- Constructive criticism of medical practice aims to improve it, not to deny its successes.
- Some of modern medicine’s advances come about through highly complex processes, which have a lot to go wrong.
- Failures may come about because the knowledge necessary to avoid them is unknown or because it is incorrectly applied.
- One of the main reasons knowledge is incorrectly applied is because practitioners have no reason to care if things are done properly or not.
The two posts will be my commentary on a couple of themes that run through the lectures, and are not intended to repeat the content of the lectures themselves which are:
Critiquing medicine is not advocating quackery
Gawande’s lectures amount to a critique of the way modern medicine is practiced. To me, it’s clear that his intention in doing so is to make medicine better. As I was listening, I realised that someone, perhaps a lot of someones, are going to think he said modern medicine is fundamentally flawed. It is not. Nothing that Gawande says amounts to advocating for medicine to be replaced with faith healing, homeopathy, untested herbal medicines or any other quackery.
To underline the point, let’s consider some of the successes of modern medicine, which are spectacular. Smallpox, which was killing and disfiguring children throughout the world as recently as 1920, was completely eradicated in 1979. Polio, which was killing and crippling children in 125 countries as recently as 1988 is now only endemic in three countries and is on track to be the next disease to be eradicated. Malaria cases have halved in the last 15 years throughout the world. In Africa, a continent that includes many of the poorest countries in the world, childhood deaths have fallen by more than a third since 1990.
Modern medicine works. The purpose of critiquing it is to make it work better, not to argue for replacing it.
Improved procedures means dealing with complexity
In his second lecture, Gawande describes the case of a three-year-old girl who made a full recovery after having been underwater for half an hour. It was an extraordinary achievement of skill and technology, but also of organisation. Specialists not only had to perform highly skilled tasks without a single mistake, but also to co-ordinate with each other on an ongoing basis. There was no schedule for when a given skill was going to be needed. They simply had to keep monitoring the girl and reacting to her.
The procedures that saved the girl were developed from the hospital’s experience with avalanche victims, and the learning process that had to happen before that girl went into the pond adds another level of complexity. It must have required analysis of every case that came in to understand where something could have been done better. For that medical team to have learned, people must have acknowledged that someone who had died may still be alive if they’d done something differently.
We all know plenty of people who learn nothing from our their mistakes because it’s easier to deny they made a mistake in the first place, even over the most trivial things. If you’re nodding at that, ask yourself if you’re any better at learning from your own mistakes. I wouldn’t claim that I am. Now I ask myself whether I’d be willing to make the admissions that people must have made months or years before that girl fell through the ice, which ultimately saved her life. I’m not sure I have the courage.
Now let’s consider how difficult it must have been to develop and implement the processes that kept that little girl alive. As I’m typing this, I’m constantly irritated that I can’t have Microsoft Word open at the same time as Adobe Reader without the latter crashing. It’s been a well-known bug for at least a couple of years, but two leading software companies have been unable to fix a simple problem of interaction. We can all be grateful that medicine sets a higher standard for itself than the software industry.
There are two points I take away from the story of the saved girl. The first is that as medicine gains in capability, it gains in complexity. Even interventions that are simple to apply, such as new drugs and vaccines, require a complex process of research and refinement to establish whether they work and how best to use them. The more complex a system becomes, the more there is to go wrong. The fact that something is difficult is no comfort if someone you care about who ends up crippled or dead because of a mistake, and nor should it be. The onus is on professional practitioners of medicine and research to get it right, not on patients to forgive them for getting it wrong. That’s why they’re called professionals. But to get it right, someone has to make a highly complex system work.
Which segues to the second point: to engage with progress is to engage with complexity. That’s not a phenomenon limited to the medical field, and for the writers amongst us, this is where Gawande’s insights can inform us on the nature of any progress we may want to write about.
Types of fallibility
Gawande goes further than simply stating that innovations are complex, and goes on to categorise the types of failure. He quotes an essay titled Toward a theory of medical fallibility which is unfortunately stuck behind a paywall. Based on the essay, Gawande identifies three types of failure:
Ignorance: The knowledge needed to reach the desired outcome does not exist.
Ineptitude: The knowledge needed to reach the desired outcome exists but is not correctly applied.
Necessary fallibility: Science is unable to deliver the knowledge needed to reach the desired outcome.
To illustrate the concept of necessary fallibility, Gawande uses the example of a hurricane. Because a hurricane behaves chaotically, it is not possible to precisely predict what it will do. Medicine deals with the human organism, which is a product of an estimated 37,200,000,000,000 human cells, and ten times as many bacteria. The cells form multiple tissues and organs that are constantly metabolising, functioning and replacing their cells while interacting with each other to form you and me. Good luck trying to understand of that lot, even before something goes badly enough wrong to involve a doctor.
Because of the complexity of the human organism, we will never escape a degree of necessary fallibility. Ignorance lies in the space between what is known and what is knowable but not yet known, so it can be addressed by scientific research. However, a doctor confronted with a patient has to work with the state of knowledge as it is at the time, not as it may be in five or ten years. Thus the source of fallibility which is directly under the control of the doctor or nurse is ineptitude.
Ineptitude may operate on many levels. A few years ago, I was working in a country that shall remain nameless. I found that although the World Health Organisation recommends influenza vaccination for all adults and especially the elderly, the pharmacies could not offer it because the government’s department of health had not licenced it. The knowledge that influenza vaccine saves lives was available, but the mechanisms in place were actively preventing that knowledge being used. It was a form of ineptitude that kicked in before systems got anywhere near practitioners.
On a more individual level, Gawande uses the example of his son’s blood oxygen levels being misread because someone had put the monitor on the wrong finger. Ineptitude in the form of a simple mistake.
In his final lecture, Gawande identified a common reason for ineptitude: no one cares. His examples of medical practice in India are terrifying: obstetricians who do not wash their hands before performing vaginal examinations and doctors prescribing medication for heart conditions on the basis of three-minute consultations. And let’s not point the finger at India just because that was where Gawande’s research was carried out. I know many people based in the UK or USA who have their own horror stories, which makes me suspect the problem is more widespread than Gawande implies. I have a few of my own, although I won’t hear a word against most of the doctors and nurses who have treated me over the last few years.
It’s not just Indian doctors whose standards are likely to slip if no one cares how they are applied. It’s human nature that if high performance is harder work than mediocre performance but receives the same reward, most people will slip into mediocre performance. Left unchecked, the situation can deteriorate to an extent that is incomprehensible to someone seeing it for the first time. I would bet a substantial amount of money that the highly publicised crisis at Stafford Hospital came about in that dangerously gradual way.
As a worker, I’ve been guilty of it myself. As a project manager, I’ve found myself engaged in an ongoing battle to prevent it.
Which brings the commentary back to fiction writing. Gawande’s critique of medicine and how to improve it could be applied to any organisation. At one point, he talks about applying principals from aviation safety to medical practice, which shows that we can take what he’s said about medicine and apply it to any situation that catches our attention. Or we could just write about medicine. He’s generated a few starting points. The challenge for the fiction writers among us is to take what Gawande is talking about and apply work them into personal situations.