, politicized structures? With armies of lobbyists to legislate their control of systems?

I think this guy is going to get eaten by the entrenched powers that be.

Though I wish him well and applaud Bezos for going after this.

Wallmart already has some opticians in their stores - I really wish they would move into pharmacies, then maybe 'family doctor locations' and then commoditizing common things and operations.

I actually think Wallmart is in many ways so much better positioned than Amazon to make their way into healthcare by grabbing the low hanging fruit and using their massive pricing power and physical installed base.

I completely agree with you philosophically, and your idea that Walmart might be better positioned than amazon makes sense to me. Owning providers (versus paying health systems massive prices for access to providers) seems to be an emerging theme.

I've spoken to / heard talks from several ex-MD hospital admins of large health systems, informatics heads at massive university health systems, and leaders of large providers, and from hearing them I just have no confidence that they have the will to enact change. They are benefiting from the current system and to do something radical to fix the system would go against everything they'd learned in their careers, and probably burn many professional bridges (they'd be fighting their former colleagues)

I'd point to Rushika Fernandopoulle at Iora health as an example of a physician with no ops experience who has excelled in fighting incumbent structures. If Atul has that phenotype, I'd take that over hospital admin experience any day. But of course thats just my perspective and I understand picking Atul is a big risk

"I just have no confidence that they have the will to enact change. They are benefiting from the current system and to do something radical to fix the system would go against everything they'd learned in their careers"

I hear you - but I also believe there are a number of them who imminently grasp the dysfunction and would like to do something about it. This is kind of out of my discipline but my Uncle was on the board of governors of a Hospital and he and the board watched as crazy stuff happened and definitely wanted to do something.

I worked in mobile at a once very succesfull handset manufacturer ... I watched the iPhone be borne and eat our lunch. As the execs failed, paradoxically, some of them knew what was happening and just could not get the system they were inside to change ... but a lot of us, were we to be in different systems, I think could be successful at it.

Anyhow. I wish him the best ...

I agree and to refine a bit, I think it depends on the type of business.

The Internet was wide open 10-15 years ago. Today, not so much.

A CEO of anything in healthcare, especially something like this, had better have a lot of domain expertise.

I took a short walk down this idea of a vertically integrated system, essentially building the system as a research lab (something like NIH building 10), including approaching some senior people. I sort of wonder if maybe they modified their expectations for the venture after a search revealed that experienced CEOs weren't interested.

You have to address questions like "Where are you going to get physicians? Nurses? Ancillary staff of all kinds?"

The real estate and financial models are trivial by comparison.

I've also done some work trying to get people to implement different models of care outside of the traditional institutions, and getting physicians on board is just a big hurdle. As a group they are pretty conservative and risk averse, hugely busy, and there aren't a lot of places where they congregate, online or otherwise, so outreach is a bit of hand to hand combat.

I have an untested hypothesis that one of the best ways to get physician mindshare is actually through think pieces in publications like the new yorker or new york times -- just the kind of articles Atul Gawande writes. The physicians that I know read these articles much more actively than they use linked in (most dont) or any other online community

Another (darker) perspective: they don’t want to lose money. Healthcare in the US is expensive in no small part because we pay more for things (duh). One of those things is physician time. Primary care physicians in the US make $60K more a year than comparable nations [1].

Dirty secret of healthcare: “efficiency” translates to “I make less money” for almost everyone in the system, very much including doctors. All will protest and justify their cost, all will make good arguments in the individual case. In the aggregate though, we pay people too much (among many many other issues).

[1] https://jamanetwork.com/journals/jama/article-abstract/26746...

I agree that profit motive is underappreciated and often is the real reason for consolidation, formation of ACOs, etc (many ACOs dont form for getting share of cost savings, rather they try to increase volume through partnerships).

However I think it's odd to point out primary care as a culprit. Prices in the US are higher across the board, so just highlighting primary care salaries doesnt tell the whole story. Better metrics are 1) ratio of average salary of specialists to primary care and 2) total supply of specialists compared to primary care. The US lags on both metrics [2]

Hospital care is the number one driver of spend in the US (over 30% of spend) [1]. A day at a hospital in the US is twice as much as in comparable countries (can dig up source if interested). Pretty sure the U.S. spends more on inpatient care as % of total spend than other countries. US is middle of the pack in terms of drug spend as % of total HC spend. Hospitals have increasingly been buying primary care and specialty practices. When an independent practice gets bought by a large system, they can instantly charge more for the same procedure, bc they're now under the large system's contracts with payers. Literally nothing changes but negotiating leverage. If you want to find a big cause of healthcare spend inefficiency in the US, look there

[1] https://www.cms.gov/Research-Statistics-Data-and-Systems/Sta...

[2] https://www.milbank.org/2017/07/getting-primary-care-oriente...

Then lets break out the wrecking ball, because most US hospitals are organized around the idea of private rooms that require more equipment, more real estate, and more staff.

Physicians, and others, pay for their medical education in the US. How do physicians pay for their education in other countries or is it paid for them by their governments?

Also, the doctors I know basically give up their 20s and early 30s in the American system. But that might be due to existing doctors making sure supply stays low so their prices stay high, and so they can do that by making credentialing lengthy and difficult.

Considering how f...ed up the American health system is on all levels I am fine with giving an outsider a chance. Gawande appears to be a reasonable guy and a good communicator. Even if he fails, nothing is lost because the system can't get worse.

Ah, the ol' MAGA argument.

I have never heard anything from Gawande that made me question his judgement. Whereas I have heard a lot from the MAGA guy that made me question his.

This would actually seem to be the misunderstand antecedent to the MAGA argument, which uses successful examples of exactly this type of "disruption" to fallacious claim replacing governance experience with business experience will have positive results.

This is exactly the same logic I heard used by many people voting for Trump. The truth is that there usually is a real downside from failure, even if it feels like our huge systems are as bad as they can get. In other words, while we do have an expensive system with worse outcomes than peer nations, at least right now we have healthcare being delivered at a first-world level, and we shouldn't take that for granted.

Well... uhh... this guy is not in charge of everyone's healthcare - he's in charge of a rather small group of companies instead.

The consequences of failure here are not exactly analogous to your example. 330 million people are not going to impacted by whatever is considered a failure here.


The three companies [Amazon, JPMorgan, and Berkshire Hathaway] are self-insured employers, which means that when you're an employee going to a doctor's appointment, your employer, rather than a health insurer, is ultimately footing the bill for the MRI exam you receive... "We're already the insurance company, we're already making these decisions, and we simply want do a better job," - JPMorgan CEO Jamie Dimon http://www.businessinsider.com/amazon-jpmorgan-and-berkshire...

Surely, that should be manageable for an insider like Atul Gawande. And it is nowhere same as wrangling with legacy American healthcare system (where one is dealing with insurance companies among others).

For now, but if I remember correctly, the goal is for these companies to offer this as their employees' health plans before expanding more broadly. For those people (and there are somewhere around a million customers between the companies), this could be worse than not being offered insurance.

They have no publicly stated goal to expand more broadly. That's nothing more than media speculation and or wishful thinking.

Buffett has repeatedly said this is not an entity that is meant to offer services beyond the scope of the three companies or similar. They plan to share what they learn, and Buffett has said he hopes that can help other companies and the wider healthcare system.

Here's probably the best talk he has given on the subject (13 minutes long, from a few months ago):


He will.be in charge of a relatively small company that still has very vague goals. He won't be running Medicare. If we are afraid of experiments on even the smallest scale there will never be any improvement.

Comparing the presidency to this CEO position is just silly.

The "outsider" in this case is still a surgeon, and teaches at Harvard. I don't think the comparison is apt.

from my experience, getting these senior insiders to lead a newco would just result in more incremental innovation. Most of them came up in and benefited from the current broken system and are either too conservative to embrace drastic change or don't want to rock the boat.

I don't think something like Kaiser could be easily rebuilt from scratch, but I don't know too much about the Mayo Clinic except for its reputation for clinical excellence and their active investments in innovation. Have they implemented new models to meaningfully lower cost of care?

I also imagine Atul gawande has enough experience with the existing system to know what ideas have a chance of working vs running into a brick wall of conflicting incentives. He can hire somebody to lead negotiations with insurance companies and providers, etc

"from my experience, getting these senior insiders to lead a newco would just result in more incremental innovation. Most of them came up in and benefited from the current broken system and are either too conservative to embrace drastic change or don't want to rock the boat. "

Exactly. Reminds me of some parts of the IT department in my company. I don't trust anybody who has worked there for a few years because any reasonable person would have left or lost his mind. They certainly will not be innovators.

>Atul Gawande is a brilliant person with interesting ideas on how to make healthcare more humane and robust

No, he’s not.

No offense to him, but he’s a -popularizer-. He takes various bits the HC quality improvement folks have been talking about / doing for years and writes (very articulate, engaging) articles that make it accessible to the wider community, including the wider medical community that normally isn’t in on those discussions. He also has a habit of relating it in a fairly shallow/one dimensional way, compared to the real deb-

Malcolm Gladwell. He’s Malcolm Gladwell, but for healthcare.

That's not at all the case.


Atul Gawande, MD, MPH, is a surgeon, writer, and public health researcher. He practices general and endocrine surgery at Brigham and Women’s Hospital. He is Professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health and the Samuel O. Thier Professor of Surgery at Harvard Medical School. He is also Executive Director of Ariadne Labs, a joint center for health systems innovation, and Chairman of Lifebox, a nonprofit organization making surgery safer globally.



Oh, I know he’s a surgeon. He and I have very similar backgrounds, save that I spent a decade in hc QI and Health insurance mgmt before going to medical school, rather than picking it up subsequently.

I point that out so you fully understand that when I say a doctor:healthcare QI as a bees:entomologist, I say that from both sides of the fence. It gives you some more insight in your little slice, but that’s it. And it’s just your little slice: I am not a surgeon, so I know jack shit about their operational processes. I do know from a recent kerfuffle in my hospital that even the surgeons don’t know much about how the OR department books rooms and schedules procedures. They certainly don’t have insight into the parts of the hospital that -aren’t- a core part of their job. Being a physician is an important window into how hc systems and organizations work, but it’s a tiny one. It doesn’t qualify one for hc QI by itself.

As to his cv, by all means, check out where he’s first author, where he’s “contributing guy with a name” (second to last), how many of them are editorials or round tables, how many of them are endocrine surgery, etc. Actual first author, non editorial healthcare ops papers are thin on the ground.

This feels like nitpicking. The guy is intelligent and accomplished, beyond question. But what he -isn’t- is a hc innovator just because he -writes- about the hc system and innovations therein. I’ve never seen him write on a topic that wasn’t already hot shit in the field for two decades; I’ve never seen him present the pile of conflicting data for his preferred solutions (eg, the Checklist Manifesto chose to elide how many hospitals implemented checklists to no improvement, despite plenty of the results being published before his book.)

Fair enough, he's a popularizer and also a top-tier surgeon.

I agree with parent comment -- there is a difference between being the person/people who came up with brilliant ideas and being the person who brought them to the masses in a pithy, cogent and engaging manner.

One might even make the argument that the latter task is relatively more important than the former for people in high-visibility figurehead type positions such as CEO of a massively ambitious new healthcare venture.

The "Gladwell for healthcare" comparison is a good one, and I say that as someone who has enjoyed reading Gawande's books.

>and also a top-tier surgeon.

The only people who can differentiate between 1)surgeons who are expert in the O.R. whose patients do well in the long run and 2)those whose reputations exceed their abilities and results are anesthesiologists. Trust me, I was one for 38 years, at UCLA, the University of Virginia, and in private hospitals. I will never forget the time a world-renowned cardiac surgeon at UCLA at the height of his career — holder of an endowed distinguished chair, first author of the then most widely acclaimed textbook in the field, whose surgical skills were so sub-par he was only allowed to operate with a senior cardiac surgeon as his "first assistant" — was repairing a child's AV septal defect by sewing on a patch (on full cardiopulmonary bypass) only to be interrupted by his "first assistant" who quietly told him, "You've got the patch on backwards." I was standing literally two feet from the two of them, behind the drape.

So what’s your point? Should no one try to differentiate good surgeons or bad unless they are their peer for years?

There’s lots of crappy programmers with good reputations too. But it’s a weird reply to “he’s a top tier surgeon” that you say it’s unknowable.

I’m sure you’re right, I’m not a surgeon so I have no idea how to evaluate a good surgeon, but there must be some way to qualify the poor ones from the great ones.

Your anecdote is a great example of high reputation, low skill. But is that the only instance. Is it 10%? Are most board certified, practice for 20 years surgeons good or bad? What’s the actionable intelligence, but it seems like the conversation ends with “it’s unknowable.”

I am sort of aware of quality measurement, but not a healthcare practitioner, but I’ve noticed this comment from lots of docs that the only way to know if medicine is good or bad is to have a doctor review it.

I see your point, but I'm pretty sure he's at least pretty good, given that he has been promoted into a supervisory role by other surgeons who are familiar with how he does surgery.

I wouldn't call him a popularizer, I'd call him a good communicator, which is an essential trait to any leader, especially one trying to do something long term and visionary. Effectively communicating new ideas to the wider medical community, especially super busy physicians, is really hard, and is the first step towards driving physician-led change in the healthcare system.

I dont think his ideas are shallow or one dimensional, but I havent read all of his work. I'd certainly push back against the comparison to Malcolm Gladwell -- atul gawande is a practicing surgeon and professor at one of the most well respected hospitals in the world. If Malcolm Gladwell wrote about the 10,000 hour rule from his personal experience becoming, say, a chess grand master through 10,000 hours of practice, then the comparison would be more apt

> I don’t think his ideas are shallow or one dimensional, but I havent read all of his work.

You wouldn’t. He adds depth through humanity, while eliding the pile of data that contradicts his points - data you have no reason to notice is missing. While the hc QI community was getting over checklists because of the number of studies showing it to be a largely ineffective intervention, he ignored the pile and kicked off a second wave. That’s not really visible to the lay reader.

>I'd certainly push back against the comparison to Malcolm Gladwell -- atul gawande is a practicing surgeon and professor at one of the most well respected hospitals in the world. If Malcolm Gladwell wrote about the 10,000 hour rule from his personal experience becoming, say, a chess grand master through 10,000 hours of practice, then the comparison would be more apt.

AG does not write about healthcare QI from the perspective of someone that works in ops or hc QI. It’s a real profession, and one he hasn’t practiced.

He writes about macroeconomics and corporate management (and if that seems wildly dissimilar to you, you have some appreciation of how far afield he pokes his nose) from the perspective of the factory worker. And when he at least stuck to his area of medical expertise, at least he had some subject matter expertise to inform his perspective. He’s expanded outward from there, with neither academic nor medical expertise on the topic. There’s nothing terrible about that, but he’s -not- 10k hr guy writing about 10k hrs. He’s a guy with a passion, who has read up a bunch on topics he’s passionate about, and written about them well. They have some small overlap with his profession (diagnosing endocrine disorders; cutting out thyroids, Not reorganizing hc delivery processes), which adds some insight. Yeah, he’s slightly better than MG, but not by an awful lot.

Those are good points. I am not familiar with the research on checklists as a QI tool so will take your word for it. However I think his articles on the "cost conundrum" and "hot spotters" are pretty insightful and his analysis is accurate and at least among the HC admins / professionals I know the insights are respected. I don't think that he's right that frequent fliers are the cause of the USs high cost of healthcare but his analysis is reasonable

I don't mean to offend if you work in HC ops or QI, but I'd rather have someone take a macroeconomic perspective than an ops perspective when looking for solutions to high HC cost. I'm aware of the HC QI field and know a few ppl who work in that space and I know how hard it is to move the needle with that work. You are fighting against a system that in many ways is not incentivized to work with you. I know there's been a lot of great work done in HC QI but frankly it hasn't moved the needle on cost of care. I think it's time to look at changing the broader system to allow all the good HC QI ideas to actually get implemented broadly

I hear your point about intellectual overreach. However many people call it another thing, but with a positive connotation: the "beginners mind". That in fact is one of the 3 criteria bezos had for the CEO. That mindset facilitates learning, growth, risk taking and innovation. Yes you'll make mistakes but that's part of the plan. The experts who never step beyond their area of expertise won't be as successful because healthcare is too interdisciplinary to have leaders who won't reach out intellectually to people from other fields, and too broken for incremental improvements to turn the tide

> While the hc QI community was getting over checklists because of the number of studies showing it to be a largely ineffective intervention, he ignored the pile and kicked off a second wave

I just thumbed through meta-analyses on Google scholar and this definitely doesn't look like the results of recent research into checklists (e.g. https://onlinelibrary.wiley.com/doi/full/10.1002/bjs.9381)

It seems like there are problems getting people to agree to do checklists or keep with them, but if you come up with the right checklist and get the right buy-in, you do see fewer complications.

(If anyone wants to look at the recent research for themselves, here's the Google Scholar search I used: https://scholar.google.ca/scholar?as_ylo=2014&q=checklist+su...)

> but if you come up with the right checklist and get the right buy-in, you do see fewer complications.


What the state of the research shows is that you have an active QI-focused culture and buy-in, checklists work over the medium long term, but not better than anything else. If you don’t have those things, the checklists do nothing after 3-6 months (a lot of studies hide this by rolling up the study period, but everyone in the field knows how rapidly the effect decays). I haven’t seen any meaningful data on them >2 years out, but let’s let that slide, out of pragmatism.

What that suggests is that checklists are irrelevant to this discussion. It’s just a lot harder to sell something as vague and nebulous as “creating a safety-focused and quality-driven culture” than it is to sell “checklists!”.

> While the hc QI community was getting over checklists because of the number of studies showing it to be a largely ineffective intervention

Do you have a cite for this?

This might be one

"Systematic review of safety checklists for use by medical care teams in acute hospital settings - limited evidence of effectiveness" (2011) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3176176/

Yes! Great minds think alike, arkades! I completely agree with you and disagree with the two commentators. Atul is absolutely a good communicator/storyteller/popularizer (whatever terminology suits people). I used to read his Cheesecake Factory article where he discussed standardization of healthcare, which I thought it was good.

In the recent years, I find him at an excess amount of healthcare conferences speaking or writing on topics that's not within his realm of expertise such as patient experience, opioid pandemic, technology, artifical intelligence. The audience is often captivated by his stories and writing to not be able to differentiate how he's really repeating others' work and quick to write about what's currently trending in healthcare.

He's a good writer, physician, knowledgeable but not an executor.

Slightly off topic, but I'm curious as to what your objection to Malcolm Gladwell is?

Fair point but Atul strikes to me as a problem solver kind of person. He has obviously got the intellect and precedent in that area. What I also think is this is _the_ job that will benefit greatly from a guy who has a fresh outlook not sullied by existing ways of doing things.

As another person said below, they could easily hire a COO to deal with existing aspects of the system and still have the overall direction in the hands of someone like Atul.

That certainly makes some sense, but in that case maybe someone who has run a big organization, or built a product would be helpful. I look around and see very few successful startups that were successful on the vision of the CEO alone. So much of success comes from being able to break down walls and get things to work together that didn’t before. Maybe he can do it, but that’s really hard to do. I’d prefer betting on someone who has demonstrated that ability.

Put another way it’s like giving $100M seed round to a visionary but completely unproven founder when the company is not even at garage stage. Might work out, but seems quite a bit more likely to fail than $100M given to someone who had done something like it before.

That's the traditional way of thinking and it might work well for traditional companies - but something as disruptive as this - I would vote for the visionary/thinker any day over the dyed in the wool, set in his ways guy.

Jobs/Sculley and later Tim Cook situation comes to mind - Sculley had the whole CEO experience but look how that turned out and look at how Tim Cook took over operations part which Jobs had no interest or knowledge of and made it work so well. If they had Tim Cook as the CEO pre-iphone days - I am not sure if we would have seen the iPhone.

Great comparison, but other than articles what kind of products or scalable accomplishments has Atul Gawande achieved in healthcare that is comparable to the impact of the iPhone?

This is getting tiring but the point is Atul can be the idea guy, the overall philosophy guy and they can hire other people who have product or scalable accomplishments to execute on the ideas. I think you're not giving Atul enough credit for what he brings to the being the idea guy and having first hand knowledge of what those ideas are about, being able to articulate those etc. He was also a WHO director who ran a successful project reducing surgical deaths around the world - https://en.wikipedia.org/wiki/Atul_Gawande

That, precisely, should be the COO’s job description. Like, almost literally.

Consider the alternative: the CEO is a professional “manager” who can run the shop, but may (or more likely, may not) understand what the shop is all about. Then who drives vision and strategy? Someone lower in the hierarchy can’t get himself taken seriously enough (sorry, but that’s just the nature of hierarchies). He (Atul) could be made the exec president or something of that sort, but an organization like this one needs a more hands-on visionary, who can corral the staff, while leaving the administrative and political minutiae to a trusted lieutenant.

For months the word from the rumor mill has been they have been struggling to find someone willing to take the job.

The ill defined mission of the organization along with perceived potential conflicts in priorities among the 3 companies has made candidates hesistent.

He's certainly a mismatch for the likes of Amazon and I'll bet won't have a long tenure. Reading about their worker healthcare ("AmCare"), one pictures a rusty tin of stained bandages. And a permanent mark on one's employee record if the tin is opened.

"Unless the plan is to create a brand new completely vertically integrated system"

Judging by the companies involved, this is most likely the plan. Whatever they create will like cause the existing system change to it and not the other way around.

Came here to say this.

This is the equivalent of promoting your best developer into management. Atul is a smart hard working guy. I’m sure he’ll work hard and do ok, but on the face of it he’s a silly choice.

Bezos has a reputation as a micromanager- I am sure between him and a COO there will be training wheels long enough for the company to reach maturity.

I would argue that you should give Jeff Bezos, Warren Buffett and Jamie Dimon more credit.

He will have great C suite of people to support him. He is compassionate, smart, good communicator, he will be fine as CEO and great choice for Amazon and others.

Dunno about this guy, but having once worked under one of the other potential CEOs who was on their short list, I can safely say that he probably would have been a much worse choice!

I would have agreed with you if Amazon wanted to build a clone of Mayo Clinic or Kaiser Medical. But they explicitly said they do not want just another medical company but something that is more radical.

Atul might be the Trump like shock that the establishment of medical sector needs.

Of course at the end of the day CEO appointments are gambles and I see this as one too.

His ideas aren't that impressive. All of his language still talks of "delivery" of health care. It's like listening to someone talk of new ways to deliver pizza. Your new delivery method may be revolutionary, but delivery is only a small part of the business. You are still delivering the same pizza. You aren't questioning whether the pizza is helping the people eating it, or whether it should be delivered in the first place.

My hope lies with those who question the product, not the delivery methodology. The US needs to rethink health care, not how they provide or pay for it. They needs to rethink how many prescriptions they shovel into the population. They need to rethink how they pigeonhole patients. They need to get people exercising. Those changes aren't going to come from anyone still talking about "how we deliver health care".

> [...] rethink how many prescriptions they shovel into the population. They need to rethink how they pigeonhole patients. They need to get people exercising. Those changes aren't going to come from anyone still talking about "how we deliver health care".

If you went to investors and used that as a pitch you'd be laughed out quick. Need to get people exercising? That's exactly the sort of unrealistic target that you don't want to have if you're going to run a company. Instead focusing on what could be realistically improved and doing that - which delivery inefficiencies are certainly a part of - that sounds like the most reasonable way to deal with something as big of a cluster f* the healthcare system in the US is.

>> to get people exercising? That's exactly the sort of unrealistic target that you don't want to have if you're going to run a company.

Funny. Morning exercises were are part of Japanese corporate culture for a generation. In many European countries employers are expected to support employee fitness goals. My job (military) mandates that we all be given five one-hour periods each week to exercise. Not weekends, during the work day. It is totally normal for someone to go from meeting to the gym and back again during the day. Our civilian employees participate in this too, although they aren't tested.

I think it totally reasonable for any large company to make exercise part of their corporate culture, particularly in the US where employers are so involved in health care. Anyone laughing such ideas out of the room needs to broaden their horizons.

I can thoroughly recommend reading Atul Gawande's "Checklist Manifesto". The premise, on the face of it, is mundane, but the stories that back up the claims are thoroughly enjoyable to read. http://atulgawande.com/book/the-checklist-manifesto/

The book is good, but the article it‘s based on is better, because there‘s simply not enough material for a whole book, so it feels a bit forced.


I wish every self help book had an article like this for it.

This was an excellent read. Thanks for the link!

Thanks for bringing this up! The name of the CEO didn't ring any bells for me until your comment. I've read the book and loved it; I second the recommendation.

Came here to say the same - book is an excellent read applicable across many professions.

This is the type of topic where I feel that HN community tends to not provide valuable insight as it's outside of the community's collective expertise. How many individuals here have hired SVP+ level employees and how would that compare to the collective experience of Bezos, Buffet, and Dimon?

Bezos, Buffet, and Dimon are unfortunately not available today to discuss this topic in the HN forum so you're stuck debating the pros and cons with us [fellow?] peasants, sorry.

Off topic sorry, but this is such a British response. Funny.

When I read the checklist manifesto I thought it was going to change my life. It didn't because I didn't put it into effect.

Then I thought it would be great if software did the work for me, including communal checklists that people can share with me. (Got a new car, here is a checklist template. Got a new house? Here is the checklist template? Is it an investment property, use this checklist. Oh, that is good for Florida, but in Texas, use this one.)

I found some software that is sort of close but nothing quite there.

Edit: Atul Gawande wrote the book so it is sort of tangentially related. I could make it more relevant by explaining how his checklists make him a general purpose leader or something, but I can't bring myself to do it.

I can recommend Wunderlist, it's quite good for having shared lists etc.

Of course, there's the usual issue of managing the 'chattiness' of the app, but I use it instead of a calendar.

Have you tried Process Street?

Just looked it up. It looks interesting for a company that wants to run a process.

I was thinking more for individuals, and note that the key is having people remember things you may not. For example, if the list has something like check your roof for leaks if its been 15 years or something you may not think of.

It's also something I always wanted after reading that book.

Care to share what you found?

Sure. Well every to-do app has most of the functionality you need (Wunderlist is the one I like the best).

They have annual reminders so you can put a checklist for taxes or something.

BJ Novak has https://li.st/bjnovak/ which is a general list sharing app.

It has the social component that I think would be very useful applied to to-do lists.

Finally, there are ready made list apps which help you maintain your home, health, car, kids, wealth etc.

I wish there was a social market place like li.st for apps like Wunderlist with multiple lists to choose from.

Mulled this idea for quite awhile as the consumer version of an enterprise app I built. PM me if you'd like to chat more on it!

I used Asana when I had a huge trip to plan for and had checklists on top of checklists

If you want to learn a little more about how Atul Gawande looks at the healthcare system read Being Mortal. IMHO it's more relevant than Checklist Manifesto, esp. wrt what Amazon could do here: https://www.amazon.com/Being-Mortal-Medicine-What-Matters/dp...

While Checklist Manifesto is about operational efficiency and quality, Being Mortal is about asking if we're doing the right things in the first place.

Literally just listened to his podcast he did with Freakonomics Radio yesterday. Definitely a great mind.

For all of you developers/operations folks out there, I recommend reading his book The Checklist Manifesto. Every team can learn so much from that book about their everyday practices. We read it at our company book club, and began taking checklists and documentation much more seriously which I attribute too much better productivity, operations and less siloed dev.

I was just about to mention that podcast episode! He clearly has a good, realistic grasp of what can be done to improve healthcare outside of the political mudpit. I was skeptical when this company was announced, but I am now extremely optimistic.


BWH culture is crumbling so I won't blame him for seeking other opportunities. However, this is an odd/weak selection where I believe Amazon-Berkshire-Chase will regret. Toby Crosgrove, former Cleveland Clinic CEO, would have been a well-qualified candidate and better choice. He has over 10+ years of leading a highly complex AMC and elevating the organization into the top 3 hospitals in the country for many consecutive years. This man can get things done via transformative, sustainable, and systematic changes. Alternatively, the CEO of Iora Health would have been a good choice too. Let's pause and compare performaces and outcome of between Cleveland Clinic under Crosgrove and Iora Health under their leader, and Adrianes lab under Atul. The result is clear. Atul doesn't have the experience only the Harvard brand. Being a CEO is different from being a professor, surgeon, philosopher, or executive director at the Adrianes Lab. In those roles and physician-led environment where MDs are treated like kings, the medical directors can put in 5-10% of their time with the expertise of administrators, interns, staffs and get away with having the breadth but little depth and claiming to be a SME. Atul seems like a good storyteller and highly intelligent physician, but he is absolutely an individual contributor. Frankly, Boston is full of highly intelligent and innovative people like Atul; the CEO of this venture should have more experience or at least specializes in one of the three verticals. Atul would have been a better executive advisor.

Concerns: - He stated not wanting to give up his privileges of practicing at BWH and professorship at Harvard meaning he can't be fully committed to leading this new organization. This is not an academic medical center environment where a physician can have multiple administrative titles and not put in the hours and work. - Atul's fame is credited to his publication, but also from the prestige of Harvard's affiliations. He knows this and is trying to strategic about not giving that up, but I would hope he realize that truly effective leaders know they can't do everything. Most of those innovator physicians stretch themselves too thin and get their hands into too many pots, making them ineffective. If he's serious, then he needs to commit and prioritize.

IMO, extreme network/lip service must have been invloved in his pursuit or the new venture and company is only buying his fame, reputation, and brand for marketing purposes.

Didn't Cosgrove retire? Why would he be interested?

Yes, he recently retired. I don't know if he would be interested but only meant to use it as an example of other well-qualified physicians leaders.

Full disclosure: I've worked in healthcare for prestigious AMCs, but have zero affiliation with Cleveland Clinic or Iora Health.

This is the kind of healthcare CEO most health tech startups should have -- someone who lives and breathes the system, intimately knows it's flaws but still has the vision and desire to change it. That is the rare and valuable skill in healthcare -- even more rare than engineering or operations skill

Rushika Fernandopulle, the healthcare CEO I most admire, fits this profile

I love Gawande; he's an amazing author and very thoughtful, systematic physician. That being said, to my knowledge he has never actually run anything before or operated on the back end of healthcare, so it seems like sort of a strange choice for an org this size and of this type.

Additionally, his (publicly stated) thinking seems to primarily revolve around systematizing routine practice to reliably increase outcomes for the majority of patients (ie what he espouses in Checklist Manifesto). While this is certainly important, routine patients are not responsible for most health care spend, edge case patients are. A tiny minority of very sick people account for a majority of health care spend, so I would argue that cost recovery should center around creative management of these patients rather than more systematic management of routine care, and the org should really be led by someone whose thinking centers on that.

To be fair the people running existing health care organisations are all experienced at creating the sort of company they want to avoid.

It's interesting reading the comments here. People with no background (I assume) in healthcare describe the guy as "brilliant" and "the perfect choice".

People with years of experience in healthcare question think he's a poor pick and just a famous name.

It's amazing what a good public relations strategy can do for someone!

People with years of experience in healthcare are invested in the status quo.

That’s Silicon Valley speak. People with actual experience on how something works and have practical ideas on how to make it better as passed over by people with better PR agencies.

This is a low-effort and mostly irrelevant argument. Who isn't invested in the status quo? Everyone has a stake in their current profession. What sets apart those in healthcare, especially someone like a surgeon, is their concurrent passion for science/biology and their desire to heal others.

IMO, the parent comment was simply remarking that those with EXPERIENCE in the field have a very different set of memories/recollections about healthcare, not to mention a lot of domain-specific knowledge, that those outside do not have. Those of us who have worked in healthcare for years, as I have, have a MUCH more intimate understanding of its vast complexities than a lay-person could. I think that's entirely reasonable and your comment assigns a negative connotation to people who are largely doing noble and important work.

Most accurate observation and comment on this topic! With 10+ years of healthcare experience including Brigham and Women's hospital many years ago, he's a good writer, storyteller, but truly is just a famous name that Amazon-Chase-Berkshire venture wants. Without the Harvard brand, his work, while good, wouldn't be that highly praised and worshipped. There are better visionary physicians out there.

My main takeaway is: being a good storyteller or facilitator on innovation does not make you any more innovative without the experience to support it. However, it can significantly elevate your personal brand beyond your qualificiations and apparently lure wealthy people to invest in you.

"The new company will be based in Boston."

Just wondering if there's a big regulatory benefit to being in Massachusetts.

Atul gawande is based there and the Boston area is actually ahead of the Bay Area in terms of biotech startup scene and similar if not better in terms of healthcare services

Not to my knowledge, but it is one of nation's healthcare and tech hubs.

Such Great Choice! Atul Gawande is the definition of integrity. On this basis alone I would subscribe as a individual or company co-founder. Bravo!

Tyler Cowen's conversation with Mr Gawande[1] was well worth the time. I don't know enough about him or the new company's plans to speculate on how this will all work out (although: neither does anyone else in this thread), but he's clearly a highly intelligent and thoughtful person with deep domain expertise. I certainly wouldn't bet against.

[1] https://medium.com/conversations-with-tyler/atul-gawande-che...

This gives me hope for the US health care system. Gawande’s ‘Being Mortal’ really helped me understand what was happening when my dad was dying. Highly recommend it

He's written a lot for the New Yorker is very intelligent and thoughtful. No idea how he'll adjust to being an executive of a corporation, but I think that is a risk worth taking. It sends a message that they will be patient-first and strongly evidence-based.


I've read most of Atul Gawande's books about the medical industry (Better, Complications, and The Checklist Manifesto) and I found the three of them extremely relevant to my career as a computer scientist. The latter book is by far his most famous, but IMHO the other two are much better.

This is a bold choice by Amazon, but it seems like a good idea even if it's just for name recognition.

I don't know how to fix this title, but it reads at a glance as either: Atul Gawande is going to be the CEO of Amazon, or that "Amazon" is the name of a Berkshire healthcare company.

EDIT: Thanks to the mods for the title fix, this is much better.

He seems like a very smart guy and an excellent communicator - I wonder if he'll be able to step up and make this role work. I will be rooting for him because the industry needs some players with deep pockets to step in and innovate.

On a side note I find it funny in a sort of inside baseball way that his description of an operation that he does, that he describes in detail and holds up as an example, drives my surgeon wife up the wall because it is not great (she does a lot more of them).

Curious, what are the n-order effects of large corporations reducing the cost of providing health insurance for their employees? My wages won't go up (probably), their profits will go up but I'm sure many other things happen in the middle. How will this affect taxes at the fed, state, local level? Will one level see an increase/decrease in taxes collected? etc.

Had a conversation with someone that had a speculation that the recent departure of Jonathan Bush of athenahealth because of Elliot Management might get him appointed to this CEO position but I guess that didn't happen.

Solid choice. He's a brilliant guy and obviously has deep knowledge of current flaws in out system.

Fragmentation - such as the creation of this company - is the primary flaw in the system. His leading that company stands in opposition to the ability to fix healthcare.

This is a separate debate, but id argue that consolidation, not fragmentation, is the current primary flaw in the system

It's a zero sum consolidation arms race between payers and providers with patients and physicians as pawns

this title could be improved, at first glance it seems to imply he will be CEO of Amazon AND some healthcare company from Berkshire. that's not the case.

Great choice.

Imagine if these three companies used their political clout to push for single payer instead of setting up yet another insurance company.

If you're asking yourself why you're getting downvoted, it's because you committed blasphemy by saying s * * * * p * * * * in the USA.

I disagree — lots of HN denizens support a single-payer model. What's silly is thinking that Amazon et al could trivially push it through within a reasonable timeframe.

Ouch. This is an incredible man who is a bad choice of CEO. CEO is fundamentally an execution-oriented, anti-creative role. Bezos know this and it implies that

1) He’s going to CEO this himself 2) He wants this intiative to fail

I think you are confusing CEO with COO.

CEO typically is providing vision, mission & strategic direction while the executive team he builds is more execution oriented.

Nah, the COO can’t really say “no” the way the CEO can to all the execs and their pet projects for their personal agenda.

Sure he can, if people know the CEO backs his decisions.

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