Atul Gawande

surgeon | Writer | Researcher

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

Atul has been a staff writer for The New Yorker magazine since 1998 and has written four New York Times bestsellers: ComplicationsBetterThe Checklist Manifesto, and most recently, Being MortalMedicine and What Matters in the End. He is the winner of two National Magazine Awards, AcademyHealth’s Impact Award for highest research impact on healthcare, a MacArthur Fellowship, and the Lewis Thomas Award for writing about science.


Transcription

Drew Kugler: So it strikes me that I met you Atul, way before you met me. And that was through an article a friend had sent me, that was written about you in April 2007 when Better came out. And that gentleman was following you were observing you in the surgical suite, commented both on the importance of your loops, first time it ever learned that word, but also went through the thing that got my attention, and that was the list of music that you listen to in the suite and you even commented that there were certain songs that you could play, unless there was someone over the age of forty five. So, the thing that struck me, and that has been one of the through lines... 

Atul Gawande: I think I said sixty-five. Was it forty-five?

DK: He was forty-five, just for the record.

AG: Now that I'm over forty-five I have to revise it.

DK: Have you changed your music; but that's a question for later. So the thing that struck me though, and they got my attention, and made me want to buy the book, wasn't so much what the article talked about, but it was a fact that you were a Bruce Springsteen fan. And we have talked often since then.

AG: As I learned not a crazy Bruce Springsteen fan like you are.

DK: Well...

AG: But I am the biggest Bruce Springsteen fan.

DK: Yes and you play Springsteen by the way—if you had to pick a Springsteen song for surgery what would it be? Do you know what you play?

AG: You know—Born to Run—it was the first thing that came to mind because it's the one I most often play in the operating room, but I'm not sure whether that's the theme you were—you know— the people listening want to be thinking about.

AG: In a surgery—no. Could leave—but from a kind of energy an emotional point of view—it's totally...midday...That's an awesome song.

DK: That's the song.

AG: You know midday through a ten, twelve hour a day—

DK: That's the one. Well, I did go buy the book and...

AG: I could name all the post 9-11 songs, or Tunnel of Love, but they are even even less thematic, right?

DK: That's right, that's right. But for all those reasons and it just being an interesting article, it did encourage me to go out and buy the book. And what I have noticed over the years and something I want to talk about at some length today, is perhaps an unintended theme—I'll let you comment on that—but as I quickly and I'd like to just jump through some of your writing... it is the jumping through. The theme that emerged as I thought about it, was actually the motivator for this podcast. Not this one, but of me stepping into the podcast world and having my, theme. And the theme is the the overarching effect that conversation has on our lives. For good, or for bad. That's what this whole series of conversations is about.

Now let me explain what I mean. Even before I knew you, you wrote a book called Complications. The doctor, a woman doctor at U.C.L.A., mentioned that when I was first getting into your writing, and she talked about the hand-washing article. And the difficulty that people were having in communicating the importance of washing hands. Going on to better, to me, and the chapter that you actually recommended yourself to me that I read in order to help other people, was the speech you gave to the graduates—the positive deviant article. And in two separate sections of that column, that speech, you encourage, on one hand, for people to stop complaining, and on the other hand,  for doctors to engage, if at all possible, for the benefit of the patient in something you call the "unscripted question". So there is more conversation. So that's just two for two.

But go on to what I tell everyone that I work with is the best book on team communication and that is the Checklist Manifesto. You have taught me and everyone that at least has read the book that I know, as to the importance of pausing in conversation, in this case a conversation that drives a surgical procedure. You talk about the importance of pause points.

You also tapped into something and a couple more minutes here and I'll get your comment on any or all of it—you also tap into something that quite frankly clients have a great deal of difficulty with, and your writing makes it a little easier for them to understand. In my world is that people have to enter into their professional work with a certain mindset. The nurse that walks in to join that surgery has to believe that he or she is worthy, is valuable, has a point of view that is important to express if so called for. So the self talk at that point has to be a very, very positive and productive one. That's the style of conversation. It goes on. Being Mortal is perhaps to me the ultimate testimony to the importance of conversation and I'll ask you more about that a little bit later. And since then you've written about again the value of people talking to people. Not the importance or the efficacy of an app, but actually real conversation. People as you said, people talking to people, and people listening. So unintentional, I called the theme. But in hearing that, A. my first thought is does that follow, have you thought of it at ever in that way, and does that make sense to you?

AG: You know, I have not thought of it as a recurrent theme, but hearing you lay it out—it makes a lot of sense to me because in each of those... for example, The Checklist Manifesto is about checklists and you wouldn't think—well you wouldn't think you'd want to read about checklists. And second of all, I wouldn't have thought that you could use checklists to cut death rates in surgery by half. Especially when you know surgeons seem to be doing a good job to begin with, right? And then third, you wouldn't imagine that what the checklist is really doing, is it's not a tick box efforts sitting in the corner of the room with a nurse going through, going check check check. It's a conversation among a team of people who need to be aligned around what the goals of this operation are, what the special considerations are, that each that someone might be aware of in the room, but others are not. And then agreeing on the direction that you're going to go forward with. As time has gone on, and I've dived into everything from how do we understand our errors and our imperfections in medicine, to how do we have our teams functioning better and better, to how do we successfully deliver care even in the most difficult phase of people's lives when they are facing the end of their life.

The thing that I come back to again and again is that there is at least two people, often more, who have to get clear about what are your goals and what are my goals? And, how do we get them into alignment? And the basic story over and over again is there is tremendous suffering whether in a surgical patient, a person at the end of life, or just a member of the team like me, trying to get good at what I do. There is tremendous suffering when we have not had that discussion about what it is we are actually aiming for, what our priorities really are, and then, are we in a relationship where we are actually pulling in the same direction.

DK: So in your experience of looking back across that spectrum of moments that patients and doctors and people face, do you have any conclusion, at least a working theory, as to if we know it works by pausing, by having the what I call deliberate intentional conversation, and most notably in a time of making perhaps difficult choices? Why don't we do that more?

AG: Well, I think there's lots of reasons and I think it's different from situation to situation, so just to take two. We asked surgeons, nurses, anesthetists, the other people who come together in an operating room, to pause right before the patient's put to sleep, just for one minute. And then, right before an incision is made for another minute, and then before you leave the room with the patient, for the third minute. And pause and have a conversation about this stage. One of the critical goals is that there's a few things—have we missed any of these key steps to stop big killers like infection or bleeding or unsafe anesthesia? And, are there any special considerations that the patient's health history or own condition suggests that they should have. When we ask people to do that, they didn't like it. First of all they thought this is idiotic— we already know what we're doing. We've been doing this over and over—we've done thousands of these operations—we know what we're doing.

Second, there's a set of values just by starting to have that conversation that are in contrast to the ones that we normally have. So, let me unpack that, it's if it's OK. The usual values you have in health care and maybe another lines of work is that certainly the way the doctor thinks about it is our highest values autonomy. That in the operating room it is built as a place where the assumption is the best thing for the patient is to be is to see that the surgeon is the customer. So whatever the surgeon wants, that's what matters. The checklist that we design around what the big killers are say actually, the surgeon's not the customer here, the patient is. And all of us have a piece of the care for that patient and the surgeon is definitely important, but so is the anesthesiologist, the nurse, and even the medical student has things to offer that could be life saving.

And the values that get expressed just by having a planned conversation, where we all know we're going to stop to talk—those values are—instead of autonomy—it's humility. That I know, that no matter how great I am as a surgeon, no matter how much experience, no matter how well-pedigreed; there will be mistakes. Things can go wrong, and will go wrong. Second, is discipline—a belief in doing certain things the same way every time—that that reduces the likelihood that something goes wrong. And the third is teamwork. The belief that anybody in the room can know things and add something that will make things better. And that expression causes some conflict for people. So long story short in the setting of the operating room—the reasons why people can have a lot of discomfort with it is it's pushing against their assumptions and values about how things are supposed to work. They think they're great already. And much of what can go wrong is often invisible to people. We have we have a ninety percent or better chance for a typical hospital operation that that the person will survive and that—it's even up to ninety-nine percent, right? But when we do thirty million operations year, fifteen million operations a year in hospitals. You're talking about one hundred fifty thousand dead per year. And at least half avoidable.

And that's what we found; is that if you impose that discipline, we can we can get markedly better results.

DK: So go on to the next book, and I'm going to ask you specifically about the Mass General research that talks about the people's—you talked about this on Charlie Rose and really surprised him—that work through the twenty-five percent getting better and then allow a follow up on that, because I'm deeply curious about this.

AG: Well so this was, my book Being Mortal was prompted by both my father being diagnosed with a brain tumor, but having many, many patients where as a cancer surgeon, where I would be responsible for trying to have a discussion about what's our plan now? When a complication has arisen from a potentially terminal condition, or the disease is simply advancing. And finding that these are incredibly aversive experiences, conversations that neither the patient likes nor the doctors like. And there was a study at the Mass General Hospital, of patients who had stage four lung cancer, so all of them died. The average length of survival from the time of diagnosis was eleven months. And they decided to agree to a study that the patients were randomized to half of them receiving the usual oncology care, and the other half receiving the usual oncology care, plus a visit with a palliative care specialist.

Now palliative care is a field where they focus on improving your quality of life and we usually think of that as something that you do in the end stages. And so seeing this study, it was striking to me, because someone saying "Hey you know maybe I'll get a palliative care clinician involved". A common response we would have is "Oh no no no no it's it's not time for that; we still have options". And instead, this study said have a palliative care clinician involved in the very beginning of diagnosis. Focusing on the quality of life, and not just the quantity of life. The result was that the group who got that additional step, had outcomes.

Well, first of all, they the patients had less suffering, less anxiety, less depression, less pain. They were more likely to choose to stop getting aggressive care, such as continuing chemotherapy. With less than half receiving—so dropping by half the number of people who are on chemotherapy in the last two months of life.—that group spent less thirty percent less money, were less likely to die in the hospital, less likely die in the I.C.U., had more time at home, started hospice sooner, and the kicker was, they lived twenty-five percent longer. Which meant that there was something the palliative care clinicians were doing, that not only improve their quality of life, and lower their costs, but also improved their quantity of life, or at least it didn't worsen along the way.

And I went interviewing people to say, “OK what is this thing?”

DK: That's my question.

AG: Right. What is this thing? And you know it's the very beginning and I thought well maybe they're getting more pain medicine or maybe they're getting into depressants or things like that. But no—with it at the beginning of diagnosis, they didn't have that many symptoms, they weren't getting more medications for symptoms and things like that; it was just conversation. They were having a conversation with the palliative care clinician about their goals for their treatment besides just survival. What do they want to live for? What are they willing to go through and not willing to go through for the sake of more time? What's the minimum quality of life they'd find acceptable? Do you want to get to Disney with your grandkids? Are you trying to get a project that you want to get done, done? Whatever happens, you know, your health may worsen. What are your priorities? And knowing those, let's make sure our care is aligned with those priorities.

And I realized I wasn't doing that, and I needed to learn how to do that. How to have that conversation. Because it's not as simple as just what are your priorities. It's a conversation.

DK: Are you better at that now?

AG: Much. I still have a lot to learn.

DK: So I'm intrigued by the question. You're intrigued by it, but for a different reason. Am I hearing you conclude that the conversations occurring, or versus not occurring, actually were the causes for that twenty-five percent lengthening of the life?

AG: Well so, we don't actually know, except that we have—you know—there have been multiple studies now, including some that we've performed, where we have made that the focus. Let us focus on teaching clinicians how to have a more effective conversation with somebody who is seriously ill with a life-limiting condition. And it's a whole frame shift that I had to learn, which is that I'm used to thinking my job as a clinician is give you the facts. I am, you know my role is to be a doctor informative. Here's what I know about your condition here are the options here is Option A. Option B. Option C. The pros., The cons, The risk. The benefits. Now, what you want? And then you tell me what you want. And invariably what people would say when I'd asked that question and they would say well, what would you what would you recommend? And then what I was taught to say is really and actually talk to say this is to say "No. no, no; this is for you to decide. Only you can know you, and I'm here to provide information".

And the flip that the palliative care doctors, and it turns out the geriatricians and others put in, is to say "No; your job is to be a counselor. Your job is to learn what people's goals are in their life, and then match what we are capable of medically, against the reality of their condition, to help them achieve those goals in so far as they can." And so the the conversation flips to saying "I need to learn to listen from you. What are the most important priorities for your life, even if your health worsens?" And you know just beside survival, and then let us maximize fitting—I can make a recommendation then, knowing what I know about all of those options and which one might be the best fit. And that conversation—we have some preliminary data—we have rolled it out of the Dana Farber Cancer Institute and showed marked improvements in depression and anxiety in our preliminary data. And marked—the conversations are happening more, they're happening earlier, and they're better conversations aligning the care more closely to people goals.

DK: So, if you go back to what you said; I found the quote about the teamwork and humility. In the middle of that quote in 2011, you posited the notion of the resistance to values, right? And you said you talked about resistance, sometimes vehement resistance, to change efforts are rooted in different values than the ones we've had, as you explained. My question is: I compare the Being Mortal findings to the checklist findings. Is there more resistance—vehement as it may become at times—is there more resistance to doctors learning about these new conversations? Rather than versus the resistance that you saw to the change in the surgical suite?

AG: I don't think we know yet. In both cases, there is a generational difference that we are observing as this rolls out. And partly it's that people who are more experienced get set in their ways, and are comfortable where they are and aren't looking for making a change. Whereas, you know younger generations will still be finding their way, and have some uncertainties and wanting to build on what's there.

I think though, that there's the resistance, is different. The thing that happens—there's a switch that happens when you have the conversation about someone's goals when they have a serious life- limiting condition. And that's when you learn to do it, it turns what is an aversive conversation, where you feel like you are across the table from the patient having an argument, and the patient is thinking, "What are they trying to tell me they don't want to give me?", right? It always feels like the normal conversation we have with people who are coming to the end of life is, "Do you want to fight—or do you want to give up?" We never want to put it that way, so we say things like, "Can we make you comfortable?" You know do all these things. But what's heard is, "My doctor's telling me to give up." And then you think the doctor is not on my side, when in fact, what you want to have is a conversation that says, "We're going to fight. What do you want to fight for? To have the best possible day you can today, regardless of the consequences tomorrow? Or, "To potentially even sacrifice your day today and how you feel today, for the sake of possible time in the future?" And, "What is it that a really good day is for you? And how do we help make that happen?" And maybe, you know, "How do we make both these things happen, have as many days with that best possible day in front of you?".

And you suddenly have this switch to being next to the person now. We're on the same side, and you don't want to go back. So, the the experience of teaching people how to do this kind of conversation is that it's a jarring change. It's a different way. You have to ask different kinds of questions like, "What are your fears if your health worsens? What are your goals of time is short?" People crying in your office. It makes you uncomfortable at first. And then suddenly, you find it's one of the most gratifying experiences that you have as a as a clinician. I never expected that one of my most gratifying experiences would be as a clinician having a conversation with people where we decided not to do surgery, and we felt we accomplished something. And in finding that you could be good at this, actually feels good.

And now, the surgery checklist, is one where you know you run through it. The team gets more aligned. Everybody's pointed in the right direction. But on any given day, you have a less than one percent chance that anything terrible will go wrong. And so you don't notice the value add, until you add it up over the course of time. And then you know A. if you cut the death rate by half, you just don't feel it. There is some way in which the team feels like it's functioning better. And that can kind of keep it going, but it's very easy for the habit to go away if someone on the team, especially if a surgeon on the team is, sort of you know, dismisses it and disregards it. You can see it decay. And so you have to reinforce it and keep it going. But what we saw—we just rolled out in the state of South Carolina—over the last over about three years with the hospitals across the state—for forty percent of the population—the hospitals were able to take it up, walk through the process that we suggest for implementing, including how to deal with surgeons when they push back. And they successfully reduce the death rate twenty two percent for forty percent of the population the state. Now they're sixty percent though, where they couldn't walk through that process, and that reflects, I think, some of this resistance. So what we're experiencing right now—is we've got a approach and innovation, a process innovation, that successfully cuts deaths and even a population scale by almost a quarter in surgery. But people aren't screaming, knocking down the door, for it. We have to go out and celebrate the conversation and how to have the serious illness conversation. Patients, families, and clinicians are and banging down our door. We can't keep up with teaching it appropriately, learning how to teach it appropriately, learning how to support it at a large scale fast enough. We're moving as fast as we can to make that happen.

DK: There's a professor here at Harvard, that commented in a book called Difficult Conversations, years ago. His name is Doug Stone, and he talked about something that has certainly changed my work. It may provide some explanatory power to what you just said; I'll take a shot. He said that the biggest challenge that we have when we go into a difficult conversation, in the past, is we go in with the wrong purpose. We go in believing at our, quote unquote, worst, most ineffective, is that we are there to deliver a message. That is our job. So that completely, because that's our mindset, that completely affects how we show up to the conversation he asks his readers and it really shifted my thinking, which you've heard some about. That what if we went into the conversation to hear the other person's story? To get them to talk? And what you just outlined, it strikes me, as that, embraced. When you go in to get people to use the checklist—it's more about—maybe it's the hospital administration—maybe it's more of—here's what we need to do to improve our surgical outcomes. Whereas, when you and your colleagues are getting your doors busted down too; because you're entering to get other people to tell their story. That just struck me, as you were telling that story, is that I wonder because I certainly hear about this across...my clients—is that people won't listen about change; people resist it. What if more people walked into more rooms trying to get other people, the people who you want to help, and to go through a change, to get them to talk, right?

AG: Yes, I think this is key. If you go into one of the things that we end up... Here's the difference is there's a difference in the power of the surgeon who's the person who existed in this case and the patients who are in the conversation that we're trying to have in serious illness. In both cases you're trying to get a larger group of people to have a voice. The patients are—and the aim is not just they have a voice—what what you go into the conversation trying to do instead of just giving information is trying to go in saying what are your goals and trying to see whether where we align around the goals we're trying to achieve. And so it's often I found myself going into conversations much more around my top priorities to figure out how to create alignment. And alignment requires my hearing you and what you care about, and where you're coming from. So with selling to surgeon, so to speak, this thing we want them to do—we're trying to sell them on the idea that they already have a voice in the operating room. It's allowing other people to have their voice. And so trying to sell them on the idea that you already got a voice. Can you let other people have the voice in the operating room? And then why? I need to know what aligns with your goals. And so the powerful thing that we had asked people to do in South Carolina is, number one, get a surgeon to be on your team for implementation. One of our gateways—tollgate, so to speak—is a we would ask teams to send a picture of your team. With a surgeon, an anesthesiologist, a nurse and a hospital leader on the team. And right there you lose about half of them; just to get the picture and get people together—find a champion who would be willing to come in from all of the different components. And then that group—we asked them to go talk to—because surgeons are often the main source of resistance—go talk to every surgeon one-on-one. And then go in and just ask them, "Will you help me?" And that opens a conversation where you can really find out where people align.

One of the things that we don't go in saying is, "Here are the facts about how great this thing is, and we know that if you just use this, you get you get better results." Partly because every surgeon thinks we're above average. And all our polling indicated that, you know, there's going to be twenty to thirty percent who really resist and don't think it's—they think it's a waste of their time it's not going to make anything better. But, then the other thing we found in our surveys was if you asked them, "I know you're great, but what do you think about your colleagues?" Ninety-five percent of the surgeons would want the checklist used if they were the patient. And so, going in to say, "Would you help us with making this place better to be the kind of place where you would want to be that patient?" Where you're willing to be the patient on the table you bring many more on board and when we ask will you help me get three kinds reactions, One is, "Wow, I've been interested in this, absolutely!" And they've become one of the champions, or they say, "Yeah, OK I'll try it." And they tried, or at least don't go on the warpath against you. They're like "Yeah, OK. Fine. I'm not really going to help." But in fact they're helping because they've decided not to go on the attack.

DK: Can you—the warpath doctors?—it raises a larger question of a general one about trying to help people change, or or influence them; what do you do—generally—whether it's giving advice to a patient or giving or inviting a doctor to try the checklist when you know that they're not going to do it? When you know it hasn't landed? What do you do next?

AG: I think—the one thing is understand there are early adopters, middle adopters and late adopters. And you want to start with the early adopters. When you get through your middle adopters, when you get to two thirds, half or two thirds and you've gotten great results, you have the you have the credibility now to say, "Look, this is just the rules." And if you go in and do that is the very first thing you do, you've killed off all the energy and the learning and the adaptation that the early and the middle adopters do to make things work and make it better. So one of the critical things is just not to expect that you can do the Big Bang and everybody is going to do it. You have to go in expecting you're starting with your early most forgiving group, and walk your way through and adapt and and figure out what works to make the ideas actually fit into their work and into whatever they're trying to do, Similarly with patients there's about ten percent, five or ten percent of patients are really serious denial; like they don't recognize and aren't really capable of recognizing how bad things have gotten and where they really are. And sometimes the patient, sometimes, is a family member and in those cases you can actually do damage trying to, trying to force them; like you know, "You're going to die!" It doesn't—all you've done is lost their trust... and traumatized them. And those are the situations where you actually, you know—we tell the clinicians, "This is a situation where you need the palliative care experts. The people who have dealt with this over and over again". And and it requires incredible nuance and patience and deciding—and the art of gentle pushing. But sometimes having an outsider come in and be the bad guy trying to say you know trying to test some of these messages and see what what reality they—whether they can deal with what you're trying to do is have people recognize the cognitive dissonance that they're experiencing between what happened yesterday and what happened the day before that what happened of the day before that, and what they're saying happened. And sometimes they lash out by saying, "I hate you and I don't ever want to see this person again." And that's fine if it's the outsider coming in. That sometimes with you have to do.

DK: One last question: Most interviews that I've seen you do—at least one other podcast I listen to and then also one of your television appearances—everybody starts off by talking about how busy you are, and they regale you with your you're your multi—the many, many tasks that you face. However, I know you. As the following I know you as a surgeon. I know you as the the head of this organization, Ariadne Labs. I know you also as a father of three and a husband. And you and I have at the same time had long talks about the importance of hard conversations. So across your many roles, where are the hardest conversations? That for you personally?

AG: Well, I'm conflict averse, as you know. And, you know, I want to go where things are—I want to keep going. One of the mantras in surgery is, "Don't go where it's hard. Go where it's easy." And the may never have to go anywhere hard. It may turn out that everything turns out easy along the way, right? And so, I like that mantra. And I don't know that it is any different a conflict in a relationship with an editor about where I'm trying to take a piece, or a book I'm writing; or a member of the research staff where things are—we're not in alignment anymore. Any time I'm not in alignment with somebody else and and we need to work together, it almost doesn't matter—could be a life on the line in an operating room. It could be just trying to get a manuscript out the door. You would think in the operating room that would be more tense, more upsetting position. But emotionally it actually is much the same. That if there's something I really care about at stake and we can't seem to —and we're butting heads, and we're we're not pulling in the same direction we're pulling in opposite directions. And I don't know how to get it so that we're back into pulling in the same direction, that's what keeps me up at night more than anything else.

DK: Yeah. Have you gotten better at those conversations?

AG: Yeah. I mean I think it's you given me a lot of tips along the way. Some of it is simply recognizing that you need to have a conversation; that when you are butting heads, that's an opportunity. And step back for a minute and plan for a conversation and name the fact that, "Hey, we're butting heads." Then begin to probe why we're not in alignment here. "You know, I'm confused. I think I'm pushing for this. I think you're pushing for that same thing, and yet we seem to be going in a different direction, and not in the same direction. Why is that?" And getting genuinely curious about that, I feel like, is the thing you keep bringing back, you know? And it works. It works and it de-escalates the tension in the situation.

DK: When I tell people about you—people come to learn about you and read the bio, the thing I think that they're—most people I talk to that are... most thrown [by] is how do you fit in? Being a dad? To all that other work you do?  So my wondering is—because I thought your answer would be, at least I believe mine are—the hardest conversations are with kids because you want them to be in alignment at times, but you also know, as somebody once said, "you're one hundred percent responsible for making them understand that they're one hundred percent responsible". So do you see a difference between talking to somebody about something difficult at work or in the surgical suite versus talking to your kids?

AG: Well... are those the most frustrating conversations I have? Yes.

DK: Hard. Right? However we can—

AG: I don't know that there might have the hardest because—they're frustrating—you know, I'm constantly reminding myself—I'm just waiting for their frontal lobe to click in. Just waiting for the frontal lobe to click in. Because it's like I've got A plus B plus C. And they're reporting that that adds up to dog. OK it's—I don't even know what... We can't even begin to talk about goals and, you know, it's like they're pieces aren't coming together. And so it's being willing to be patient and trust in the fact that that it'll be fine, and they will get there. And let them make their mistakes. So the hardest part of those conversations is aligning with my wife around how we handle this; because we don't approach it in the same way all the time.

DK: Exactly right. Exactly right. Atul, thank you, to say the least. I hope this has given my listeners, so to speak, some insights into somebody who's had an enormous influence on how I think about my work, and how many people around the world, and I finally I'm able to now tell people when they say, you know, this stuff isn't life or death. So it—you know, we can figure it out. It's nice to know that when it comes to life or death conversations and doing them with deal with with deliberate and intentional focus and purpose. You've taught me a lot about that, so I think you hear and I look forward to our future conversations.

AG: And I thank you, Drew, for the conversations we've had and will continue to have.