The annual metronome to British public service broadcasting, the Reith Lectures, have begun this year’s tick, with Dr Atul Gawande doing the tocking. A smooth tocker with hints of George W Bush style pulsing rising enunciation, today’s first lecture – the first of four, we should note – asked ‘Why do Doctors Fail?’. Master of the personal anecdote, Gawande told the tale of a certain Baby Walker – not the contraption, but his son – who survived despite being born with an aortic abnormality, while the baby in the next cot with the same condition did not. The answer, by and large, was systems failure: Baby Walker ended up in the right place at the right time, while Baby Maine next door did not: the right place, perhaps, but too late. Walker walked, Maine died.
Being in the right place at the right time also means access to the right people. Hospital admission tests suggested Walker had good oxygen levels and a primary diagnosis of pneumonia. It took an astute paediatrician to spot the oxygen sensor was on the wrong hand – the right monitor, but in the wrong place – and get to the correct diagnosis, and so treatment. On this part of the anecdote, Gawande developed his wider theme: failures caused by ignorance (what we don’t know) and failures caused by ineptitude (not applying what we do know). Jogging alongside, not entirely comfortably, was the ice cube theme: ice cubes are predictable – put any one in the fire, and it melts – whereas hurricanes (and humans) individually are not. Even when we know the general pattern of behaviour, our predictions go awry because each hurricane (human) is unique, a uniqueness aided and indeed abetted by the large number of complex organ systems present in each and every one of us.
Dr No suggests ‘not entirely comfortably’ because, while Dr No may also worship at the altar of individual uniqueness, much of medicine, especially modern evidence based medicine, relies on the fact we are not unique. It relies on the fact that most people are like most other people. If the drug works for people in the clinical trial, then it will work for (most similar – the caveats are necessary, because in the real world, despite the general, there are always exceptions) people outside the trial. Like the ice cubes that melt, most people are predictable, a premise so fundamental to evidence based medicine that without it evidence based medicine becomes a meaningless fantasy.
So why do doctors fail? Gawande’s short answer is we have no black boxes. Because we have no black boxes, no consultation recorders that can be analysed after an adverse event, we don’t know what went wrong, and caused the doctor – if it was the doctor, for the question is somewhat prejudicial – to fail. Even today, medicine is practised in a world of opacity, the sanctity of the consultation the veil that bars all insight, all light, from outside, from shining into the sacred space. There are exceptions – JT posted recently on GPs watching other GPs consultations, and ward rounds and operating theatres are hardly private places – but by and large, most medicine is practised in private.
There are good reasons for this. As well as lofty notions like the right to privacy, there are practical matters. The sanctity, and the confidentiality and opacity that go with it, are there to allow patients to talk as best they can without fear of what ails them, and to give an honest account of their history, and both are crucial to reaching the right diagnosis, and so treatment. For doctors, with transparency comes the growing threat of know-it-all managers, guideline fetishists, ambulance chasing lawyers and, perhaps most alarming of all to individual doctors, the introduction of piranhas if not into the gold-fish bowl itself, then alongside, in the shape of GMC goons given line-of-sight fire through the consulting room window. With transparency comes the blowback of defensive medicine, poor or even bad medicine done not because it is the right thing to do, but to appease the watching controllers.
Not all Hawthorne effects – that people, including doctors, change their behaviour when observed – are bad, but equally there is nothing that guarantees Hawthorne effects will always be positive. Some of Gawande’s best known work has been on pre-flight checklists in medicine. With ‘we have no black boxes’, Gawande introduces another aviation staple into medicine. Both ideas, especially checklists, have merit. But are consulting room black boxes the answer in medicine?
As it happens, aviators have for some decades been wont to peer from time to time through the medical cockpit window, and by and large their reaction has been WTF – why can’t these guys get even the safety basics right? Parallels are drawn between the catastrophic costs of failure in both medicine and flying, and contrasts exposed between respective achievements in improving safety. Others – notably Don Berwick last year in his report on patient safety in the NHS – have borrowed aviation’s no-blame culture concept, and suggested it holds the answer to reducing times when both doctors and the wider NHS fail.
But we must not forget that medicine is not an airliner, nor the consulting room a flight deck. Yes, we have no black boxes, but do we need them? Tinkling away in the back of Dr No’s mind is that familiar refrain ‘Yes! We have no bananas’. Further back, in the internal kaleidoscope of absurdity that is the kernel of his brain, the missing black boxes have turned into missing bananas. Could it be that, if we give the doctors their black boxes, the kaleidoscope of human nature will turn those black boxes into bananas, and so the doctors into monkeys?
Meanwhile, the non-absurd Dr No awaits Dr Gawande’s coming Reith lectures with great interest.