WEBVTT

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I don't come to you today as an expert.

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I come to you as someone
who has been really interested

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in how I get better at what I do

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and how we all do.

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I think it's not just
how good you are now,

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I think it's how good you're going to be
that really matters.

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I was visiting this birth center
in the north of India.

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I was watching the birth attendants,

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and I realized I was witnessing in them
an extreme form of this very struggle,

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which is how people improve
in the face of complexity --

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or don't.

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The women here are delivering in a region

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where the typical birth center
has a one-in-20 death rate for the babies,

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and the moms are dying at a rate
ten times higher than they do elsewhere.

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Now, we've known the critical practices

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that stop the big killers
in birth for decades,

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and the thing about it is
that even in this place --

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in this place especially,

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the simplest things are not simple.

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We know for example you should wash hands
and put on clean gloves,

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but here,

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the tap is in another room,

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and they don't have clean gloves.

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To reuse their gloves,

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they wash them in this basin
of dilute bleach,

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but you can see there's still blood
on the gloves from the last delivery.

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Ten percent of babies are born
with difficulty breathing everywhere.

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We know what to do.

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You dry the baby with a clean cloth
to stimulate them to breathe.

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If they don't start to breathe,

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you suction out their airways.

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And if that doesn't work,
you give them breaths with the baby mask.

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But these are skills that they've learned
mostly from textbooks,

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and that baby mask is broken.

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In this one disturbing image for me

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is a picture that brings home
just how dire the situation is.

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This is a baby 10 minutes after birth,

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and he's alive,

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but only just.

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No clean cloth,

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has not been dried,

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not warming skin to skin,

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an unsterile clamp across the cord.

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He's an infection waiting to happen,

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and he's losing
his temperature by the minute.

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Successful child delivery
requires a successful team of people.

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A whole team has to be
skilled and coordinated;

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the nurses who do the deliveries
in a place like this,

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the doctor who backs them up,

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the supply clerk who's responsible
for 22 critical drugs and supplies

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being in stock and at the bedside,

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the medical officer in charge,

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responsible for the quality
of the whole facility.

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The thing is they are all
experienced professionals.

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I didn't meet anybody who hadn't been
part of thousands of deliveries.

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But against the complexities
that they face,

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they seem to be at their limits.

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They were not getting better anymore.

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It's how good you're going to be
that really matters.

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It presses on a fundamental question.

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How do professionals
get better at what they do?

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How do they get great?

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And there are two views about this.

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One is the traditional pedagogical view.

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That is that you go to school,

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you study, you practice,
you learn, you graduate,

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and then you go out into the world

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and you make your way on your own.

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A professional is someone who is capable
of managing their own improvement.

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That is the approach that virtually
all professionals have learned by.

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That's how doctors learn,

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that's how lawyers do,

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scientists ...

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musicians.

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And the thing is, it works.

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Consider for example legendary
Juilliard violin instructor Dorothy DeLay.

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She trained an amazing roster
of violin virtuosos:

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Midori, Sarah Chang, Itzhak Perlman.

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Each of them came to her as young talents,

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and they worked with her over years.

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What she worked on most, she said,

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was inculcating in them
habits of thinking and of learning

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so that they could make their way
in the world without her

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when they were done.

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Now, the contrasting view
comes out of sports.

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And they say "You are never done,

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everybody needs a coach."

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Everyone.

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The greatest in the world needs a coach.

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So I tried to think
about this as a surgeon.

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Pay someone to come
into my operating room,

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observe me and critique me.

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That seems absurd.

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Expertise means not needing to be coached.

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So then which view is right?

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I learned that coaching came into sports
as a very American idea.

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In 1875,

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Harvard and Yale played one of the very
first American-rules football games.

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Yale hired a head coach;

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Harvard did not.

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The results?

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Over the next three decades,

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Harvard won just four times.

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Harvard hired a coach.

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(Laughter)

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And it became the way that sports works.

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But is it necessary then?

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Does it transfer into other fields?

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I decided to ask, of all people,

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Itzhak Perlman.

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He had trained the Dorothy DeLay way

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and became arguably the greatest
violinist of his generation.

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One of the beautiful things about
getting to write for "The New Yorker"

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is I call people up,
and they return my phone calls.

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(Laughter)

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And Perlman returned my phone call.

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So we ended up having
an almost two-hour conversation

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about how he got
to where he got in his career.

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And I asked him, I said,
"Why don't violinists have coaches?"

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And he said, "I don't know,

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but I always had a coach."

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"You always had a coach?"

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"Oh yeah, my wife, Toby."

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They had graduated
together from Juilliard,

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and she had given up her job
as a concert violinist

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to be his coach,

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sitting in the audience,

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observing him and giving him feedback.

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"Itzhak, in that middle section,

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you know you sounded
a little bit mechanical.

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What can you differently next time?"

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It was crucial to everything
he became, he said.

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Turns out there are numerous problems
in making it on your own.

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You don't recognize the issues
that are standing in your way

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or if you do,

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you don't necessarily
know how to fix them.

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And the result is
that somewhere along the way,

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you stop improving.

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And I thought about that,

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and I realized that was exactly
what had happened to me as a surgeon.

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I'd entered practice in 2003,

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and for the first several years,

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it was just this steady, upward
improvement in my learning curve.

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I watched my complication rates drop
from one year to the next.

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And after about five years,

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they leveled out.

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And a few more years after that,

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I realized I wasn't getting
any better anymore.

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And I thought: "Is this
as good as I'm going to get?"

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So I thought a little more and I said ...

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"OK,

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I'll try a coach."

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So I asked a former professor
of mine who had retired,

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his name is Bob Osteen,

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and he agreed to come to my operating room

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and observe me.

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The case --

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I remember that first case.

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It went beautifully.

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I didn't think there would be
anything much he'd have to say

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when we were done.

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Instead, he had a whole page
dense with notes.

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(Laughter)

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"Just small things," he said.

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(Laughter)

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But it's the small things that matter.

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"Did you notice that the light
had swung out of the wound

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during the case?

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You spent about half an hour

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just operating off the light
from reflected surfaces."

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"Another thing I noticed," he said,

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"Your elbow goes up in the air
every once in a while.

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That means you're not in full control.

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A surgeon's elbows should be down
at their sides resting comfortably.

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So that means if you feel
your elbow going in the air,

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you should get a different instrument,
or just move your feet."

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It was a whole other level of awareness.

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And I had to think,

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you know, there was something
fundamentally profound about this.

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He was describing what great coaches do,

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and what they do is they are
your external eyes and ears,

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providing a more accurate
picture of your reality.

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They're recognizing the fundamentals.

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They're breaking your actions down

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and then helping you
build them back up again.

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After two months of coaching,

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I felt myself getting better again.

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And after a year,

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I saw my complications
drop down even further.

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It was painful.

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I didn't like being observed,

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and at times I didn't want
to have to work on things.

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I also felt there were periods where
I would get worse before I got better.

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But it made me realize

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that the coaches were onto something
profoundly important.

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In my other work,

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I lead a health systems innovation center
called Ariadne Labs,

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where we work on problems
in the delivery of health care,

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including global childbirth.

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As part of it,

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we had worked with
the World Health Organization

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to devise a safe childbirth checklist.

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It lays out the fundamentals.

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It breaks down the fundamentals --

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the critical actions
a team needs to go through

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when a woman comes in in labor,

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when she's ready to push,

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when the baby is out,

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and then when the mom and baby
are ready to go home.

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And we knew

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that just handing out a checklist
wasn't going to change very much,

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and even just teaching it in the classroom
wasn't necessarily going to be enough

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to get people to make the changes
that you needed to bring it alive.

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And I thought on my experience and said,

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"What if we tried coaching?

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What if we tried coaching
at a massive scale?"

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We found some incredible partners,

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including the government of India,

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and we ran a trial there
in 120 birth centers.

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In Uttar Pradesh,
in India's largest state.

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Half of the centers
basically we just observed,

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but the other half
got visits from coaches.

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We trained an army
of doctors and nurses like this one

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who learned to observe the care
and also the managers

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and then help them
build on their strengths

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and address their weaknesses.

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One of the skills for example
they had to work on with people --

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turned out to be
fundamentally important --

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was communication.

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Getting the nurses to practice speaking up
when the baby mask is broken

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or the gloves are not in stock

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or someone's not washing their hands.

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And then getting others,
including the managers,

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to practice listening.

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This small army of coaches
ended up coaching 400 nurses

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and other birth attendants,

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and 100 physicians and managers.

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We tracked the results
across 160,000 births.

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The results ...

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in the control group you had --

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and these are the ones
who did not get coaching --

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they delivered on only one-third
of 18 basic practices

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that we were measuring.

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And most important was
over the course of the years of study,

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we saw no improvement over time.

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The other folks
got four months of coaching

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and then it tapered off over eight months,

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and we saw them increase

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to greater than two-thirds
of the practices being delivered.

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It works.

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We could see the improvement in quality,

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and you could see it happen
across a whole range of centers

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that suggested that coaching
could be a whole line of way

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that we bring value to what we do.

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You can imagine the whole job category
that could reach out in the world

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and that millions of people could fulfill.

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We were clearly
at the beginning of it, though,

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because there was still a distance to go.

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You have to put
all of the checklist together

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to achieve the substantial
reductions in mortality.

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But we began seeing the first places
that were getting there,

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and this center was one of them

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because coaching helped them
learn to execute on the fundamentals.

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And you could see it here.

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This is a 23-year-old woman

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who had come in by ambulance,

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in labor with her third child.

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She broke her water in the triage area,

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so they brought her directly
to the labor and delivery room,

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and then they ran through their checks.

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I put the time stamp on here

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so you could see
how quickly all of this happens

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and how much more complicated
that makes things.

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Within four minutes,

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they had taken the blood pressure,
measured her pulse

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and also measured
the heart rate of the baby.

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That meant that the blood pressure cuff
and the fetal Doppler monitor,

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they were all there,
and the nurse knew how to use them.

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The team was skilled and coordinated.

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The mom was doing great,

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the baby's heart rate was 143,
which is normal.

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Eight minutes later, the intensity
of the contractions picked up,

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so the nurse washed her hands,

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put on clean gloves,

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examined her and found
that her cervix was fully dilated.

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The baby was ready to come.

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She then went straight over
to do her next set of checks.

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All of the equipment,
she worked her way through

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and made sure she had everything
she needed at the bedside.

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The baby mask was there,
the sterile towel,

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the sterile equipment that you needed.

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And then three minutes later,
one push and that baby was out.

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(Applause)

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I was watching this delivery,

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and suddenly I realized that the mood
in that room had changed.

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The nurse was looking
at the community health worker

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who had come in with the woman

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because that baby
did not seem to be alive.

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She was blue and floppy and not breathing.

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She would be one of that one-in-20.

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But the nurse kept going
with her checkpoints.

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She dried that baby with a clean towel.

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And after a minute,
when that didn't stimulate that baby,

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she ran to get the baby mask

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and the other one went to get the suction.

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She didn't have a mechanical suction
because you could count on electricity,

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so she used a mouth suction,

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and within 20 seconds,

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she was clearing out
that little girl's airways.

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And she got back a green, thick liquid,

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and within a minute
of being able to do that

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and suctioning out over and over,

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that baby started to breathe.

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(Applause)

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Another minute and that baby was crying.

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And five minutes after that,

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she was pink and warming
on her mother's chest,

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and that mother reached out
to grab that nurse's hand,

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and they could all breathe.

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I saw a team transformed
because of coaching.

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And I saw at least one life
saved because of it.

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We followed up with that mother
a few months later.

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Mom and baby were doing great.

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The baby's name is Anshika.

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It means "beautiful."

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And she is what's possible

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when we really understand

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how people get better at what they do.

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Thank you.

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(Applause)