Thursday, June 2, 2011

A Response to Atul Gawande

And since you know you cannot see yourself;
so well as by reflection, I, your glass,
will modestly discover yourself,
that of yourself which you yet know not of. ~ William Shakespeare

You know how some words immediately leap an image into your minds eye? Just like that! One word and the image comes tumbling down. I say, Rose and you the reader immediately grasp the essence of what I am saying. The word invokes the image, the fragrance and sometimes even an event associated with it. Well then let me say Cowboy. What comes to mind in your head?

Wild Bill Hickok?  Poor James Butler Hickok died at the tender age of 39 years with a lead shot in the back of his head. He was a gambler, Marksman and a gunfighter.

Sundance Kid? Well Harry Alonzo Longabaugh was a robber and member of the Wild Bunch gang and committed suicide when surrounded by the posse at age 42 years.

Okay one more and then we will get to the real story. Jesse James? Young Jesse Woodson James alas got some lead in the back of his head also at an even more tender age of 35 years. He was an outlaw, a bank and train robber and member of a Clement Gang.

So what did these people have in common besides the obvious? You might have guessed it they were all Cowboys!

So the other day I read a commencement address given by none other than the “Checklist” fame guy Atul Gawande MD and it made sense to consider the Cowboys and Indians story once again. Atul is certainly not like Geronimo or Chief Sitting Bull or even Chief Crazy Horse, even though his parents hail from India.

Now what was Atul preaching to the young, impressionable newly minted Harvard Medical School graduates? Ah but that brings us to the crux of this story.

Are the independent thinking doctors now to be labeled “Cowboys” for outside the box thinking. And does Atul want to take that rarity of independent thought away and render them to the heap of little Indians without a Chief? A weighty question, don’t you think?

The concept did arise in my mind when he went on to say that doctors no longer have the luxury of practicing the art of medicine. Well, he did not in so many words but definitely his words implied to that effect. For he preached that medicine will now be guided by the largesse of evidence based guidelines and that doctors may become irrelevant as decision makers except in a team spirit. The first part of that statement any hard-working, sleep-deprived physician will find issues with, but the second part implies that doctors don’t get along with each other and don’t seek each others opinions –that they do!

Atul then goes on to say that doctors of the future will have to rely on other paramedical personnel for proper case management. Atul the docs certainly rely on all possible means to heal their patients today, especially when they need supportive help from other disciplines. But that is not what you are talking about is it? You meant, and I don’t want to put words in your mouth, that the proper decision making for patient care would be rendered with much more alacrity by nurses, Social Health Care Workers and the “Panels that will determine the need for any care?” Don’t you? Have you bought into the new science of “Global Societal Struggle and Health Care Rationing?”

Well Dr. Gawande if what you propose is to pass, according to your progressive agenda, then far be it for me to force you to consider the foundational basis of medicine that harks back to the days of people like, Marie Curie, Edward Jenner, Louis Pasteur, William Harvey and the like. Whose names will join with that illustrious group?  Medicine has not sprung from little Indians thinking as a “Borg Collective.” If it were, then and maybe only then, I might consider some advancement in science that could plod along in an advanced society, but even then it would be no match for the surprise, adeptness and intellectual leap of a single Captain Kirk! No not these little Indians, Pit Crews as you call them, they are being taught to mimic what is preached in the gospel written by the writers and the dreamers of progressive social coherence and they will merrily belch along to keep things simmering for a long, long time.

Oh, my dear man, what happened to you after borrowing the Checklist concept from the aviation industry ("The Checklist Manifesto") and making a name for your self, you have resorted to telling young and plastic minds in medicine that they must be reasonable in their thoughts when they practice. And by reasonable, you mean, make use of the template and lose their inherent wisdom? It reminds me of a quote by George Bernard Shaw, “The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt ... Therefore all progress depends on the unreasonable man”

Oh by the way, I did like three of your Five Rules from 2005. (1)

Rule #1.
Ask an unscripted question. Or speak to strangers – in other words communicate with our patients. Great!
Rule #2
Don’t Whine. Even you must whine at times to let off steam. Maybe not. Maybe you are perfect.
Rule #3:
Count Something. Maybe good advice but all you are counting is sponges left in someone’s belly, rather then counting the Ns in a study using statistical manipulation to prove the improbable.
Rule #4:
Write Something. I wholly endorse this one. Bravo!
Rule #5
Change. Early adoption. Also a very important step for a scientist and someone energized to do the very best for his or her patient.

Even though the Five Rules in 2005 gave me some goose-pumps,  your entire 2011 monologue delivered at the Harvard Medial School Commencement Address covered me in a rash of bleeding blisters. (2)

Five Quotes from Atul Gwande’s Speech to Harvard Medical School in May 2011:

1. “We train, hire, and pay doctors to be cowboys. But it’s pit crews people need, the ability to implement at scale, the ability to get colleagues along the entire chain of care functioning like pit crews for patients.”

So what happened to that man that claimed such simple powerful ideas and morphed himself into advocating doctors to become “Pit Crews”

2. “I was part of the reason my children didn’t have enough teachers. We all are in medicine.”
Using political rhetoric of money for education, knowing full well that creativity, inspiration and devotion in teachers are not motivated by money and excellence in schools is NOT as a result of funding! You seem to want to anneal together the “knee bone” with the “breast bone.”

3. “We are now witnessing a global societal struggle to assure universal delivery of our know-how.”
There is a lot of nobility in that statement, and universal delivery of our know-hows are certainly needed in impoverished lands. Believe it or not the United States spends millions if not billions of dollars in medical supplies overseas. There are scores of Missionaries that carry out their selfless brave work in impoverished areas to their own detriment.

4. “They are symptoms of a deeper condition—which is the reality that medicine’s complexity has exceeded our individual capabilities as doctors.”
I don’t know about you, but the human body, its physiology and pathology has not changed much. Knowledge has increased but you can carry that in your iPhone, Blackberry or other device. It is the interpretation of the information that a doctor excels in and not the excessive content of information. So I don’t think our capabilities have been exceeded yet.

5. “Even the cowboys, it turns out, function like pit crews now.”  Corralling a disease also requires many disciplines, yet each person has an opinion to express and each opinion must carry its own weight.

In the end, I don’t think doctors act with the same irrational, impulsive grandiosity as the “Real Cowboys” of the years past. Most doctors are concerned, focused, disciplined and hard-working as they always have been. They do not gamble with any person’s life. So much so that it takes a piece of them when they lose a life. But you call the previous generation of doctors as "cowboys" and end up adding notoriety to them while simultaneously denigrating the spirit of what they do. I am sorry for that.

Oh my, how the incline in your ascent has perched you into the hypoxic stratosphere of non-limbic thinking. Yes Atul you have achieved success but remember it lasts only for 15 minutes until some one else comes up with another catchy “template.” Even though you have crossed the finish line ahead of others in this marathon, please do not cast an eye on those behind and consider them as a faceless, homogenized mass of protoplasm worthy only of collective thought. They each have a name, a face and a brain worthy to be in that illustrious of places where Sir William Osler and Jonas Edward Salk reside.

I must be cruel only to be kind;
Thus bad begins, and worse remains behind. ~ William Shakespeare

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