Lessons from Professor Atul Gawande
Atul Gawande, surgeon, New Yorker magazine writer and Professor at Harvard spoke to the Commonwealth Club in San Francisco in 2007; much of his speech was broadcast in the ABC Radio National program “Background Briefing” in January 2008.
Here are some stories from Gawande’s talk.
In his final year as a medical student training at a hospital, Gawande attended a patient under the instruction of the intern. He went to see her twice each day for the next several days, checked her vital signs, listened to her lungs, looked up her labs. Each day, she stayed more or less the same. She had a cough, she had no fever, she just didn’t feel good. “We’d give her antibiotics and wait her out, I figured. She’d be fine.”
One morning on 7 o’clock rounds she complained of insomnia and having sweats overnight. “We checked the vitals, she still had no fever, her blood pressure was normal, her heart rate was running maybe slightly faster than before, but that was all. ‘Keep a close eye on her’, the senior resident told me. Of course’, I said.”
In fact the senior resident decided to check on the patient himself: she turned out to have a high fever, low blood pressure and other complications. He put her on new antibiotics, intravenous fluids, and medications to support her blood pressure for what was developing into septic shock from a fulminant, resistant pneumonia. She survived! Indeed she never needed to be put on a ventilator, the fever stopped in 24 hours and she got home in three days. “The senior resident had seen something about her that worried him when he first visited with the intern. He could have had a nurse check on her. He visited even though it disrupted his other activities to which he had committed himself.”
Warren Warwick is at theUniversity of Minnesota Program in Minneapolis ““ it’s the top centre for the treatment of Cystic Fibrosis (CF), a genetic disease that there is no cure for, a disease that gums up their lungs, interferes with their ability to digest food, and it is the disease they will die from some day. Gawande joined Warwick as he saw a 17-year-old high school senior named Janelle, who had been diagnosed with CF at the age of 6, and had been under his care ever since. “She’d come for her routine 3-months check-up, she wore dyed black hair to her shoulder blades, black eyeliner, 4 ear-rings in each ear, 2 more in an eyebrow, and a stud in her tongue. Warwick was 76 years old, tall, stooped and frumpy-looking, with a well-worn tweed jacket, liver spots dotting his skin, whispey grey hair, by all appearances a doddering, mid-century academic.
“Warwick pulled out her latest lung function measurements. There had been a slight dip. Although she was doing well ““ in fact better than the average child without CF. But now she was at around 90% compared with 109% three months earlier. Ups and downs are to be expected but this was not the way Warwick saw the results. He believed that excellence came from seeing on a daily basis the difference between being 99.5% successful, and being 99.95% successful.”
Warwick kept asking questions. It turned out that she had a new boyfriend, a new job and was working nights after school. “The boyfriend had his own apartment, and she was either there or at a friend’s house most of the time. So she rarely made it home to take her treatments. At school, new rules required her to go to the nurse for each dose of medicine during the day, so she skipped going. ‘It’s such a pain’, she said. He learned that there were some medicines she took and some she didn’t.”
“Warwick proposed a deal. Janelle would go home for a breathing treatment every day after school and get her best friend to hold her to it. She’d also keep her medications in her bag, or her pocket at school, and take them on her own. ‘The nurse won’t let me’, she said. ‘Don’t tell her’, he said. And thereby deftly turned taking care of herself, into an act of rebellion.
“There are a few attributes to the people who are in the institutions that are at the top of the curve, for what they do, in something like medicine. One, and you saw this in Warwick, is that they have the capacity for diligence, attention to detail. And you saw it in the way that he dove down into Janelle’s life enough to grasp not only that she was not taking her medicines, but then also why. The way the boyfriend played into her life, her job, everything else.”
Gawande concluded his talk by recounting a quite different situation. “thinking about how [the military] succeeded in saving so many lives in this war compared to previous wars? Well in the Persian Gulf war, we had a 25% likelihood that a soldier injured on the battlefield would die. And in this war it’s less than 10%. Their weekly effort to follow exactly how often people are wounded, and then whether they died, what their outcomes were. That allowed them to find holes, failures, things that could be fixed. They recognised for example, that soldiers weren’t wearing their Kevlar, they would be coming in with heart and lung wounds that they shouldn’t have been having if they had their Kevlar vests on. And so they held the commanders responsible for making sure that the soldiers wore their Kevlar always, even if it was 110-degrees outside. Even if they complained about the 18 pound weight that they had to lug around.”
They also recognised that the transport time from the battlefield to the operating table was too long. And they did a kind of counter-intuitive thing: they decided to move the surgeons and the nurses, the anaesthetists, right out near the battlefield in tents. “Because they had to be stripped down to what they could carry in a few armoured trucks, they had to actually forego a lot of the technology we depend on nowadays. But the process ended up saving more lives than we’ve ever saved in history from devastating wounds, people surviving damage that we always thought was unsurvivable before.”
“So besides diligence, besides surveillance, another attribute of those who were at the top of what they were doing in medicine, is that they’ve learned to do right, despite enormous obstacles to success. Despite sometimes moral obstacles.
“There is an essay, one of my favourite essays by two philosophers named Samuel Gorwitz and Alastair Macintyre, and it’s on the nature of fallibility. What they pointed out was that there are in essence, only two main reasons why people are fallible, why we have failure. One reason is ignorance, meaning that we have a general lack of knowledge about the particulars of how the world really works. But a second source of failure is ineptitude, as they call it, meaning that the knowledge is there, but an individual fails to apply it correctly.”