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

Atul Gawande is one of those sickeningly accomplished individuals who succeeds at everything they do. His day job is surgery but he is world renowned for his work on healthcare and healthcare systems. I have found his previous writing stimulating but have not yet read his latest work Being Mortal. He is giving this year’s Reith Lectures and I am going to try and write something on each one. 

This is Part 1, and is related to Gawande’s first talk ‘Why Do Doctor’s Fail?

Offering an enlightening mix of the personal and the professional the first of Gawande’s Reith Lectures addresses the question ‘Why do Doctors Fail?’ Whilst much of his career, particularly the Checklist Manifesto, has been concerned with the avoidance of preventable error and ensuring the practice of medicine meets the highest standards possible this lecture engages with a broader set of concerns. 

To this end he makes use of a perspective set out by MacIntrye and Gorowitz in a 1976 article ‘Towards a Theory of Medical Fallibility.’ The articles subtitle - Distinguishing Culpability from Necessary Error - makes clear their view. There are medical errors for which medical professionals are responsible but there are others that are unavoidable: there can be no error-free medical practice. 

The point is tied to the human condition and the limits of our knowledge or knowledge-ability. It is not simply that physicians are fallible human beings – although they certainly are such creatures – but that medical science is an imperfect body of knowledge. It is a set of generalizations and simplifications that purport to describe the complexity of the human body. Thus, when encountering the bodies of actual human beings, or patients, it regularly proves an incomplete guide to what might be wrong and how it might be fixed. 

Gawande’s account is interesting but there is, I think, another way of framing the issue. Our understanding of what medicine can offer us or, at least, what it might potentially offer us, is hopelessly utopian. Indeed the point is not so much that we have an inflated sense of the abilities of what medicine can offer us. Rather we have an inflated sense of what science can promise. Our faith in science is such that we not only imagine that it can be applied to everything, with the result that everything that can be known will be known, but that this omni-science will constitute omniscience. 

Nevertheless our responses to modern medicine are increasingly ambivalent. On the one hand we still have faith that, at its best, medicine can provide us with the correct diagnosis and cure. As exemplified by the first question Gawande took from the audience we now seek information about the performance and outcomes of individual professionals in an attempt to select ‘the right’ the doctor. However the contradictions are self-evident. There is nowhere, no place or time, in which all patients can be seen only by ‘the best’ doctors or can be operated on only by the best surgeons. Indeed, we cannot all see an above average doctor. Instead we must trust in the system as a whole and in the idea that its doctors are ‘good enough.’ 

The other side of our currently renewing relationship with medicine is that we increasingly questioning whether medicine is, after all, what we seek. Gawande’s final question was concerned with care at the end of life and terminally ill hospice patients. The interlocutor suggested that some individuals greatest fear was not death but being sent to hospital where they would be subject to interventions that whilst potentially life prolonging would be likely to lower their quality of life and, therefore, death. Furthermore, such interventions would, ultimately, prove unsuccessful, as death was prognostic certainty. 

Strictly speaking this is not a choice between medicine and not medicine but between care and cure. It is about knowing, and accepting, the limits of medicine and our selves. Whilst our utopian dreams have, and will continue, to take us forward in medicine and beyond, reality will always come calling. Gawande has suggested he is in the business of disturbance. Another way to put it might be that he is in the business of showing us disturbing parts of our socio-medical reality, parts that are all to easily ignored when what we are looking for - what we are hoping to find - is a medical utopia or, at least, the possibility that it might be out there. 

The next lecture will be broadcast tomorrow; I will be trying to write something before the end of the week!