Sunday, June 20, 2010

Gawande on the Matrix

Atul Gawande gave the commencement address at Stanford medical school this year. I thought it might be fun to rip-off a Bill Simmons schtick and do a retro-diary of my thoughts as I read through it. So here goes. (Text borrowowed from the New Yorker.)

Many of you have worked for four solid years—or five, or six, or nine—and we are here to declare that, as of today, you officially know enough stuff to be called a graduate of the Stanford School of Medicine. You are Doctors of Medicine, Doctors of Philosophy, Masters of Science. It’s been certified. Each of you is now an expert. Congratulations.
(Frank Drackman additionally received a Masters of His Own Domain upon graduation)

So why—in your heart of hearts—do you not quite feel that way?
(Because we just finished the entirely useless, waste of time, summer vacation known as fourth year of medical school!)

The experience of a medical and scientific education is transformational. It is like moving to a new country. At first, you don’t know the language, let alone the customs and concepts. But then, almost imperceptibly, that changes. Half the words you now routinely use you did not know existed when you started: words like arterial-blood gas, nasogastric tube, microarray, logistic regression, NMDA receptor, velluvial matrix.
(I use the word 'microarray' at least 17 times a day)

O.K., I made that last one up. But the velluvial matrix sounds like something you should know about, doesn’t it? And that’s the problem. I will let you in on a little secret. You never stop wondering if there is a velluvial matrix you should know about.
(When I was 11, my older cousin Chris told me all about his girlfriend's velluvial matrix. I acted like I knew exactly what he was talking about.)

Since I graduated from medical school, my family and friends have had their share of medical issues, just as you and your family will. And, inevitably, they turn to the medical graduate in the house for advice and explanation.

I remember one time when a friend came with a question. “You’re a doctor now,” he said. “So tell me: where exactly is the solar plexus?”

I was stumped. The information was not anywhere in the textbooks.

“I don’t know,” I finally confessed.

“What kind of doctor are you?” he said.
(Now come one. Solar plexus? Did this anecdote really happen? And was Gawande truly upset that he didn't know the location of a solar plexus? Did he crack open his anatomy textbook, frantically leaf through the index searching? In the words of my pretentious feminazi freshman English comp instructor---it just doesn't "ring true".)

I didn’t feel much better equipped when my wife had two miscarriages, or when our first child was born with part of his aorta missing, or when my daughter had a fall and dislocated her elbow, and I failed to recognize it, or when my wife tore a ligament in her wrist that I’d never heard of—her velluvial matrix, I think it was.
(Damn. Don't I feel like an ass after all those anti-Cost Conundrum posts. I hereby retract all jokes re:Gawande. The dude's had a tough life.)

This is a deeper, more fundamental problem than we acknowledge. The truth is that the volume and complexity of the knowledge that we need to master has grown exponentially beyond our capacity as individuals. Worse, the fear is that the knowledge has grown beyond our capacity as a society. When we talk about the uncontrollable explosion in the costs of health care in America, for instance—about the reality that we in medicine are gradually bankrupting the country—we’re not talking about a problem rooted in economics. We’re talking about a problem rooted in scientific complexity.
(Now we get into the meat of his point--that the complexity and depth of modern medicine is "too much" for the individual physician. More on this later.)

Half a century ago, medicine was neither costly nor effective. Since then, however, science has combatted our ignorance. It has enumerated and identified, according to the international disease-classification system, more than 13,600 diagnoses—13,600 different ways our bodies can fail. And for each one we’ve discovered beneficial remedies—remedies that can reduce suffering, extend lives, and sometimes stop a disease altogether. But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures. Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive. And we’re struggling. There is no industry in the world with 13,600 different service lines to deliver.
(Service line? Why are we using corporate jargon all of a sudden?)

It should be no wonder that you have not mastered the understanding of them all. No one ever will. That’s why we as doctors and scientists have become ever more finely specialized. If I can’t handle 13,600 diagnoses, well, maybe there are fifty that I can handle—or just one that I might focus on in my research. The result, however, is that we find ourselves to be specialists, worried almost exclusively about our particular niche, and not the larger question of whether we as a group are making the whole system of care better for people. I think we were fooled by penicillin. When penicillin was discovered, in 1929, it suggested that treatment of disease could be simple—an injection that could miraculously cure a breathtaking range of infectious diseases. Maybe there’d be an injection for cancer and another one for heart disease. It made us believe that discovery was the only hard part. Execution would be easy.
(This part seems forced and a little disingenuous. The multitude of diagnoses and treatment options available to doctors today does not necessarily demand instantaneous memorized command of all facets of medicine. I have no problem using these things called the "internet" and "medical textbooks" to read about topics I don't know or have forgotten. For big cases I prepare by reviewing the surgical atlas and reading up on the latest literature. For management of hypertensive crisis in the ICU, I quickly log on to UpToDate and then call back the nurse with an answer. It doesn't take long. Just because the answer to a patient problem initially eludes you, it doesn't mean you have to throw your hands up in the air and retreat to the safety of the "50 or so diagnoses you are comfy with".)

But this could not be further from the truth. Diagnosis and treatment of most conditions require complex steps and considerations, and often multiple people and technologies. The result is that more than forty per cent of patients with common conditions like coronary artery disease, stroke, or asthma receive incomplete or inappropriate care in our communities. And the country is also struggling mightily with the costs. By the end of the decade, at the present rate of cost growth, the price of a family insurance plan will rise to $27,000. Health care will go from ten per cent to seventeen per cent of labor costs for business, and workers’ wages will have to fall. State budgets will have to double to maintain current health programs. And then there is the frightening federal debt we will face. By 2025, we will owe more money than our economy produces. One side says war spending is the problem, the other says it’s the economic bailout plan. But take both away and you’ve made almost no difference. Our deficit problem—far and away—is the soaring and seemingly unstoppable cost of health care.
(Yes, occupying three countries half way around the world is a mere drop in the pan of federal spending!)

We in medicine have watched all this mainly with bafflement, even indifference. This is just what good medicine is like, we’re tempted to say. But we’d be ignoring the evidence. For health care is not practiced the same way across the country. There is remarkable variability in the cost and quality of care. Two communities in the same state with the same levels of poverty and health can differ by more than fifty per cent in their Medicare costs. There is a bell curve for cost and quality, and it is frustrating—but also hopeful. For those getting the best results—the hospitals and doctors measured at the top of the curve for patient outcomes—are not the most expensive. They are sometimes among the least.
(Aha! It seems the good doctor has backed off a bit from his conclusions in the Cost Conundrum article that communities that spend more per capita on healthcare have worse outcomes. Now he hedges a bit, using the modifier "sometimes" to describe discrepancies in health care spending as they relate to outcomes. See this for details.)

Like politics, all medicine is local. Medicine requires the successful function of systems—of people and of technologies. Among our most profound difficulties is making them work together. If I want to give my patients the best care possible, not only must I do a good job, but a whole collection of diverse components must somehow mesh effectively.
(For now on, all doctors who practice in a hospital setting need to meet for three hours every other Monday morning with representatives from ancillary care, hospital administration, nursing, physical therapy, food services, patient transportation, the candy stripers, the old lady who brings around the gentle giant siberian husky petting dog for patients to touch, janitorial services, etc for a collegial intradiscplinary staff meeting to discuss ways of enhancing hospital teamwork.)

Having great components is not enough. We’ve been obsessed in medicine with having the best drugs, the best devices, the best specialists—but we’ve paid little attention to how to make them fit together well. Don Berwick, of the Institute for Healthcare Improvement, has noted how wrongheaded this is. “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,” he says. He gives the example of a famous thought experiment in which an attempt is made to build the world’s greatest car by assembling the world’s greatest car parts. We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo: “What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.” Nonetheless, in medicine, that’s exactly what we have done.
(And if you take the engine of a Pinto, the body of a Edsel, the transmission of any 1980's era Chevrolet you get: a very cheap and ugly piece of shit.)

Earlier this year, I received a letter from a patient named Duane Smith. He was a thirty-four-year-old assistant grocery-store manager when he had a terrible head-on car collision that left him with a broken leg, a broken pelvis, and a broken arm, two collapsed lungs, and uncontrolled internal bleeding. The members of his hospital’s trauma team went swiftly into action. They stabilized his fractured leg and pelvis. They put tubes in both sides of his chest to reĆ«xpand his lungs. They gave him blood and got him to an operating room fast enough to remove the ruptured spleen that was the source of his bleeding. He required intensive care and three weeks of hospital recovery to get through all this. The clinicians did almost every single thing right. Smith told me that to this day he remains deeply grateful to the people who saved him.

But they missed one small step. They forgot to give him the vaccines that every patient who has his spleen removed requires, vaccines against three bacteria that the spleen usually fights off. Maybe the surgeons thought the critical-care doctors were going to give the vaccines, and maybe the critical-care doctors thought the primary-care physician was going to give them, and maybe the primary-care physician thought the surgeons already had. Or maybe they all forgot. Whatever the case, two years later, Duane Smith was on a beach vacation when he picked up an ordinary strep infection. Because he hadn’t had those vaccines, the infection spread rapidly throughout his body. He survived—but it cost him all his fingers and all his toes. It was, as he summed it up in his note, the worst vacation ever.

When Duane Smith’s car crashed, he was cared for by good, hardworking people. They had every technology available, but they did not have an actual system of care. And the most damning thing is that no one learned a thing from Duane Smith. For we have since had the exact same story occur in Boston, with an even worse outcome. Indeed, I would bet you that, across this country, we miss the basic, unglamorous step of vaccination in probably half of emergency splenectomy patients.
(Ok. Now we have to interrogate this line of thinking. No more jokes. Gawande seems to be advocating for an algorithmic, systems-based paradigm of medicine, one in which the parts, i.e physicians, are mere cogs in some sprawling, evidence-based machine of health care delivery. There are too many diagnoses, too many treatment options, and too much innovation to be apprised of, as individual doctors. Therefore, we need to limit our spheres of responsibility. A specialist for every facet of health care. Blood pressure too high? Go see a cardiologist. That rash you got after hiking in the woods? Go see this dermatologist. Need your thyroid removed? Go downtown to see the endocrine surgeon. This is an attack on generalists, an attack on the idea that an individual doctor, dedicated and intellectually curious, can provide optimal care for his/her patients. And the example he provides of Duane Smith seems to paradoxically repudiate his entire theorem. All these good doctors working together but somehow they all forgot to prescribe the necessary vaccination. Gawande would say that the problem lay in an inappropriately designed and monitored 'system'. I would counter that the component parts, the doctors, individually failed the profession and henceforth the patient. How do you forget to give Pneumovax after taking out a spleen? That's simply bad doctoring. That's a general surgery 101 exam question.)

Why does anyone receive suboptimal care? After all, society could not have given us people with more talent, more dedication, and more training than the people in medical science have—than you have. I think the answer is that we have not grappled with the fact that the complexity of science has changed medicine fundamentally. This can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door. We have to be more like engineers building a mechanism whose parts actually fit together, whose workings are ever more finely tuned and tweaked for ever better performance in providing aid and comfort to human beings.
(This resigned attitude to the impossibility of staying up to date on the latest medical developments is saddening. I don't know what to say. Maybe I'm just a 37 year old dinosaur.)

You come into medicine and science at a time of radical transition. You have met the older doctors and scientists who tell the pollsters that they wouldn’t choose their profession if they were given the choice all over again. But you are the generation that was wise enough to ignore them: for what you are hearing is the pain of people experiencing an utter transformation of their world. Doctors and scientists are now being asked to accept a new understanding of what great medicine requires. It is not just the focus of an individual artisan-specialist, however skilled and caring. And it is not just the discovery of a new drug or operation, however effective it may seem in an isolated trial. Great medicine requires the innovation of entire packages of care—with medicines and technologies and clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually, and shown to produce ever better service and results for people at the lowest possible cost for society.
(Yikes. That last sentence evokes an uneasy Orwellian utopia. Do I have to report to room 101 for a session with O'Brien if I write for Nexium instead of Prilosec for GI ulcer prophylaxis on a post op patient??)

When you are sick, this is what you want from medicine. When you are a taxpayer, this is what you want from medicine. And when you are a doctor or a medical scientist this is the work you want to do. It is work with a different set of values from the ones that medicine traditionally has had: values of teamwork instead of individual autonomy, ambition for the right process rather than the right technology, and, perhaps above all, humility—for we need the humility to recognize that, under conditions of complexity, no technology will be infallible. No individual will be, either. There is always a velluvial matrix to know about.
(Subsume the individual into the Great Intradisciplinary Whole! The Maoist in me is feeling warm and fuzzy right now. But seriously, it's one thing to encourage greater communication between different specialists and to penalize those docs who are doing unnecessary procedures just for the compensation; it's quite another to throw in the towel on individual accountability and the ideal of the dedicated, astute physician who always strives to do the right thing for his/her patients. Kierkegaardian Individual Ethos trampled under foot by Henry Fordian mechanization and interchangeable parts! Listen, we don't need a brand new system or a restructuring of some quasi private/public healthcare bureaucracy. We need better doctors. We need to inculcate a stronger ethic of personal responsibility, both to our patients and to the health care system as a whole. I've said it a million times in this blog--- becoming a doctor ought not to be some default pathway for high achieving college kids who can't decide what else they want to do. It's a hard job, but rewarding as hell when you approach it with the right mind frame.)

You are joining a special profession. Doctors and scientists, we are all in the survival business, but we are also in the mortality business. Our successes will always be restricted by the limits of knowledge and human capability, by the inevitability of suffering and death. Meaning comes from each of us finding ways to help people and communities make the most of what is known and cope with what is not.
(I can't argue with those sentiments.)

This will take science. It will take art. It will take innovation. It will take ambition. And it will take humility. But the fantastic thing is: This is what you get to do.
/mass of students toss grad hats and gowns in the air and charge out of locker room screaming and yelling like banshees into the Pacific Ocean and swim for an undeteremined hospital in China.
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Josh said...

This is what I don't understand about people who devote themselves so entirely to the idea that medical science and evidence based medicine is ALWAYS going to be best option and is ALWAYS right. Because even the most recent medical history doesn't support it at all. People thought there was no way bacteria could live in the stomach and cause ulcers. Remember intensive insulin control? - first it was good, now its bad. Or Xigris? And what about all of these 'never' events that actually seem to happen a few times in all studies regardless if everyone did everything possible to prevent them. 'Evidence-based medicine' is like a Garmin GPS for your car - its good to have, it generally does a good job, but every once in a while it drives you to the projects when you're trying to go to dinner at a colleague's house. That's why there's a person with a brain who is capable of synthesizing all of the real-time data before him/her that is actually navigating the car and can thus determine that things actually don't look quite right. This is somewhat akin to the difficult role the modern doctor must assume, and that's where your call for personal responsibility comes in, and I think it can't be echoed enough. I wonder how much 'in the trenches' patient care someone who thinks otherwise is actually doing, because it sounds much more like the words of a hospital administrator than a busy practicing physician.

Emmanuelle said...

Can I just say how much I adore you?
When i read this post, I'm thinking "yes, this is exactly what I think or how I feel' but I would never be able to articulate it even one tenth as well as you do. For the most part, it's still somewhere in my brain in a shapeless magma...
And yes, it makes me seethe that 99.9% of the time, this whole "team" concept translates onto no one taking responsibility for anything.

james gaulte said...

Yes, I think much of the message of the graduation address was "the notion of an individual physician taking care of an individual patient and being responsible for that care is sooo last year's approach." I am amazed and gratified that a surgeon younger than 40 years shares some common values with a retired doc who began practice at a time when no one even questioned the primacy of the fiduciary duty of the physician to the patient and physician responsibility and no one blamed a screw up on a system failure.

Anonymous said...

I agree!

Buckeye, an entire generation is coming up having had no personal responsibility and expecting to have none. You get kind of tired constantly being the one to grab that basketball before it rolls off the court. You can throw it back in to one of the "team" but more often that person will just stand there and let the ball hit them rather than catch it... then you get accused of changing the game to dodgeball just because you naturally start to throw that ball a little harder :o)


Anonymous said...

I'm reading "Complications" right now, and I think you and I are picking up different ideas from what Gawande is saying.

I don't see Gawande calling for the individual doctor to give up responsibility or to be subsumed within a giant Medical System. I see him calling for a more systematic consideration of errors and how they can be fixed.

Back in the 70s, Lockheed had a quality control program called Zero Defects. They honest-to-God aimed to turn out airplanes -- complex, combat-ready airplanes comprising millions of parts -- with absolutely nothing wrong with them. They put together study groups, committees and research projects to look into everything that went into building a plane, trying to make the process foolproof every time. I don't know how well they succeeded, but I know there are plenty of C141s, C130s and C5As from that era still in service today.

I work for a cellphone company allied to several power companies. Many people in the power companies have dangerous jobs. They work with high voltage electric currents. They climb power poles. They drive hundreds of miles per day on their inspection routes. Even in my company, there are dangerous jobs. The guys who maintain our equipment have a lot to contend with under the best of circumstances. But they're needed most when the cicrumstances are worst; they sometimes have to get police escorts to take them into areas that are being evacuated because a hurricane is coming. The power crews will be out in force when the hurricane moves out, and all of them will need to use our system to communicate, so our guys have to install extra equipment before the hurricane arrives.

Accidents are inevitable when you work in an environment like this, with a lot of people who do things that are inherently unsafe. But a few years ago the top management in our companies looked at both the economic and human costs of accidents and decided we needed to do something. They began a program to reduce our accident rate to zero. They formed committees to figure out how to make jobs safer -- more training, better equipment, more emphasis on safe procedures. Safety became a factor in our annual bonuses. As you would guess, vehicle accidents are a concern, and they rose to a crisis level when a van full of power company employees on the way home from work got into an accident a little more than a year ago. Another driver failed to maintain his lane and clipped the van; the van rolled over and several employees were killed. Although the driver of the van was in no way at fault, management promptly enrolled every employee in all our companies in a defensive driving course. Everyone whose job involves significant driving had to take a road course; those of us with office jobs took the course online.

Although this emphasis on safety sometimes descends to the level of mere cheerleading, although it has cost the company a lot of money and although some of the measures it has led to are a hassle, you can't argue with the results. My particular company has now gone 613 days without a reportable accident. Our previous best was 276 days. Results for the power companies aren't quite as good because the power companies are bigger, but even there the emphasis on safety has reduced accidents to a place where they are rare. And let me point out that none of this has in any way reduced the level of responsibility of our employees or reduced the level of complexity of our jobs.

Medical errors are dangerous, relatively common, and could be prevented if doctors would get behind an effort like this. In "Complications," Gawande describes how anesthesiologists, in a single decade, reduced the number of anesthesia-related deaths to 1/20th of what they had been. Imagine the savings in money, lives and suffering if every medical specialty would do the same. That's what I hear Gawande calling for.

Anonymous said...

The Decreased Mortality in Anesthesia was due to
1: Pulse Oximetry
2: End Tidal CO2 Monitoring
3: Connecting the O2 and Nitrous knobs so you can't turn the oxygen any lower than 250 ml/min
99% of the preventable deaths were unrecognized Esophageal Intubations. Surgery/OB/everything else doesn't have anything that simple to prevent.


Anonymous said...

Surgery/OB/everything else doesn't know what can be prevented because there's no organized effort to conduct broad studies and make changes. What doctors mostly know about medical errors are the ones they've seen in their own practice, and that's too small a sample to draw any conclusions from. (You can see that I start with the premise that nearly all doctors are well-trained, conscientious and well-meaning!) Gawande mentions all the things you mention as helping to end anesthesia deaths, but those improvements didn't happen randomly. Random anesthesiologists didn't individually kill enough people over the course of their careers to make them change their patterns of practice. It took someone to study the causes of error and someone to champion broad changes to correct the errors. Someone has to create a culture in which safe practices -- like using pulse oximetry -- become standard.

In our company, for instance, we identified vehicle accidents as a safety concern that could be fixed. Statistically, the most common accidents are backing accidents. They can also be extraordinarily damaging. Think of all the incidents you've read about in which someone accidentally backs over their own child in the driveway. So in our company, everyone who drives a company vehicle or is on company business is required to walk a full circle around the vehicle before backing. When you back your service vehicle out of the parking lot in the morning. When you go to a customer location and need to back out. When you go to lunch at a restaurant. It is NEVER all right to back your vehicle without making the circle.

Needless to say, it's a firing offense if you text while driving in a company vehicle or while on company business. You don't even have to have an accident; your boss just has to find out about it.

Now, it's not that we ever had an unusual number of backing or texting accidents. Like everyone, we find lots of different ways to screw up. But if you want to eliminate accidents -- and we do -- you have to make people adopt safe habits and use them all the time. Maybe we'd only have one backing accident in a year if we didn't make everyone walk the circle. By requiring that walk, we eliminate that one accident. It's worthwhile. Like they used to say about millions of dollars, an accident here, an accident there, pretty soon it starts to add up.

Before medical errors can be reduced, doctors have to accept the idea that they can be. That's a hard sell. (The benefits of having medical practitioners wash their hands before seeing patients have been known for centuries, yet some hospitals are still fighting that battle!) Doctors generally do a stupendous job, but there's room for improvement.