Atul Gawande delivered the commencement address at Harvard Medical School this year, and it was published in The New Yorker.
The Phantom would like you to know, right from the start, he is a big fan of Dr. Gawande, of Harvard Medical School and of The New Yorker (not necessarily in that order.)
But there is something disturbing about Dr. Gawande's remarks, and I'm having trouble distilling just what it is that bothers me. The word "facile" keeps percolating up, and that's not a word I'm fond of. But it sort of gets stuck in place, somewhere in the higher cortices, blocking synapses and I'm stuck with it.
Here's how it breaks down: First, there is the history of medical practice as depicted by Dr. Gawande, which does not fit the history I have lived through over the past decades. I think I can speak for almost the past 50 years of medical practice even though I haven't been in medicine quite that long--I have my sources. Second, there are the claims about what ails us now (an unwillingness to work in groups and big organizations). Third, there is the solution, or set of solutions (checklists, identifying best practices, insisting on these clearly identifiable best practices and using this approach to solve the financial problems of American healthcare) and Lastly, there's the endorsement of where our new young doctors are heading, the skills they seek and the values they embrace.
History as He Sees It:
"We are at a cusp in medical generations."
I heard that at my own graduation nearly forty years ago and have heard it every year since. It seems medicine is forever on the cusp of something.
"When doctors could hold all the key information patients needed in their heads and manage everything required themselves."
He alludes to 1937, and maybe doctors could know it all then, but clearly, I did not think I had a chance to know it all, forty years ago. Even when doctors were mixing up their own medicines, I doubt they thought they knew it all. There was never a use-to-was like this, the good old days when things were simply and a doctor could know everything. Good doctors have always been humble enough to know how little they knew.
"One needed only an ethic of hard work, a prescription pad, a secretary and a hospital willing to serve as one's workshop."
Dream on. Never was such a time.
What Ails Us Now:
"Two million patients pick up infections in American hospitals."
"Forty per cent of coronary disease patients and sixty percent of asthma patients receive incomplete or inappropriate care."
I'm sure he's referring to some study or another, but ask yourself, how would you design a study to actually figure out exactly where patients picked up their infections and whether or not patients were appropriately treated? First you'd have to know exactly when and where those infections were acquired and you'd need to be able to know really adequate coronary and pulmonary care when you saw it and you'd need really nifty metrics to figure out how often this care was delivered.
Just a for instance: When beta blockers were new, back in the 1970's, the worst thing you could do with them was to give them to a patient in congestive heart failure. Giving spironolactone to a patient with congestive heart failure was thought to be pissing in the wind--more potent diuretics meant good care. Aspirin was thought to be irrelevant. Today, quality of care people track beta blockers, spironolactone and aspirin as indices of good care. So what was bad to ineffective care then is good care now. Do you really think these things will still be good care ten years from now? So how do we get so high and mighty about knowing what the right thing to do for Americans hearts really is?
"It's like no one's in charge--because one is."
Again, teamwork and working as part of a big system is nothing new. As a medical student and an intern, forty years ago I worried I could never survive in private practice because all I knew was my part as part of the big wheel of the hospital. I realized there were dozens of people who were behind me every time I treated a GI bleeder, from the lab techs to the blood bank techs to the nurses to the guy in the ER who screened the patient. Cooperation is nothing new in American Medicine.
"Medical performance follows a bell curve, with a wide gap between the best and worst results."
Interesting if you could actually identify metrics for what makes for good medical performance. This reminds me (you knew this was coming) of The Wire that wonderful scene where Howard "Bunny" Colvin tells his young detective sergeant, Carver, about the destructive effects statistics have had on police work. When all you care about is how many arrests you've made, or how many pounds of heroin you've seized, you stop talking to the woman on her stoop, who might tell you who raped the girl down the block, or who shot the kid in the street. You're too busy buffing your statistics; you don't care about getting to know the woman on the stoop.
The Solutions:
"You must acquire an ability to recognize when you've succeeded and when you've failed for patients."
He's right about that. What is more interesting is how.
"People in effective systems become interested in data. They put effort into collecting them, refining them, understanding what they say about their performance."
Actually, I couldn't agree more. This is really Moneyball , which every doctor should read. When you just care about batting averages, you miss better metrics, like on base percentage.
"The simplest checklist...[can allow us to] eliminate many hospital infections, to cut deaths in surgery by as much as half globally, and to slash costs, as well."
He's written a whole book about checklists. He is a true believer. But the first sign of aging is when you find you are repeating yourself. I really like checklists. Use them all the time. If they are good enough for airline pilots, they are good enough for me.
"The recognition that others can save you from failure no matter who they are in the hierarchy."
This is really a cool idea. Not new, but very cool. When I was a third year medical student, I was astonished when the circulating nurse in the OR told the surgeon, who everyone was afraid of, to reglove because he had "Broken scrub." The system was in place then, as I'm sure it still is. The nurses watched the surgeons and no surgeon could pull rank when it came to breaking sterile field.
The New Young Doctors Will Save Us
"I see this in the burst of students obtaining extra degrees in fields like public health, business administration, public policy...Of some two hundred students graduating today, more than thirty five are getting such degrees, intuiting that ordinary medical training wouldn't prepare you for the world to come."
I'd love to believe this. But another way to see it is this new crop of physicians and surgeons are not committed to medicine; they have seen the future and they realize they need a way out of medicine. Or as one fourth year student told his Dean, "I do not want to do research. I do not want to teach in a medical school. I want to do my colonoscopies from nine in the morning to three PM and be on the boat with my family by 4 PM."
And this is the generation of medical students who call the ROAD to happiness Radiology, Opthalmology, Anesthesia and Dermatology--specialities which have the following characteristics :1/ High income 2/ Minimal interaction with patients 3/ Good, predictable hours.
So Atul, I love your enthusiasm and your drive to improve medical care in America.
But as my mother, who taught high school, once told me, when I asked her what the job of a high school principal is, she replied, very simply: "He has to know what good is. And that's no small task."
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