how war democrats going to entice enough republicans to come over to the democrats and that is a tough hurdle. >> i want to ask you about your

suggestions for reform but first, i now know if you have looked at other countries in the world but is there such a thing, does the filibustered system around the world and if not, why not? >> i don't know enough as they should about legislatures and there are some legislations that have passed that have these types legislators keep them for the same reason as taxes, they selectively use them. i know california has one to pass a budget. where they find them? we find legislatures that have a tough time moving. >> what do you suggest in your book for freeform, for the senate rules or do you suggest reform? >> well, we published this book, steve smith and i beckett 1997 at the heights of efforts to try to reform the filibuster. there are a number of things that could be done, all within sort of formal framework of the

rules. when we can get a process to slow lee ratchet down the number of votes required for cloture so say 60 boze the first time we try, three days later another cloture motion, 57 votes and 54 votes and then 51 votes so over a period you get down to majority rule eventually and that i think would preserve the minority's ability to debate and try to change minds but also preserve the majority civility to haksel that is one possibility. the other possibilities to cut down the number of opportunities that are debatable than the senate. right now you can filibuster the motion to proceed to a bill. they don't have the bill on the floors of that filibuster keeps those of the floral together. that doesn't need to be a filibuster. their three motions to go to a concert with the house. that is crazy. even one would be enough if not none. they should be able to conference. you can still filibuster the

conference bill in the end. other things to do? this ayn periodically actually even though we tend not to recognize the create for themselves what are known as fast-track procedures. we see it on budget bills amo wykoff reconciliation. the war powers act has a filibuster. entire regulatory bill has filibuster band, environment, energy all sorts of issues are embedded in the statues that have filibuster bands of the question is could this senate selectively create some of those to apply to judicial nominations could they apply to foreign spending? could they apply to health care? episodes like that. >> i couldn't leave here-- what is the so-called nuclear option? >> okay, the republicans' 2005 were very frustrated with democrats filibustering judicial nomination so they came up with a series of rulings they were going to try.

some of which have been tried in the past but they were willing to not change the rules formally but we interpret the rules which is why it was neutral. ute cange re-interpret the rules to say that they mean something they don't mean so they said look we are going to take the cloture rule and in a series of steps by majority vote interpreted to mean he can't filibuster judicial nominations and democrats said look at the letter of the rule. it applies to motions, applies to nominations. through this series of steps they are going to do away with filibusters by majority vote. that was neutral because democrats said if we do that we are going to blow up every pridgeon site. in the end did republicans have 51 votes to go nuclear? aye unskeptical landed that the thing was the real when democrats and republicans got together and said wait, we all benefit from a filibuster we don't want to be so rash.

>> what is wrong with legislation passing, everything passing the senate with 51 votes? >> the defense of the filibuster is the senate was intended to be different and even if it wasn't really intended to be different that the note was supposed to be a smaller body and supposed to have staggered terms that are supposed to be insulated a bit from public opinion so the argument against 51 votes is to say look we need time to slow down rash majorities and majorities can be wrong. that is really the best i think of the arguments into say look, the longer debate goes on sometimes it changes public opinion. >> "politics or principle," filibustering in the united states senate. to lose your co-author? >> stephen smith. >> and were in george washington university, what do you do there? >> professor republic science here george washington. >> at brookings? >> is senior fellow at brookings

were but the filibuster buchan still toil away and talk about commercial politics. >> atul gawande shows how something as simple as a checklist can reduce complications in surgery's. he appeared on c-span's washington journal. this is an hour. >> host: we are going to introduce you to our guests, dr. atul gawande who is a surgeon and also inside the debate over public policy on health care for a decade and a half now. he has in the pastored number of books including a surgeon's notes on performance complications a surgeon's notes on imperfect science and his latest book is called "the checklist manifesto," how to get things right. we will talk to him this morning. during the clinton years he served as senior health policy adviser for the campaign and during the white house 9293 and you can read him on a fairly regular basis in "the new yorker" sarah thanks for being

here. when did you make the decision in addition to practicing would also be involved in health care policy? >> guest: it was, i tried to avoid being a doctor for a while. the son of two indian doctors who naturally arby going to, a doctor yourself and i wanted to push against my own inevitable path and during a time i did in masters and politics and philosophy and then came to washington and worked for jim cooper, a conservative democrat from tennessee. i worked on al gore campaign for the president back in 88 and then in 92, came back from the medical school which became the thing i keep falling back to because i didn't like depending on working for other people to figure out how to, what i really think and how we can contribute. >> host: let's get to sort of the 30,000-foot field of health care in the united states. willen to give this your view of what kind of health care the

american public has right now and then let's talk about some of the other side of that, how much it costs us to get it in how many people don't have access. >> guest: in many ways we have amazing cutting-edge health care and we have access to one believable technologies and unbelievably well trained people, and at the same time you can find some really abysmal health care, with lack of access in poor communities right within our own cities and neighborhoods. and that stark contrast is a major problem we are struggling with. i would say the second major problem we are struggling with is the pieces don't fit together for any of us. the thing we are struggling with and health reform, we have focused a lot on the insurance hassles and the insurance organization but we have missed the point that the deepest trouble here is with the complexity. science is given us 13,000

diagnoses that we act now identified as problems with the human body. 13,000 ways the human body can sale. we came out last entry was 6,000 drugs, 4,000 surgical procedures and we are trying to deploy its city by city of somalia at the right time and place for people and we are having a hard time. >> host: is there a big fix that is possible? >> guest: this is the stark difference between coverage and the problems of cost and quality. coverage, providing insurance to the white population of people who were missing it, 45 million, we have ted solutions on the shelf for 30 years now. is it public coverage, is that private coverage but whichever way there is a solution. when it comes to quality and cost this is more a management problem. you never fix the dolleck once and we have this great frustration about the health care bill that where is the master plan for solving cost 1

cent for all? and, the reality is that in order to organize care more effectively we know we have some fundamental problems. doctors don't work together. we are fragmented and the incentives in the system where we are paid piecemeal, fee-for-service have led to piecemeal care with overtreatment in certain sectors, under treatment of problems where we have primary care, mental health care gaps and mistreatment, mistakes in care that happen all too frequently. host: so you have had some time in there, some differences but the broad areas of agreement between the house and senate bills. have you come to a conclusion about what they are not what is moving along the track at capitol hill taking us in a new direction? >> guest: you know, my litmus test is are their tools here that we as clinicians working with patients would be able to use to make care better in our

local communities? the coverage parts are ones that will mean that that 15% of our patients to come in the door and don't have coverage, that is a constant clinical battle. i am a cancer surgeon. i spent years with struggling with what we are going to do about chemotherapy or radiation treatments for people who could afford them and when massachusetts plastics plant it disappeared as an issue. bee still have our struggles with some cost aspects for the patients but that coverage part is there. the second part though is we really have not as a community clinicians work on how do we make care more consistent, more reliable and less wasteful and for the first time i am hearing people and our conventions, in our meetings in their hospital organizations trying to figure out that this bill passes there

is a lot in here to push us in the right direction. i am hearing discussions i had never heard before about what we should do about getting our costs down. >> host: we would like to invite you to take part in this conversations. many of you are involved in health care debate and we have been talking about it a lot that is the congress comes back to work and opportunity for you to get engaged once again in the discussion with our guest, dr. atul gawande. we will take your calls and you can send send e-mail and a twitter message if you would like. one last question, ask you to tell us your views about the implications of the aging baby boomer generation both on the kinds of care people will be seeking in the country's ability to pay for it? >> guest: the interesting-- we are covering 45 million people and where are we going to get the primary care doctors to help with that but the even larger issue is over the next thing 15 years the population over 65 is going to double which means the

number of breast cancer, colon cancer's and heart attacks are going to nearly double. our workforce for managing those problems is not going to get bigger and we have not been thinking through how we organize ourselves to handle a larger population of people with more complex needs and not as many people in the system. we are thinking let's hire more, hire more, spend more, spend more and i think there is every sign the can make safer higher-quality care and organize ourselves better and ways we can handle the problem without expecting 50% americans to become doctors. >> host: how does that get implemented? how does it break into the system as an idea that is that the the pawn? >> guest: let me give you a small example. asthma care, talking to a children's hospital recently and one thing they finally decided to do is organize themselves to making sure you get the right steps and they did it by implementing chuckful less, an

idea for expert. when they did half a dozen things they made sure happen for each patient, they found that you tackle things like making sure you have calls to keep the money inhalers and so one. their admission rates for asthma fell 80%. guess what their number one ribbon assorts was? asthma the missions and they found they were losing millions of dollars. under reform, for the first time you were saying experiments that say let's try to pay package, for a. egyptair for those great results rather than extra money for every time you bring a kid into the hospital and as we began doing that we are seeing hospitals talk about how to organize care so we actually become more efficient and get better results for people. it is going to be a real turn in how we think of ourselves as doctors, nurses and others working on problems but it is the kinds of experiments we have to be taking seriously.

>> host: let's get to calls. buffalo comissary, dean you are on the air. >> caller: good morning susan. what i wanted to talk to you about, susan too. senator coburn was on your show than a month to go, and he was talking about running all of these tests that he knew were not necessary, but he had-- for his liability. is that not waste, fraud and abuse? if i were to do something like that, i would be in jail and i know of their doctors that do this. i am 63. i am in the va system. they control my copd, high blood pressure and everything in it doesn't cost me a dime.

i could be on manicure, but i chose not to do it. i have been with the va since i got out of the service and 71. but, why are all these tests being run and i know it costs money? >> host: thank you dean. when that testing in how much doctors employed them has been a regular theme of yours. here is one new yorker article. however we got to the point where doctors are calling upon lots of tests that even sometimes they say are gold-plated? >> guest: your caller did hit the button on one of the issues driving the process which is our malpractice system, which is driven in ways that, so let me give you an example. headaches. one community actually try to look how many ct scans in cedar rapids, iowa they were doing. they found they did 50,000 ct scans for a population of 300,000 people in a year.

all of this know this is a necessary and 10,000 of them were for head ct scans. only a tiny number ended up turning up in that morality. mini which is for ordinary headaches. some of it was fear of malpractice suits and even more significant part of it is that we have not really established what it is our process is, our appropriate guideline for care for handling the headache so that we can do with the right way so we have tens of thousands of unnecessary ct scans that actually are causing more harm because we have radiation exposure and we are seeing increases in cancer likely to appear over the next ten to 15 years, said the situation is not going to be sold entirely by malpractice reforms and one frustration is not saying that as part of the component of this package, but it is out of the leading communities to begin looking at their numbers in

finding ways to drive down their use of these gantz and we found communities that are doing it even without malpractice changes, are able to drive higher-quality lower cost geren began a overtreatment. >> host: is malpractice the primary driver or the scenario you talked about early, that people make money on the tests? >> guest: i wrote an article for "the new yorker" in june were inducted to communities in texas where there was malpractice reform and after substantial malpractice reform there has not been a damping down of the cost and then when you compare the two communities, to counties on the border that had similar public health populations, they had one community that's than twice as much money for health care sphere of there and what you saw was business incentives and home care agencies and others that have cropped up to take a damage of the insurance system and you saw really fragmented

disorganized care, where doctors had not organized to make sure we are taking care of the good primary-care up front, avoiding overtesting in even more if you saw two to three times as much surgery in the population. as a surgeon, we really are doing surgery just to protect ourselves from malpractice suits. winstead you have gray zones. you have the patient with a gallbladder attack. do you watch to see if there are more rdu take up the gallbladder which the first attack? the textbooks say you wait but when you make no money watching and he makes some money, some dollars by doing the operation there's that tension between the business need and the patient needed and we see it playing out in different ways across communities. hosts the janesville, wisconsin is next, scott on our independent line. >> caller: good morning. i have a question about efficiency and automation.

is it possible that because, i know that there is a lot of advancements in surgery and things, and is it possible that we could have a loss of jobs because our medical system kit selee vision, like what happened in industry of working-class people, fabrics, automotive, woods and things like that? because, is that a possibility that that could happen? >> guest: it is. it is actually, the move towards their being more efficient, we can have lots of people who are digging ditches and we can hire more people to dig ditches and fill them back up again but if they are not providing value than it actually doesn't help

our economy and in a similar way in health care, if we are moving more and more the labor force into that sector of our economy it means we are not able to grow many other parts of our economies of the places we are going, we are far from a world where we are about to-- one of the striking things is in this recession health care is one industry where it has continued to grow in employment. we have expanded spending in health care over 130% over the last ten years and a lot of that has been the middlemen in the system without necessarily giving you more time with their doctor. that is one of the bizarre parts here. it is why in my unexpected leave for me i end up writing a book about checklists and health care because solving these problems is really about saying we are going to be much more disciplined and organized about how we provide care. i designed with my teammates surgical checklist with the world health organization that

is a two minute check to make sure there are 19 things to get right in every operation and i was stunned to see into out of three cases before we brought it in patients had one of those key life saving steps missing. we then implemented it in eight hospitals. we saw in a thousand patients the reduce the complication rates by more than 35% in the savings from this kind of program which we depletive need cities, is massively more than anything we have invested in it, but we don't work on these kinds of organizational problems and medicine probably because the incentives have not been there and partly because we as experts don't think of these as problems to work on. >> host: the next question is from illinois, and the on our republican line. >> caller: hi susan. every caller seems like call suppa gice hogue you were feeling this morning or how you were doing this morning. you answered once at 6:00 in the

morning and you don't have to answer it anymore. it is crazy colors do that. anyway, the reason we have got the best health care in the world is because we spend so much on it and we have spent at the wrong way. what we should do is, we need to specialize, when i need a gallon of milk i know where to buy a gallon of milk it the best price, the best value for my money but when i break my leg, i don't know, where's the best value what can go for my money? what we need to do is promote the capitalism in health care, and get it back come and get it away from the insurance model. i am so tired of everybody saying we need to have coverage. we don't need the coverage. what we need to do is to be able to know where to go to buy the quality care at the best price for our money. >> host: let me interrupt for a second to put her on the edges of your analogy here.

with the milk you know you want milk but you don't necessarily know you have broken your leg when you have fallen so there's a first that been here which is getting a diagnosis. how does that work in your process? >> caller: exactly. we have got the internet. we can go to-- i am actually writing a book on how to fix all of this and i don't know how to fix the health care system in this country. completely opposite from what they are doing in congress, to unleash the specialization-- several economic principles, specialization, supply and demand. we need to make supply, have health care professionals much greater, train them in free or nearly free clinics where people are means tested in habit co-pay. electronic medical records for every american. several points and two the till

the going to here. >> host: let's pick it up with what you'd have put on the table so far. thanks for the call. >> guest: he is on to something that is right. we have a failure to be able to really be transparent about where the choices are in madison and one of the fascinating things to me about the bill is its effort to create these kinds of phinias for this. i think that's the real choice and competition here is that we want organizations that are willing to be accountable for the false bannack your health care and applying it well. whether it is really these vertically integrated marbles of health care that we are seeing in places like the mayo clinic. i am part of the system that is trying to move in this direction, partners healthcare system in parson and what the systems are about as being able to say to people, we will provide the full package of services even the complications,

and we will work to ensure their higher-quality, lower costs and the bill offers a world where we have competing insurers in exchanges that are driving in the direction of giving people more choices like these. but the second part of it is that we have not been willing to be as transparent about their results or to work on these organizational problems, and so my sense of it here it is, we want the desire to sweep away the old system, drop it on anyone and everyone that the reality is we have to build from where we are today and it is taking steps forward including the ideas of really driving our reform process in the direction we have got. half of the 2000 bill was about coverage and insurance plans but the other half are experiments in changing the way we pay for health care and how we measure

and make health care more transparent. >> host: dr. gawande's latest book "the checklist manifesto" is available anyplace to buy books and you have a web site. >> guest: www.gawande.com. host: what will people find there? >> guest: two things. some information of the books but also research we do on programs like the health care organization where we are developing ways and applying them through surgery, in child books and dionne. >> host: new jersey on the new jersey shore, patricia. >> caller: hi susan nan dr. gawande. i am a retired nurse practitioner. i just wanted to discuss two issues that i find for reforming the health care system. and one of them is, you had a guest on susan, i don't know if

you were the moderator at the time, but some months ago it was either from johns hopkins or the mayo clinic, and he confessed that there were no standards of practice for high-risk surgery's in hospitals, and that astounded me, because i feel that that is really you know, it is a tremendous waste regarding reform. i think that it is necessary to have standards of practice in hospitals where they perform high-risk surgeries and this is the fault of the physician in the hospitals, that they should pay out their patient who suffered, even the family, the patient who dies or the patient had long term-net results. and this would reduce tort reform immensely as far as i am concerned. secondly, i want to talk about primary-care physicians.

i know that president obama is pushing for primary care physicians to increase health in rural areas especially, however i go to a primary-care physician and i like him very much. however, i had an experience with the drug they put me on while i was on chemo. that raised my blood pressure and i was put on al tase and i'm sure the doctor knows how that works. and-- >> host: patricia with all apologies, your point pleased because we have a lot of callers. >> caller: anyway after they found out my kidney function test or elevated, the primary care physician did not listen to me. i said it's the altace. >> host: patricia? what is the point about primary-care physicians? >> caller: the point is i was sent to other physicians and multiple tests were done in this

to me was a waste in manicure and by private insurance had to pay for all of this place. all i am trying to say is that you are going to put primary-care physicians in you have to teach them to know what they are doing rather than to rely on specialist to get the answers. >> host: thank you. sorry to interrupt you. >> guest: underlying what she is describing here is a world that we are struggling with the medicine. the average physician 6300 to 500 new diagnoses sigir, prescribes 400 drugs and we can't know at all. we have been unwilling to it that that. we have been trained to really get the idea that it is all going to be in our heads and we have not developed the systems in our place that can change that. it is why i ended up writing on something as mundane as developing the checklist across medicine and klee looked at the aviation world and how they

handle themselves in the skyscraper world and found the first principle of making a success under conditions of complexity is for the experts even to wood to themselves that they are fallable, that they will fail at times. they won't remember everything and then to build than the standards of practice that we talked about the checks on the half-dozen things that we should just never forget, that we check before we go out the door. it runs against our expert in stings. becoming an expert is about the idea that we don't use jeckel guilt i am smart enough to know what i do and that is for vos debose people but this week began testing these tools and developing them and asking people to use them, they are saving over and over. i started using a checklist for my own operations in seeing patients only because i didn't want to be a hypocrite introducing them in other hospitals. and then i have not gotten through a week without finding

that our checks are catching problems like this sort she is describing, the complexity has gone beyond their individual capabilities but we have tools that can improve our quality while saving costs. >> host: ramona, california. mark on the independent line. >> caller: in covering the medical malpractice issue here, which contributes to the cost of health care and as far as the necessary surgery is that they are being done, unnecessary tests. the press is representing this and repeating statements from some of those who are involved, which implied to the public that these tests are done or surgeries are done because of the risk of medical malpractice, when in fact surgery is probably the most risky thing you can do and it is absurd to make this claim to the public on a regular

basis in the press of course is giving an enormous amount of advertising. when you get hit by a car on the street you are going to go to the hospital. you don't need to see full page ads in the newspapers but cash money coming into the newspaper every day, every day that full-page ad appears in the newspaper, lasik surgery in different kinds of advertising, different methods of pumping money into the news began to correct the bribes being paid-- >> host: mark tummulty get the point. thank you. >> guest: it is hard for me to blame the news media. i did research about malpractice cost drivers and how much they contribute and the reality it is 3% of our increase cost comes from malpractices some of the data i produces used by both sides the summerside sing see how much money is coming from the malpractice system and the others pointing out is a small

part of our overall cost drivers here. there are multiple drivers, and the striking thing is that it has to do with yes some of the fears about malpractice. a lot about our disorganization in our care, a lot about the way we pay for care on a piecemeal basis, and it has to do with the sheer complexity and technology of our care and wanting to be sure that we have access to the right technologies. so, here's the heartening thing i would point out. we have about a third of our communities that are providing higher than average quality with lower than average costs, and moving our communities to embrace what those kinds of practices are at the medical front lines is likely to be the place we will get the most bang for the buchan actually make a difference. with our economy struggling

because our wages are being diverted over to our health care benefit costs, where we have run into this wall. it is why reform keeps pushing ahead even though it is complexing gives all of this headaches and we worry about where i can go. it is because if we don't act we are going to, we already are finding ourselves in trouble, so it is hard for me to blamed the news media on that one. >> host: we are having a discussion about health care and the delivery mechanism for the this country and what we can do to improve it with atul gawande. the next phone caller is from alabama and this is linda on the republican line. >> caller: good morning. i have two questions and i will try to make them grief. the doctor i am listening to, the first question is my husband was rushed to the emergency room august 19, 2009. my son said he had no strength and he could not stand.

after nine and a half hours in the er the doctor came in in stated, i believe your father has suffered a stroke and he was going to discharge him and said there was nothing we could do for him. my son said, what could they do? i could not get him home. my father is gravely ill. he said if you want to question my diagnosis and go above me i have the form you can fill out at discharge and the labuff my recommendation for discharge. my son did that. they admitted my husband around 2:00 a.m.. call on tire stanley drove seven hours to get to birmingham and the doctor said he suffered a stroke. they did nothing. they did not come into the room and the nurse did not take files. they dispersed him that afternoon, three weeks later. scenario, my son called me 35 miles away.

i said you call 911 and call them now. they got there and my ex-husband on august 19th had been in birmingham alabama, a downtown birmingham. they did not do a simple test techs ran him. he had pneumonia. it turned into acute respiratory failure. he was fighting for his life. that dr. god in my face and said, you will not dispute would i as a medical doctor professionals have told you. you are going against me. we realize there were-- mic diagnosed. he got a bill for that one day, $18,000. >> guest: the kind of story were telling gets at the heart i think of many issues that i think we are all struggling with. look, first of all, if you have a stroke, don't necessarily know

but it is slurred speech or you are not moving one side of your body and family member needs to call 911 right away. a stroke needs to be treated within 90 minutes in but they have his numbers, 60% of our strokes in our country are treated in completely or inappropriately in our hospitals. we want to say is that hospital or that doctor. for the most part what they find is unbelievably hard-working people, unbelievably trained but pushed against the limits of the complexity of delivering things. i say were fooled by penicillin where we thought most medical treatment by the 21st century would be giving people an injection that would make an infection go way, make a stroke go way, make a cardiac problem go away. in reality it has been much more complex than that and that pneumonia you talked about, 40% of pneumonia's are treated in completely or inappropriately not because people are not

hard-working and smart. it is that we are fragmented in our care. you experience the drops in communication between one person coming on shift in the next person, and where we have not move forward is in embracing ideas that are really in some other industries, as professionals we see mistakes by lawyers. we see mistakes right now in foreign intelligence failures and the conmen issue here is what the public feels about what the philosophers call an aptitude. our biggest troubles are no longer with ignorance although we still have the areas of scientific ignorance. we now have knowledge of what to do but we are having a hard time applying it in the solutions are going to come from moving ourselves from focusing on the individual experts to thinking of ourselves as teams that have to live here to discipline, standards and most critically effective kinds of checks on

ourselves that can aid an expert to be more effective. >> host: lana, texas, martha, democrats line. >> caller: yes, i have two things to say. one i think doctors prescribe pharmaceutical drugs to much. i think you should be the last option. the other thing is i am wanting a public health care option. i am self-employed. i have had terrible health insurance my whole life, and i am healthy, but just unlucky on that. said those are my two questions. hustle let's start with prescribing too many drugs. >> guest: we have clear evidence of the areas i described under treatment in areas and we have areas of clear overtreatment and mistreatment. drugs are often not given four key conditions especially preventive care. drugs like statins for people

who have high coronary artery disease risk are often not, are not offered as consistently as we should and yet in other instances we are over prescribing drugs. of the question is how do we get on top of these problems? do we have command and control with washington panels trying to drive things? do we have complete, let the experts locally learn things exactly as they want without any sense of feedback information about it? the reality is we are no actually on the way to carving a path between these. of course we don't want command-and-control because no one who is even 100 feet away from the doctor's office can know what the best tips are in care. what we want our tools like better statistics and information about how well we are doing with overtreatment and under treatment, having that information in a timely way for

counties. we don't tell people how well their pneumonia is being treated. how well our heart attacks being treated? what is the use of drugs and ct scans like in your county? that information is critically needed and what comes behind that is doctors will-- i have a patient who was come have a new once said of depression and went to a doctor. they tried antidepressant medication after antidepressant medication in just couldn't find anything that would work for her. then realized three years later they had forgotten to check a thyroid hormone level. the problem wasn't too many drugs or too little drugs. it was that they had missed the basic check along the way. once she got the thyroid hormone within two weeks she was better. >> host: do you advocate continuation of drug advertisements? >> guest: ibm conflicted about

my feeling concerning drug advertisement. i think they are largely unproductive spending in that the reason they spend money on drug advertisements is because of the survey show zero% of the time when a patient comes in with an advertisement to the doctor's office they get exactly that drug prescribed for them because you have the 15th minute to visit and trying to argue somebody out of it just takes too long. what we really need though, i have no idea about the legal issues concerning whether you can then this sort of thing are not. what it reflects is we have value the payments for things, drugs, it's, operations the negedu without dawe ewing the time that a doctor spends with people where you can talk through what the best, what is the problem here and how do we best take care of it? doctors time is actually cheaper than many of the technologies we have and we have undervalued that critical humane component

and it is not just doctors. it is nurse practitioners, physician assistants, the team of people that can help people more likely get the right ^ the right time. >> host: fort knox, kentucky. robert, a good morning to you. >> caller: good morning. i was wondering, this whole margin of high-profile drugs and stuff like that, what kind of an effect is that really have? you have a lot of patients that go to the doctor for something they have seen on tv and is not necessarily something that they really suffer from but because they had one of the symptoms-- also with a lot of these desired drugs for some of the minor afflictions, have some pretty severe side effects. is that something the fda is getting on top of? there are a lot of people that that can affect an extremely of first place that could open the door for malpractice issues. >> guest: when a patient comes in the door to see me with a

particular treatment that they want, a surgery potentially or a drug, if it is completely under indicated, that is an easy call. you know, do you want that blood pressure drug when your blood pressure is normal? the hard parts are when people are responding to an advertisement or just the year. a patient who comes then, has had a fever for one day and the temptation is to prescribe an antibiotic when in certain circumstances a cold this much more likely and our over prescription of antibiotics is led to massive resistance, bacterial resistance to the antibiotics were using. we want to be able to push back and say in this circumstance we should provide an antibiotic but under the time pressures and the production model of the medical world it is often easier for physicians just to not battling and write the prescription or

get that mri scan. sometimes even to an operation. and understanding how we can make systems that recognize, we don't even measure how much overtreatment there is, help identify the places we can work get it and work as communities towards being sure that the mix of care patients get is much more suited to what their problems are and what their needs are. >> host: it seems to me a computer flow chart for diagnosis and treatment is a no-brainer. a high tech checklists, a. if that is what you are promoting how challenging hasn't been to incorporate that into use in major practices and hospitals and that sort of thing? >> guest: on the one hand we have had pockets and we have seen improvement each time we have done it that it has to be clinicians who are willing to embrace it because there is a huge difference between good checklist approaches and that

checklist approach is. if they are poorly designed, if they are way too long, if they distract you from the houston the doctor can i use them at the bedside or finds them on helpful. when we put in our approach for surgical care, we found a greater than one-third production with complications with the two minute check before you made the incision as the team for the one of the reasons it is then gradually, we have 21 countries that adopt it that the u.s.'s only had 20% of hospitals moving with this idea partly because we all work is so low agents and not used to getting together as an organization. coast skill as opposed to the national health care system where it is easy to implement? >> guest: that is right, the country of france-- about a month ago had and the other component of it is everywhere brought in here experts are resistant to these kinds of ideas. we don't like having checks.

when we survey teams after they implemented the checklist, at the beginning they didn't like it in by the end 80% like it that we still have 20% who hated it who said this is a waste of time, i don't like this. then we asked one more question. if you were having an operation would you want the checklist to be part of your care and 94% said yes. >> host: fort myers, florida, lilly, republican line. good morning. >> caller: i basically have two questions for the doctor. doctor, when you are doing surgery on someone, do you get compensated for your cost, and rightfully so. and, does the materials that surround the surgery, be it the gauze pads are with them for medical supplies you need for this patient to recover, do they surpass even what you charge for

surgery, and the lobbyists, the second question is the lobbyists in congress, to what-- is the hospital the administrator obligated for these high costs that really influence the way insurance pays off in the boy that patient pays of. have a wonderful day, folks. >> guest: thank you for your question. under our structure i get paid 1 feet, the anesthesiologists gets paid 1 feet. if there there specialist and vault they get paid one fee in the hospital gets paid a fee including the cost of the gauze and everything else in one of the interesting phenomena is the person who decides whether we open net disposable equipment, whether we use that 1,000-dollar item, is the surgeon and not, i remember going into a case just a couple of weeks ago where we

wasted $500 worth of stuff. first of all i try to find out how much does that stuff kostin took a week. nobody could quite figure it out until i finally found the right person and second of all the striking thing to me was i hadn't really noticed it until i started writing about these issues because the coach of us are so separated in our responsibilities that we never actually look at the whole system of care as something where we said let's do this operation in the most efficient way possible, with the best quality results working together as the team. b2 that in my hospital in the sense of wanting to be as clinically smart as possible but really organizing ourselves, taking ideas from other places, trying interesting things, think of ourselves is that kind of an organization moving in that direction. that is new to us and that is something of a surprise but it is the way we happened in the

future, and the fascinating thing to me is as the incentives of the health reform package moving through our materializing and people are saying what they are, for the first time i'm hearing those conversations in our conference rooms, in our meetings where we are saying okay, how could be as large groups of people, the surgeons working with the anesthesiologists and the primary physicians and others make it so we have a package of care for people that is smarter and less costly? >> host: who want to show you a few of the headlines regarding health care in this morning's newspaper today. from the politics page of the "washington times" pelosi sees democrats close on health care in the meeting with the president yesterday. to stories about the meeting and the use of an excise task-- the difference between the house and senate in the "new york times" obama encourages exci tax on high-cost insurance, an idea that is met resistance in the house and in "the washington post" today experts remain

skeptical of taxing health benefits, suggesting it won't have the cost curving approach that those are suggesting is supported and finally in the ball street journut the lessonsf manicure part d including markets to work but prices don't always do theredictable and programs never cost what the experts predict. those are some of his lessons on party and from a local perspective a discussion about access for the "miami herald" has a front-page story about jackson health system halting dialysis of poor patients in dozens of patients facing life or death situations after the joe jack-- jackson health systems stock paying for treatment of their kidneys because they can pay for it anymore. >> guest: the striking thing to me is we are becoming aware of these situations. it has been, it is the lesson into me that that is a front-page piece of news because

the point at which we have been turning people away from care struggling for figuring out how to get coverage for people with they have dialysis, whether they have cancer troubles, these have been an underlying current in our experience for awhile. >> host: it is interesting, the chief executive of jackson health system, the dialysis treatments is quoted as saying the decision was not taken lightly. the stations can still get treated in the emergency rooms of their when to seek treatment but going to high cost emergency rooms. >> guest: the way that happens is when you have kidney failure, you can function for a while and then after a week or two, you become so sick your ed death's door and you can go into the emergency room and get emergency dialysis but what you really need is dialysis on at least three times a week basis, sometimes daily basis to survive

and it is an appalling situation for a country like ours which has as one of the callers noted amazing capability and technology invacare, highways we can organize better put this fundamental commitment is one that were if pelosi is right and we are as close to changing that is possible i think we underestimate the ways in which that represents a significant change for the health of the country. >> host: minneapolis, derrick, democrats line. you are on. >> caller: good morning. i have a question for dr. gawande. what is your take on people who are living with hiv/aids? and, the health care, you know, how you know they plan on cutting, i think you said they were planning on cutting manicure part d or doing

something with manicure part d. you know, i believe that hiv/aids has come a long way. since 1980, but now that they are cutting the manicure part d, what is your take on that? thank you. >> the hiv/aids patients' care is a nice microcosm for thinking about what is happening. it is not being cut. the two different bills add money for pharmaceutical drug coverage but why would an hiv/aids patient qualified for those under 65 and what is fascinating is our science of how to treat hiv and aids has reached the point where we are able to keep people remarkably

healthy, turn it from a deadly acute illness into a chronic one that people can be healthy with and live on with come up but because of the inability to get insurance coverage especially if you are self-employed or needing to get individual coverage, the preexisting conditions make it so these patients can't get coverage. the only way they get coverage is at the actually file for disability and no longer work anymore because of their elma so they don't get treatment. they then filed for disability and we are now into this roundabout where we have lost productivity of a significant part of the population where science is able to help them. the prospect of health reform is with the elimination of those kinds of preexisting condition exclusions we can have a larger population of people that we began to really move back into being as productive and in our lives as possible and have the

vanishes of science of a can also help contribute to our economic recovery. >> host: just a few minutes left on our are long conversation with dr. atul gawande. our next question, arlington heights, illinois, chris on the independent line. >> caller: hello susan in dr. gawande. good morning. my first question is how was health care reform going to affect-- my doctor every day, are they going to be able to check on all the basic things are is it going to be a lot quicker than normal? secondly, correct me if i am wrong but is malpractice insurance costs driving our health care costs of or is it just a red herring to throw us off the health care reform does? >> guest: let me answer the question about physicians and then come to the second one. i think the guide of what has happened in massachusetts

reflects vote will have been around the country because two years ago massachusetts took an approach similar to what is in the reform package offering for people who don't have access to insurance or for whom insurance is too expensive the choice of plans. go on to the web and if your income is very low, it can even be free. it has kept the cost at about 8% of income and it has allowed people a choice of plans and we have gone from 12% without insurance to only 2% without insurance. now, the striking thing is for most of us in the clinical world, for all our other patients we have not noticed the difference at all. all we have noticed as we are suddenly not, i am a cancer surgeon and i've not seen a patient who is head insurance coverage problems like we used to have been two years and it has been an amazing thing. it can affect physicians in the sense that we are starting to-- to think about how we deal with

cosson that means some struggle at the local level for us to begin thinking about can i offer a package price for the services i provide as he position? can i join up with my colleagues in the hospital so that we may change the way we have organized their care? and, it is an opportunity and also one that we will find hard. malpractice reform, i have been in favor of. i am not in favor of caps but instead moving to a no fault practice system but as a driver of costed is one, but it is a driver of about 3% of the increasing cost from the studies that i have been part of and others have been able to do. so, it falls in between. and it is not quite a red herring to talk about malpractice reform because it is one of the levers available to us and as long as we are being fair in