Comments on Atul Gawande’s 2014 Reith Lectures: The Future of Medicine (Part 2)

I have been blogging about the 2014 Reith Lectures currently being given by Atul Gawande. This is Part 2, and is related to Gawande’s second talk entitled ‘The Century of the System.’ Part 1, which responds to the first lecture ‘Why Doctors Fail,' is here

Gawande devoted much of this lecture to recounting the case history of a three-year-old child who plunged through the ice into a pond, spent thirty minutes under water and ultimately survived with no apparent negative consequences. The tale is, I think, designed to illustrate the value of a systemic approach to medical practice. The young girl’s life was saved as a result of a lot of different interventions happening at the right time and in the right order over the course of at least 2 days. As one of the commentators following the lecture pointed out, this is a highly unusual occurrence. Certainly people who drown in warmer conditions will die. Thus, in this case, the circumstances of the injury are an important part of medicines ability to save the lives of people like this young girl.

Whilst this case took place in a relatively small hospital, the interventions required – like heart/ lung bypass and ECMO machines - are high tech. However the point Gawande is making is not about the power of particular medical technologies or the conditions we can survive given certain, quite specific, circumstances. Rather, and as indicated by the title of this weeks lecture, it is about systematization and the power of adopting a ‘systems’ perspective. The title of the first lecture was ‘Why Do Doctors Fail?’ this week’s might well have been called ‘How Do Doctors Succeed?’ The answer is that it is down the use of procedures, protocols and checklists to guide medical practice It is the organisational power of these tools that ensure medical treatments are the best they can be or, at least, that is what Gawande appears to be suggesting. 

Much of medicine can be cast in terms of systems thinking. First the body can be conceptualized as a biomechanical system or, perhaps better, an interlinked set of biomechanical systems, with the major organs being the crucial units of our biological machinery. Thus the biotechnologies that saved the live of the young girl in the case study can be seen as taking over the functions of the heart and lungs by oxygenating blood and circulating it until they can be restored. They provide a temporary replacement for our biological systems. We can also consider the operating room and the intensive care unit as systems, a thought that can be generalized to the hospital as a whole or to the various iterations of ‘the clinic.’ Of course an essential part of these systems are human beings. Modern healthcare is, therefore, a inherently social system, one that requires a high degree of organization, communication and management if it is to be implemented in such a way as to deliver the full potential of modern medicine. How to best organize and managing the social complexity of clinical practice is, at least in part, what Gawande’s previous work on (surgical) checklists has been about. 

Some of the other health concerns Gawande mentions are rather less involved with high tech medicine than the case study he describes. He highlights the fact that the treatment standard of many common, long-term and chronic illnesses – such as coronary heart disease, asthma, high blood pressure and hypertension - are not met. Often patients with these diseases are not correctly managed. However, the implication of Gawande’s thinking is that the treatment of an illness is not merely a matter of following the recommended protocol but of the wider systems we put in place to facilitate the delivery, ensure patients adhere to their prescriptions and to monitor treatment progress. It is a matter of responding to the complexity of healthcare, both in terms of the specific medical conditions of patients and in terms of healthcare systems as a whole. 

The question is, of course, what this might mean in general, in regards particular diseases and their treatments, and in respect of specific patients and their particular illnesses. Part of the answer concerns the need for health and social care professionals to work in a more integrated manner. Thus the question of systemic medical care is, in fact, a question of systemic health and social care. It is, therefore, less about the (social) organization of biotechnological and pharmaceutical interventions than it is about the social organization of people – patients and professionals. 

Gawande briefly mentions the potential of new technologies to facilitate this organization, largely thorough allowing patients to take a greater role in the management of their conditions. This is something that will also increase the degree to which healthcare professionals can subject patients to monitoring. As this indicates our ability to systematize can have both positive and negative consequences. Adopting a systematic approach to the social organization of medicine means subjecting it to bureaucratic forms of management and governance. This is already something that happens, often under the label Quality of Care. However, it is an inherently ambiguous term and institutionalizing standardized measures to ensure it can often have counter productive results. Health – or Biohealth – has come to be seen as an unassailable good. Virtually anything can be done in its name and it often seems as if the only cardinal sin of modernity is to sin against it. Increasing the scope of medicine’s ability to make us better will mean increasing the structural influence it has over our lives and the actions of healthcare professionals. A medicalised or biomedicalised society is a systematized society. The question is not whether or not this should be allowed to happen, but how we can best ensure that the positive effects outweigh the negative.

Comments on Atul Gawande’s 2014 Reith Lectures: The Future of Medicine (Part 1)