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Dr. Bob dials up Dr. Donald Berwick for a big-picture discussion about improving healthcare – generally, and as it relates to COVID. Don talks about the origins of the patient safety movement, his time running the Centers for Medicare & Medicaid Services during the passage and implementation of the Affordable Care Act, and what lessons he’s taking away from the pandemic. Plus, how to tackle the longstanding inequities in health care – and beyond – in America.

 

Follow Dr. Bob on Twitter @Bob_Wachter and check out In the Bubble’s new Twitter account @inthebubblepod.

 

Follow Don Berwick on Twitter @donberwick.

 

Keep up with Andy in D.C. on Twitter @ASlavitt and Instagram @andyslavitt.

 

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Check out these resources from today’s episode: 

 

• Keep up with all the work being done at the Institute for Healthcare Improvement (IHI) at their website: http://www.ihi.org/
• Check out the book Don mentioned, The Health Gap by Michael Marmot: https://www.bloomsbury.com/us/the-health-gap-9781632860781/
• Learn more about the Swiss Cheese Model of pandemic defense: https://www.nytimes.com/2020/12/05/health/coronavirus-swiss-cheese-infection-mackay.html
• Read the 1999 Institute of Medicine report on medical mistakes that Bob mentions in today’s episode: https://www.nap.edu/resource/9728/To-Err-is-Human-1999–report-brief.pdf
• Watch Don’s full 2012 Harvard Medical School commencement speech: https://youtu.be/wmEbO58chac
• Learn more about Dr. Bob Wachter and the UCSF Department of Medicine here: https://medicine.ucsf.edu/

 

To follow along with a transcript and/or take notes for friends and family, go to www.lemonadamedia.com/show/in-the-bubble shortly after the air date.

 

Stay up to date with us on Twitter, Facebook, and Instagram at @LemonadaMedia. For additional resources, information, and a transcript of the episode, visit lemonadamedia.com.

Transcript

SPEAKERS

Dr. Don Berwick, Dr. Bob Wachter

Dr. Don Berwick  00:00

In the great entrance hall to the Hubert Humphrey building, that’s the headquarters, where CMS is, where I worked. Chiseled on the wall of the Great Hall, in massive letters of the words of Senator Hubert Humphrey, which he spoke at the dedication of that building in his name. He said, “The moral test of government is how it treats people in the dawn of life, the children, the twilight of life, the aged, and in the shadows of life, the sick, the needy, and the handicapped.” I think this is the moral test to professions as well. These among us in the shadows, they don’t speak, not loudly.

Dr. Don Berwick

They often don’t vote. They don’t contribute to political campaigns or PACs. They employ no lobbyists, they write no op eds, we pass by their coin cups outstretched, as if invisible on the corner as we head for Starbucks. And Congress passes them by two, because they don’t vote. And campaigns cost money. And if those in power do not choose, have their own free will to speak for them, the silence descends. This is what I learned in Washington.

Dr. Bob Wachter 

Welcome to IN THE BUBBLE, I’m your host, Dr. Bob Wachter. You’ve just heard the graduation speech at Harvard Medical School in 2012. The speaker was Dr. Don Berwick, who we will hear from today. When I went to med school about 100 years ago, we learned how to be a doctor. But we learned absolutely nothing as I think back about how to improve the system that we were working in. And it struck me through my entire career as a practicing physician and as an administrator. How big a gap that was, that, you know, we now understand that being a good doctor or a good nurse or a good pharmacist involves not only the way that you take care of individual patients, but if you work in a dysfunctional system, you can be terrific in the one-on-one care of people and yet the outcomes that patients have are not going to be what we all hope for.

Dr. Bob Wachter  02:20

So, one of the important evolutions in healthcare generally in medicine, particularly over the last couple of decades, is a deepening appreciation of the role of what we call systems thinking. That the things that go into whether patients get the care that they need and do as well as they can do are not only how good the individual doctor is in one on one with a patient, but also whether the system functions effectively. There is no one in the universe who has done more to promote that understanding and to taking that understanding and approaching it in practical ways to make the healthcare system better. There’s no one who has had more of an impact on that than our guest today Dr. Don Berwick.

Dr. Bob Wachter 

Don is truly the international leader in the fields of patient safety and health care quality. He’s the founding director of the Institute for Healthcare Improvement, which is the most influential improvement organization in health care in the world. As COVID has unfolded, I’ve been struck by the number of lessons that I learned from the safety and quality field that have now been applied to COVID. You may have heard of the Swiss cheese model, the idea that, you know, we only get it right when all the different layers come together. That’s something that was first introduced in healthcare in the field of patient safety, you know, how do medical errors happen and how do we prevent them?

Dr. Bob Wachter 

We’ve talked about the virtue of simplicity, particularly in the vaccine rollout, the importance of teamwork, the importance and increasing appreciation of the importance of equity, and social and socio-economic determinants of health. As has been often stated that your zip code has more to do with your ultimate longevity and healthcare outcomes than your genetic code. These are concepts that for some people are being introduced to them for the first time in COVID, but really were introduced in healthcare over the last 20 or 30 years and many of them by Don Berwick. After finishing his stint with the Institute for Healthcare Improvement, Don went to Washington for several years, where he was the administrator of the Centers for Medicare and Medicaid Services.

Dr. Bob Wachter  04:28

That’s the same organization that Andy Slavitt ran a few years ago. Don was the administrator of that organization at the time the Affordable Care Act was rolling out the first couple of years of the Obama administration. So he learned a lot about the ways of Washington, not all of the lessons were pleasant, but he was as responsible as anyone for getting the ACA, through the sausage factory. And obviously it’s been incredibly important in helping patients get the care that they need. So, in the last few years, DOD has come back to working with his institute, The institute for Healthcare Improvement, and has also remained a crucial thought leader in the areas of improving health care generally and his applied thinking to COVID.

Dr. Bob Wachter

So, he’ll be talking to us about some of the lessons of COVID, some of the lessons from his career before that, and how we think about health care improvement in the context of this pandemic. So with that, I really look forward to talking to Don Berwick, let us ring him up.

Dr. Bob Wachter 

Don Berwick, we’re thrilled to have you, thank you for being on today.

Dr. Don Berwick 

It’s my pleasure, Bob. Thank you.

Dr. Bob Wachter 

Don, you’ve had a central role in improving health care through your own work and that of your organization, you founded the Institute for Healthcare Improvement—IHI, and it’s largely from taking lessons from other industries about how to improve quality and to achieve excellence and importing them into health care. One of the key epiphanies from your work, at least for me was that it wasn’t just about the excellence of the individual clinician, whether it was a doctor or nurse, pharmacist. It was also about how well the system works. How important was this concept to you? And how did you address the messaging since most people probably thought that bad outcomes or medical errors were the result of flawed human beings.

Dr. Don Berwick  06:20

And that’s the that’s how I was trained that excellence came from heroism and dedication and professionalism and effort. And that when things went wrong, somebody let it down. And sometimes that happens, there are people who shouldn’t be doctors or who were doing things that are miscreants of some form. But almost everything that you want to make better is not made better by heroism, that that’s what I began to learn. The whole idea is to develop a system in which average people can perform spectacularly. And that requires designs around them that are highly supportive and help people get what they need.

Dr. Don Berwick 

It’s also important to have an external focus, equality in the modern world is not defined through the eyes of the professionals defined through the eyes of the beneficiary, the patient, family community, and that whole externalization the definition is a very, very important idea. It was a change, it was a change for me, you know, I spent many nights up in my 36 on 12 of you know, training agenda, training era’s thinking that if I just did if I just did everything right, it would come out, right. And that just that isn’t true, it isn’t true.

Dr. Don Berwick

And Bob, you were there ahead of most people, yourself, as you conceived of what it would be like to develop the hospitalist community. You were a systems thinker at that, at that point. And it is disruptive, but it’s also a relief, because to be a doctor or nurse or pharmacist and believe that if you, you know, everything depends on you being perfect. That’s a formula for a pretty sad and unsuccessful life.

Dr. Bob Wachter 

Yeah, I remember having read some of your work in the mid to late 90s, and then walking out my office into my hospital. And it almost felt like I was wearing new glasses, you know, all of the flaws. They were just everywhere. And this is arguably one of the best hospitals in the world. And yet, so many things went wrong. And it became obvious that if you were dependent on people being perfect if that’s your safety system, that’s a cruel joke, not only on the patients, but on the clinicians themselves. It just can’t work.

Dr. Don Berwick  08:20

The softer side of it I also believe is that people are trying they want to be Dr. W. Edwards Deming used to say, he used to say trying harder is the worst plan. But he also said that everyone, almost everyone wants to be proud of their work. They want to feel good about what they’ve done. And so you can you can harness energy and intelligence and perceptions and efforts. It’s there. It’s there for the asking, but not through exhortation, or blame. It’s done by invitation to change work together.

Dr. Bob Wachter 

Why was healthcare so late to this understanding? You mentioned that you didn’t invent a lot of these techniques, they were already well known in other industries.

Dr. Don Berwick 

In those days, yeah, I think healthcare has gone on and done a lot of pioneering work about systems. But in those days, it was imported. I don’t know, it’s been canonical to say that it’s the three industries that really resisted modern approaches to making things better have been education, healthcare and government. And it’s in those three I don’t know, in in health care, one of the culprits is fragmentation. Just the whole thing, the way the whole thing got set up with highly separate disciplines, financial systems that encourage a very local thinking, we cut it into more and more pieces and you don’t get you just don’t get excellence from pieces, you get excellence from connections.

Dr. Don Berwick 

And it’s also hard, you know, healthcare is quite complicated. And, you know, you can’t just take you know, things you learn by putting together a good computer or a good toaster and say, Okay, let’s now put that in healthcare. No, no, no, there have to be a lot of adaptations. Also tensions and emotions are very high in healthcare, this is something people care deeply about. And so even as simple a thing as recognizing when something goes wrong, has an affective, emotional, super ego component to it, it’s very hard to deal with, if you actually believe it’s your fault. And then it’s hard. It’s hard to say things go wrong, even if they are. So opening eyes, which you’ve done brilliantly in your work, Bob, is a threshold, it’s a little hard to cross in healthcare.

Dr. Bob Wachter  10:26

You mentioned the Institute of Medicine report on medical mistakes, which came out in late 1999. It was really this, it was sort of the beginning of the modern patient safety era. And it’s some except the beginning of the modern improvement era where people kind of got the idea that it’s mostly about systems. One of the things that was most distinctive about that report was an analogy. I don’t know if you were the source of it, or someone else in the group. But here it came out and it said 44,000 to 98,000 people are dying a year from medical mistakes. And that might have made it to page seven in the newspapers.

Dr. Bob Wachter 

Back then with these things called newspapers, but then it went on and said that would be the equivalent of a jumbo jet crashing every day. Where did that come from? And why was it so important to get the communication right, we’ll start making some connections to COVID in a second. But I have in mind, the relatively poor job we’ve done in communicating some complicated things over the past year. So that seemed like a really impressive analogy that really turned things quite a bit.

Dr. Don Berwick 

It was frightening, least serendipitous. But you’re right, the story, the way the story gets told matters a ton. So Janet Corrigan deserves credit I think for the 44,000-98,000 calculation, which he did late one evening, just before the report came out, actually, before the report got put into final form, based on the […] in Utah study in the Harvard medical practice study. And those were very charismatic numbers, tragic charismatic numbers, I think it was Lucian Leape, who offered the analogy to the jumbo jet crashes, but you are right, you know, this, it’s not enough just to have the facts, they have to put in a form that people can notice and remember.

Dr. Bob Wachter  12:20

Let’s talk about one more part of your past history before we move on to COVID. So, early, in the days of the Obama administration, you were asked to become the administrator of CMS—Center for Medicare and Medicaid Services—just make the point that Andy Slavitt, who normally hosts his podcasts, that was his former job as well in the government. So you took it, it struck me that, you know, having run IHI for a long time, this was very, very different than anything you’d ever done before. So what did you think you were getting yourself into? And what were the lessons over the next 18 months that you learned that you didn’t really understand?

Dr. Don Berwick 

It was a complete surprise, I got a call from Senator Tom Daschle, who at the time was going to be the secretary designate, and he and I had had some interactions around what could be possible if government got organized around quality and improvement as a fundamental strategic agenda. And then the Affordable Care Act would began to be boring. And he asked if I would accept a nomination from the president to head CMS, which I thought hard about and decided to do the scale, the possibility of scaling improvement. But with such large lever was very attractive. I’ve always felt that we’re four tests to any policy change. One is can we get toward health care as a human right? Can we improve quality? Can we prove the social determinants of health and illness?

Dr. Don Berwick 

And can we reduce costs and the methods that I become familiar with and use did I tried thought could work at scale was quite thrilling. And of course, the Affordable Care Act offered traction on the first which is moving toward healthcare as human rights. So it was a stunningly interesting opportunity for me. And I felt very privileged. I was a little concerned about moving from a small organization to such a large one. And I knew that the atmosphere would be very charged politically as indeed it was. It was the best experience of my professional life overall, although I must say it was difficult politically, you know, the politics were hard, but the opportunities were massive, the energy and the government to try to get healthcare where it should be was probably at a level. I mean, I’ve been there before.

Dr. Don Berwick  14:37

And what I discovered to my joy was the workforce, there were 5,500 people working in CMS, who had not had a fully empowered administrator, everyone else had been acting. I was not acting. I was recess appointee, but I was full administrator for six years. And I went there and just began talking about the Triple Aim—better care, better health and lower cost—as the goals that the organization I said, would be a major force in a trustworthy partner for the continual improvement of health and health care for all Americans, that was the strap line. And I, you know, I just told him thought was the potential. And then the Affordable Care Act had so many tools in it to help make care better.

Dr. Don Berwick 

Most people think of it primarily as a coverage law, it is, there are 10 titles, and I’d say about five of them are about coverage, but the other five are about quality. So there’s a lot in there to make care better. And it was just so resonant. It’s so exciting to discover this workforce that just, they just wanted to help. It was amazing experience. For me, my learning curve is vertical, learning how to prepare regulation or to guide, you know, sub regulatory guidance document or to work with the white house or work with Congress was all is something I had to learn.

Dr. Don Berwick 

But I had to per backup and the support was phenomenal. So it was a wonderful experience. Bob, I wish I could have stayed. But the appointment was a recess appointment. And at that point, Congress was so fractionated that there was no way that we’re going to confirm any significant Obama appointment. But it was quite an amazing experience.

Dr. Bob Wachter  16:15

It’s wonderful to hear you say that I have to say there were times where I watched you in a congressional hearing, for example, and just felt terrible for you knowing how amazing an individual you are, and to see the partisanship and the way you were grilled with silly, you know, everything about scoring points have nothing to do with substance. How did you deal with that?

Dr. Don Berwick 

A couple ways. One is you what you couldn’t see is the amount of support I had for the administration and from my staff and others who were saying, Okay, Senator, such as such is going to ask you this, here’s some background, I was very well supported and prepared, I cared deeply about the work and the job. And that’s where the meaning is. And you’re right, a lot of the very partisan attacks were to say the least ill-informed of something they were sometimes they were lies, sometimes they were just total misconceptions. And I, I dealt with the like, deal with the rain, you know, it’s falling. So that’s going to happen.

Dr. Don Berwick

But Bob, you know, the amount, what you’ve got what I got to do in that, in that position to helping people in institutions finally get to homes where instead of institutional care to work on really important efforts and patient safety to try to get 20 million people health coverage to establish, you know, a whole culture within the organization, in which the self-perception was of a public health agency, something where they really could help and work that was, it made the noise sort of go away, and I wasn’t, I didn’t welcome the attacks, they were deeply ill informed. And one of the disappointments was the lack of an ability at that level of polarization to actually have a civil, respectful dialogue. You know, that simply wasn’t what people seem to be interested in, at least in the opposition at that time.

Dr. Bob Wachter  18:00

Yeah. hasn’t gotten better is my, just my perception. So let’s pick it to COVID. Let’s start sort of at 35,000 feet, and then we’ll drill down, what are the lessons from the past year that you take away from COVID that, you know, maybe things that you didn’t fully understand, or that have really become crystal clear in the past year to all of us?

Dr. Don Berwick 

I guess, on the positive side, we’ve learned we can move very fast, the pace of change in delivery has been stunning and good. And I think, you know, in this industry, it doesn’t make change like that, that fast that well, here we are moving knowledge around the planet at a pace I’ve never seen before. And I think committing to a kind of form of standardization that I also value, which is we instead of everybody saying I do it my way, you know, this is my autonomy people are doing are being curious about who knows something I don’t know, and what have they learned in Italy or Wuhan or wherever that I could use here in my town. So I think that the move towards science based, evidence-based care has been vibrant in in the professions.

Dr. Don Berwick  19:08

It hasn’t been in the White House to say the least. But that’s going to change now. But I think we made COVID told us facts help facts matter. I think that I personally believe the move to virtual care is very good. I actually would differ in all respects to you, Bob, given your scholarship on this, but I you know, we’ve talked about digital care, virtual care for a long time, not had much of it. Now we have a ton of it. And I think it’s going okay; I think we are going to have to grapple with some issues around cost. I think that parity pricing for example, needs to be very strongly reconsidered that’s a good short-term solution. But what is the proper price and cost structure for virtual care system?

Dr. Don Berwick  19:47

I’ve had three medical encounters myself in the past few weeks, nothing serious but stuff I needed and it was all virtual, all perfect, all immediate. I got team-based care was great. So that’s a good lesson and embedded in that is something we haven’t really looked at yet, which I’d love to hear your thoughts about Bob and that is the care we didn’t need, that is people didn’t show up for stuff they did need, but they also didn’t show up for stuff that it turns out, they didn’t need it all. And if we’re smart, we’ll be able to get overused. On the downside what, we weren’t prepared, we were rated as prepared as a nation, the highest rating possible from the UN rating, preparedness rating scores of the mid part of the decade.

Dr. Don Berwick  20:26

But, man, we were caught on our heels, not to not even to mention the poor execution in the prior administration. So we’re gonna have to reconsider what preparedness means. And hopefully learn from this. Equity is the big thing here, which is people of color, communities that are isolated, incarcerated people, people of disadvantaged got hit a heck of a lot harder. Part of our action is well, duh, you know, it’s been going on for centuries COVID just makes it more evident, it’s been there, but maybe this is a time when we’re gonna finally face the music on this foot or to do something about it. And so it’s a terrible, terrible need, that we need that reminder. But we’ve got the reminder, one area that I know is not popular politically, but I care a lot about criminal justice, if you watch what’s been happening in our prisons and jails, it is terrible, and remediable.

Dr. Don Berwick  21:21

And maybe we’ll wake up to that. So there’s a reckoning. And then last is the workforce where we kind of let it down. You know, obviously, lack of the N95 masks and equipment, that’s part of it. But it’s much, much deeper issue here about what the workforce is who they are. And a lot of vulnerable people in health care who don’t happen to have MDF to their names, […] and getting paid in some cases minimum wage. They’re the workforce too. And they were left exposed in a way that we really can’t allow in the future. So some good news, a lot of open questions and some things we have to reckon with.

Dr. Bob Wachter  21:58

Yeah. Do you think the issue of inequity is have you focused a lot on this over the decades? Is it exposed now? Because COVID was so visible? Or is it exposed because of the confluence of George Floyd and similar acts at the same time COVID hit, in some ways, it’s a coincidence of these two pillars hitting at the same time?

Dr. Don Berwick  22:17

Yeah, you could think of other guests you could have that would know more than me about it. I think the George Floyd murder and Breonna Taylor and the others, they did make a difference. There was something about that timing and the Black Lives Matter movement that hit a spot where we got more alerted, more aware, you know, those of us in the scholarship of health were aware of for a long, long time, but the public is, I think, was reminded the data that the numbers and COVID are so asymmetric, that it also makes it hard to ignore for, especially for African Americans to Latinx, at some point. It’s to some degree and also, very importantly, Native Americans who really, really took they’re having a very hard time. So you’re right the numbers […]. We’ll see if this does outlast the pandemic, I hope it does.

Dr. Don Berwick  23:07

I hope we’re going to say now we’re going to invest and as I said, the science is there I often work lecture and quote from Sir Michael Marmot, amazing book, which I’d recommend to any of your listeners. The book, “The Health Gap” which was a turning point book for me period in 2015, and Marmot’s book, “The Health Gap” it digested really a century of research on disparities. And then org made it orderly like, well, what is this? What’s doing this and he has his categories, and it’s the education and experience with young children. It’s the vibrancy of education systems, its conditions in the workplace, especially generous conditions of minimum wage. So people have incomes they can really not just live on but thrive on. It’s eldercare, what society’s systematic about it and its community infrastructures like transportation, housing, food security, criminal justice, recreation, these all matter a ton.

Dr. Don Berwick  23:59

And those are the social determinants. That’s what’s making us sick or not in COVID underlines every single one of them. So why now? I don’t know. But certainly the racial side of this has come forward. To get through it, to get into a better place, Marmot would challenge us that we have to reconsider values, there’s a sense of solidarity, community and interdependence, kind of caring for each other. That has to be foundational to working on the true causes of illness and injury and disability and suffering. And if we can discover that among us, we stand a chance if we don’t. We don’t stand a chance.

Dr. Bob Wachter  24:53

As you think of the stage we’re at now with COVID, the vaccines being out and you see the way that that has been playing out. What’s your take on it? Is it just the sort of last vestiges of the competence problem under the last administration? Do you think we’re gonna get on top of the vaccine issue?

Dr. Don Berwick  25:08

Well, the level of neglect in competence, even sabotage of what would have been the proper kind of public health 101 response when the pandemic began, that is very damaging, it’s not going to the damage is not going to go away immediately. So a lot of this, I still think has to do with the fact of how high and dry we were left as a nation with respect to vaccines, testing, surveillance. We have to see what the deck of card with the hand was dealt, I would say, well, I’m not just pleased but quite thrilled by the people that President Biden appears to have drawn around him to try to solve the problem, not least of which is Andy Slavitt himself.

Dr. Don Berwick  25:50

But if you look at the roster of people that he’s brought together to try to work on it, it’s good, it’s really good. Science backed in the proper position, he’s elevated the presidential science advisor position itself to a cabinet level, which has never been done before. That’s spectacularly good idea. I think the logistics of the vaccines as we try to work out the state federal relationships and supply chain issues. That’s very hard work. But I think I see the people in place who can do that. Good leadership now for CDC and probably CDC land will be honored instead of criticized and will rejoin the world community because there’s a lot of help and advice and guidance we can get by learning from other countries even as we help them.

Dr. Don Berwick  26:34

So I’m optimistic the results aren’t in hand yet, we still have ways to go. And this virus is for 15 genes, it’s pretty darn clever. I’ll tell you this thing. It’s formidable enemy. And, you know, I’m worried now about what could happen to […] and but now with science back in the front seat, and with the kind of competence of the people I see assembled, I think we’ve this, we will succeed, we will succeed. And I worry a lot about other countries in especially the global south who don’t have the resources we’ve got to throw at this.

Dr. Don Berwick  27:12

And I hope this administration is able to find the political leverage and political will to say, yes, we need to save our country. But we live in a world in which we’re interdependent and have responsibilities to so I think our job is also to make sure that vaccines become available to those countries and people who are going to need some help to get them for example. So I hope that’s on table.

Dr. Bob Wachter  27:36

Yeah. In a recent New Yorker article, you were quoted as saying “command and control is never going to work in America” an interesting comment in that there’s a lot of criticism for the lack of federal control and coordination for the last four years. So how do you see that balance between what the federal response needs to be but also that comment about command and control?

Dr. Don Berwick  27:59

Well, it’s like anything in quality, you can have wonderful concepts. And we do need those. We need a CDC that’s strong. I’m not sure I’d say the word would be commanding, but have gravitas and expertise and be trusted, we need a president who says let’s take this hill, you do need leadership, we absolutely need it. And we’ve lacked it to our terrible disadvantage. But as you know, in our world, Bob, in the quality world, when you finally get to the last mile, where people have to use the knowledge and be supported to do that, it’s a locale-by-locale thing to do, the way we’ll get 100% vaccinations country will come down to a granularity, individual communities that have they feel empowered, they feel able to be creative and to do their work.

Dr. Don Berwick  28:41

And that’s sort of what I meant by that, quote, it meant, you know, this is an enlistment and engagement problem as much as it is a get be smart enough to have the right answer problem. So it’s really it’s a booth and, and yes, I’d say if we if I had to say what we lacked most in the prior four years, and in the COVID, first year in the pandemic, it was leadership, it was direction, leadership priorities. Take that hill.

Dr. Bob Wachter  29:08

Yeah. I’m gonna ask you about two, two things we’ve mentioned already. But I’d love you to project how it’s going to go in the future. We’ve talked about health inequities, and social determinants of health. And as you said, this is a moment where they’re receiving the attention that they should have always received, but really are receiving it now. And the second is preparedness in the public health system. And in both cases, it feels like everybody’s saying the right thing.

Dr. Bob Wachter  29:33

But I wonder about whether we really will turn the battleship around. There are some forces in both accounts that make it make it hard to do, hard to resource them appropriately in case of preparedness hard to sustain it to piggybank that often gets rated when times are tight. So how do you think about both of those issues? And are you hopeful about the future for them or you think that this may be sort of during the pandemic? Sure, sure, sure, but after the pandemic goes away, we may begin to neglect them again.

Dr. Don Berwick  30:00

I try to be optimistic and stay hopeful with respect to inequity, disparities, which aren’t just in health, but they are in health. I served on the Biden-Sanders Unity Task Force when President Biden locked up the nomination, he and Bernie Sanders had an agreement to set up six task forces to come up with consensus, policy statements in six areas—immigration, environment, criminal justice, education, economy and healthcare. And Senator Sanders appointed three and Biden five to each of those. So I was a Sanders appointee to the healthcare unity task force, which meant I spent about two months in very detailed and extensive efforts to try to reconcile things, we came together around a recommendation that I deeply believe in, which is that the equity issues in this country need to be dealt with what I call an all of government approach.

Dr. Don Berwick  30:52

Whether a young vulnerable kid is going to live a full life or an impoverished family’s going to find a way out of poverty. It doesn’t belong to any depart, there’s no single effort. It’s a shared network of activities from the government’s point of view. And therefore we urge that, then President Elect, President Biden might consider a sort of Oval Office initiative. And all of government issues lead from the White House to say to every single cabinet department and all the willing private sector stakeholders, let’s close these gaps. We’re going to do this together. And everyone’s got a role to play, no bystanders, and we’re going to end up in with a nation with no hungry child, no, no, no family without home, no incarcerated person without a route back to society. You know what, let’s pick some of these social determinants and work on them.

Dr. Don Berwick  31:46

I still believe that’s the right thing to do. I’m sure President Biden is a very busy man; he’s got a lot on the table. But I hope that maybe maybe maybe we’ll see a sort of White House led effort around equity that will be multiyear and continue even from this administration to another. If that happened, I would be very hopeful. We have the resources; we’re spending more on equity now than we would have to if we actually came together and made it a national goal with respect..

Dr. Bob Wachter  32:12

The public, whether the public health system and preparedness

Dr. Don Berwick  32:15

Yeah, it’s sort of harder because we have so much to do now that to be truly prepared for any threat is going to be really hard. That’s an engineering problem. That’s can we become together as a country and figure out what the clever way to be ready, ready not just to get rid of COVID but ready for the next virus, ready for the grid to go down, ready for bioterrorism ready for a cyber-attack. There’s a plenty of documentation I chaired a national academy committee, workshop series, the year before COVID on preparedness our finding was we’re not prepared. But we can do it. We have some actually great thinking going on in this country about preparedness.

Dr. Don Berwick  32:56

And that’s going to be it’s going to take some really serious design work. It’s very hard, technically possible. We have good models so I guess I’m optimistic about that too. And we could do both. But you know, Bob, if we don’t find a way to close these enormous gaps in well-being in our country from the haves to the have nots from the richest to the poorest. It’s going to be really hard to get the rest of the work done so that’s the thing that’s on my mind most right now.

Dr. Bob Wachter  33:29

How’s this past year been for you, Don? You have  a big family and children, grandchildren. How have you dealt with it personally and what are you most looking forward to as we pull ourselves out of this thing?

Dr. Don Berwick  33:40

Hugging my grandchildren is what I’m looking forward to. You know, it’s been the same presses for you I feel so lucky we are, how lucky could I be you know I’m safe in a home I don’t have to worry about food or income and my wife with me. We were living in the mountains so we have a weekend home in New Hampshire we moved here and I’ve been here for a year because it’s a safe, very safe place to be the price of that personally of course has been much less contact with my four children and eight grandchildren and I miss it desperately but I understand we have to do every time I get to be with a friend now because circumstances allow I feel specially lucky.

Dr. Don Berwick  34:23

So value intimacy now how could we have taken it so much for granted? You know, sometimes I wonder. But I see the suffering. I see the fear out there that many many people not as lucky as me and that that eats away at me. I’ll be glad when this thing is gone. I’m so glad to have a competent white house now. I think that’s gonna make a difference. And in terms of the personal challenges, it’s the same ones we all face. How do you stay healthy in this get out every day and exercise try to do what I can and read a lot right a lot. work has been great. The Justice we’ve been able to shift healthcare largely virtual. I’m having more meetings. I’m involved in more active So I’m on more committees than ever before. So I have no complaints at all about that. So I hope you’re well too, Bob, I know it’s, it’s a hard time for everyone.

Dr. Bob Wachter  35:09

Same experience hard, but very lucky. And the work seems almost never has had been more meaningful. And interesting, really, you know, just think about all the dimensions of this problem. It’s feels like I got a PhD in COVID over the past year, all of if you if you came at this as a clinician or as a social worker, or as a politician or an economist, you had to learn about all of these other disciplines to make any sense of it. So that part’s been gratifying. But I’ll be thrilled when this thing is over.

Dr. Don Berwick  35:39

Your voice in this tough time has been very valuable, widely spoken out. So well. And so hopefully, thank you.

Dr. Bob Wachter  35:45

Well, thank you. Thank you, Don. It is always a joy to talk to you. And thank you for your work in COVID. And thank you for your work over your entire career, really more than anyone I can think of you would made the health care system better and safer and, and more humane. So I’m grateful and everybody out there should be

Dr. Don Berwick  36:03

Means a lot to me, Bob. Thank you so much.

Dr. Bob Wachter  36:18

A real thanks to Dr. Don Berwick for spending time with us I just find on just about the most thoughtful person I have had the luck to, to encounter and to work with in health care. And one of the most deeply moral people I have met, it’s been fascinating over the last 10 or 20 years. Don has recognized that just improving the health care system without improving the things that go into people’s health and many of them outside the healthcare system. Many of them relate to poverty and education and social justice and criminal justice system and all those things are absolutely crucial. And as Don recognized how important they were, it wouldn’t be in him not to jump in and try to make a difference. So I think you heard that in the interview. I learned a lot from talking to Don and I hope you enjoyed it as well.

Dr. Bob Wachter  37:08

We have some more fantastic episodes coming up on IN THE BUBBLE. We will do another episode of Safe or Not Safe. Something we’ve done several times before with our guest epidemiologist Caitlin Rivers from Johns Hopkins and Farzad Mostashari. This will be—Safe or Not Safe: Vaccine Edition—where we spend a lot of our time talking about different situations. But when some people are vaccinated, some people aren’t Is it safe to get a haircut? Is it safe to see the dentist? Is it safe for grandparents to hug their grandchildren and particularly when some are vaccinated, some are not so it’s really going to be a fascinating episode. I hope you have a chance to tune in.

Dr. Bob Wachter  37:49

After that we have a couple of other wonderful episodes coming up, Peter Hotez, who is one of the leading vaccine ologists in the world. Peter is a professor at Baylor will come on and talk to us about vaccines, including what we’ve learned about the Pfizer and Moderna, but also the new vaccines that are coming down the pike, we should have more of them approved in the next few weeks. And also this extraordinary high stakes race that we’re in between vaccines and variants. Peter has been all over the media talking about that, and we have a chance to chat with him for a while on the show and in the next week or so. So you will enjoy that.

Dr. Bob Wachter  38:27

And finally, a really wonderful episode with the Platt family and the Platt family is this extraordinary family of people that have made a huge impact in the arts, particularly in the world of theater, and movies. Marc Platt, the dad has been nominated for a couple of Academy Awards, produced LaLa Land, produced Wicked on Broadway. His two sons, Jonah and Ben are prominent actors. Ben has won the Tony Award for his performance in Dear Evan Hansen is an extraordinarily accomplished and prominent singer, and has performed both on Broadway and in movies. And Jonah has had major theater performances as well.

Dr. Bob Wachter  39:11

So we’ll hear from them about what COVID has done to the arts, and some of the backflips that the arts have had to do to try to keep some things running including filming some movies during the pandemic, you’ll hear about how they’ve managed to do that. So really interesting episode as we talk about the impact of COVID on an important part of all of our lives and that is the arts and theater and movies. Lots of great stuff coming up some other great shows after that so please continue to tune in until then stay safe and look forward to speaking with you soon.

CREDITS

We’re a production of Lemonada Media. Kryssy Pease and Alex McOwen produced our show. Our mix is by Ivan Kuraev. Jessica Cordova Kramer and Stephanie Wittels Wachs executive produced the show. Our theme was composed by Dan Molad and Oliver Hill and additional music by Ivan Kuraev. You can find out more about our show on social media at @InTheBubblePod. Until next time, stay safe and stay sane. Thanks so much for listening.