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Discipline Makes Daring Possible

Posted by Dr No on 02 December 2014

daring.jpgWhen the Chief Medical Officer feels uncomfortable, should the nation tremble? Probably not. Certainly, Dr Atul Gawande didn’t, fielding Dame Sally Davies’s troubled comments after giving his second 2014 Reith Lecture, broadcast this morning on Radio Four. Speaking in his now familiar, you know, George W Bush style “Our people done a really good job…of, you know…hauling in a lot of the key operators”, Gawande extolled the virtues of getting systems right. Goaded by air industry experts baffled at the casual approach of surgeons to their work, Gawande developed The CheckList. Depending on viewpoint, the CheckList is either strictly for the dumb-assed, or a sort of systems alchemy that transforms the inept into the ept, and experts into super-experts. Doubters are stumped and declared out for a duck by asking them a simple question: “If you’re having an operation, would you want the team to use the checklist?” Unsurprisingly, ninety four percent did, though that leaves the intriguing question what did the other six percent want? Dr Frankenstein? A one armed blind surgeon with a prosthetic hand and Parkinson’s disease? We’ll probably never know, because by now they will have maimed or killed themselves some other way.

Dame Sally’s discomfort rose on two counts. The first was the master of the anecdote’s masterly use of a dodgy anecdote. The girl from the car that ended up in an icy river who was well enough to be discharged a few days later did well not because the systems worked perfectly, though one can’t help thinking they must have played a part, but because of an accident that was part of the accident: she’d been thoroughly chilled by the icy water, and that bought time for the systems to do their stuff. Her second concern – and this wasn’t the only pop at surgeon Gawande by an audience loaded with public health types – was that isolated heroics by trauma teams after the event missed the larger point, which was to prevent common illnesses before they even appeared in the first place.

This was a bit unfair, given that Gawande had already identified high blood pressure as a major but all too often untreated risk factor. He went even further, and elevated it to the major risk factor. But this was red to Dame Sally’s bull, which, being a public health bull, wanted to impale its horns as far upstream as possible, specifically in obesity, smoking and alcohol. Since all three are themselves causes of high blood pressure, there is some merit in the Dame’s argument, though it can also be said that the distinction is as much about the difference in temperament between surgeons and physicians, especially public health physicians, with the former being of the ‘stuff happens - and we’re here to fix it’ tendency, the latter of the ‘stuff shouldn’t happen’ tendency, a tendency that has a tendency to over-reach itself even into the unhealthy realms of coercive healthism.

Sue Lawley, the one who sounds like blue stockings would sound if they could talk, was hosting. Keen to show off her grasp of medical jargon, she wondered, along with many of her guests whether all this talk of perfect systems and clever checklists – clever checklists ask questions more than they dictate actions – was going to ‘ossify medicine’. Ali Pasta, late of Circle now of Babylon, plugged his latest mobile app, and asked about making use in medicine of artificial intelligence, presumably from Babylon. Given old-time Babylon’s fate in the Book of Revelations, this may not bode well, though we should perhaps note that at one stage the Persians conquered Babylon. Perhaps Mr Pasta has the same sort of caper in mind. More than a few in the audience worried that checklists were bound to suffocate the two Big Cs, Care and Compassion.

Gawande’s punch-line, if lectures can have punch-lines, was ‘discipline makes daring possible’. It’s an old idea, with roots in the military, where discipline is King, to academia – we even talk of academic discipline – and many other fields of human endeavour. Even the Church gets in on the act, with the disciples, who followed a certain, err, discipline. Though the word also has corrective and punitive uses, as when we talk of disciplinary hearings or carrying out disciplinary measures, the word has less strict Latin roots, from discipulus, meaning pupil or learner, and to that extent Gawande’s punch-line is ‘learning makes daring possible’. Put in that softer form, it certainly seems plausible. That’s why we learn the disciplines of say the sea, or a musical instrument, so we can dare to do more.

But in modern use, discipline is also a binder, a constrictor. It restricts. It is all very well if we have the discipline to march up the mountain, but what use to us is that discipline if we, precisely because of that discipline, lack the imagination or, and Dr No prefers this word, the agility to jump away from the avalanche now about to crash down on us? The discipline, once so necessary to get up the mountain, is now, quite literally our downfall. If we’re lucky, one of Gawande’s crack mountain rescue teams will be on hand, but if they are not, then most likely it’s bye bye cruel world for us, all because our discipline restricted our agility.

So, if discipline isn’t the ultimate enabler, what is? What and where is this higher plane? Has Gawande been mistaking the finger pointing at the moon for the moon itself? Dr No suggests the higher plane is mastery, a state above discipline that contains discipline but has added the agility to know when to abandon discipline and jump like hell. He proposes a mini one question survey: “If you’re having an operation, would you want the disciplined surgeon with the checklist, or the master surgeon with the agility to know what to do when your operation goes off-piste?”. Call him smug, but Dr No has a hunch ninety four percent would choose the latter, with the other six percent – well, they are already off-piste, hurtling unstoppable towards the unforgiving pine trees.

1 comment:

'Dr No suggests the higher plane is mastery, a state above discipline that contains discipline but has added the agility to know when to abandon discipline and jump like hell' - in practical terms the two are not mutually exclusive, as Dr No well knows.

This post had me thinking of Philip Goulds account of his own cancer.
Gould, presumably because he was so well connected was able to shop around for a cancer master in a manner that would be totally alien to a typical NHS patient.
Gould ultimately opted for a US oncologist but was later to regret this decision feeling an NHS master would have treated his condition more effectively.

Be that as it may Gawande argues 2 central points - the average patient, in the average health setting is less likely to be killed or maimed once discipline becomes de rigueur rather than an exception.
He goes on to say that medicine is now so hyper-specialised that not even uber-experts arrive at the same conclusions (as Gould ultimately found out with regard to the pros/cons of radical surgery).
As a comparitor Gawande considers the way the construction of buildings has drastically evolved from the era of the 'master builder' to large, multi-disciplinary teams including architects, engineers, technicians, and craftsmen required for todays super-structures - the inter-related complexity of such projects, Gawande maintains, somehow re-casts the role of an individual within a system.

Whenever I think of checklists Martin Bromiley's 'Just A Routine Operation' comes to mind

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