Doctoring

In my first year in college, all the scientists learned Chemistry and Physics and Biology, regardless of what discipline they thought they were going to later on. These classes were enormous: a couple of hundred students crammed into a tiered lecture theatre being taught about Sulphur or Hooke's Law. The row behind my habitual seat 2/3 of the way back was inhabited by a handful of pre-med students and while waiting for the Professor to turn up, we'd often chat in a desultory fashion. One of these chaps, by name Mac, eventually married a cousin of The Beloved around about the time several years later that he graduated with his MB.  In the 1980s, prospects were bleak in Ireland unless you were exceptionally well-connected and stellar-brilliant and a lot of us left the country to seek a modest fortune elsewhere.  Mac upped-stakes with his family of tots to Canada where, if you served the Canadian community for a few years, you could earn a decent salary, get a wealth of experience and the grateful Canucks would settle citizenship on you and yours if you wanted to stay. They were much less interested in foreign doctors who wanted a practice in Toronto or Ottawa. I wrote last year about a medical friend who served his couple of years on Fogo, a storm-wracked speck of an island off the coast of Newfoundland. Mac finished up in Uranium City, way up North in Saskachewan just shy of the border with Northwest Territories. He got a wide experience, being flown to remote outposts in a Cessna to deliver babies on kitchen tables and to triage arms that had been ripped up by some monstrous piece of mining machinery. After serving his time in the uncompromising outback, he came South to Halifax, NS and acquired a reputation as a general surgeon developing a specialty in liver transplants.

Every so often, Mac comes back to Ireland and we catch up a little.  Once, a couple of years ago. I'd just read a long article by Atul Gawande, who has perhaps the widest circulation of anyone who writes lucidly and critically about the US healthcare system.  Gawande was born in NYC but both his parents were doctors from India who were living the American dream in the New World.  Dr Gawande Jr. is articulate and passionately engaged in his profession, so much so that he's taken time off from his career as a doctor to help forward the careers of such Democratic hopefuls as Al Gore and Bill Clinton.  Betting right on Clinton opened a number of doors for him, but his writing style and willingness to lift the carpet on some of the murkier aspects of American healthcare has won him respect and a regular column in the New Yorker.  The article I'd read was a long-form synopsis of Gawande's third book The Checklist Manifesto: How to Get Things Right (2009). The bottom line seems to be that if you formally tick boxes on your standard operating procedures (SOPs) then you are less likely, in the heat of the moment or having worked a 30-hour shift without sleep, to forget something crucial.  I'm a sucker for a well written argument, so I was convinced and I asked Mac for his view of the concept from the trenches.

Mac said it was all tosh, that he and his team didn't need to have "checklists" to not leave swabs and clamps in the abdomen.  He also said that the key, and oft-cited, study demonstrating the usefulness of checklists was a three centre meta-analysis involving two hospitals in Boston and one in similarly-sized city in India. The study showed that checklists had a significant positive impact on outcome.  But if you partitioned the data, all the positive-for-checklist results came from the Subcontinent where, in his experience, things could be a little ropey.  He'd done a few tours of duty with the Canadian army in Afghanistan and most of their work was pro-bono nipping and tucking for the local community.  After time in the recovery room, these people would be discharged to the local hospital for sub-acute care and convalescence. After a while, Mac stopped routinely asking after his discharged patients because they frequently couldn't be located in the hospital records - far from misplacing a catheter they had lost an Ibrahim Mohammed.  His take on checkpointing hospitals in developing countries was that things were so bad, administratively, technically, and financially that any form of attention from outside would help everyone to up their game.

Why is this uppermost in my 'mind'?  Because Gawande is on the BBC News having achieved real immortal fame (forget all that New Yorker stuff) by being invited to give the 2014 Reith Lectures.  The first one Why Do Doctors Fail? of four lectures was broadcast on Monday 02 Dec 14 from Boston, but you can catch the whole thing on the BBC podcast wireless.  Hang around for the questions!  They are at the end but more articulate and probing than maybe the talk itself.  If you can't listen then the basic story (less the questions) is summarised in the Grauniad.  The very last question comes from another doctor who works in a Boston hospice who says that such terminal people do not, in the main, fear dying, what they are terrified of is that they will be sent back to hospital.  The implication is that they will there be tricked about with by a succession of know-better medicos.  Gawande takes this on "we have to  acknowledge that people have priorities other than living longer; how do we reveal what these desires and priorities might be? We should ask them . . . but we don't".  He is going to address these end-of-life issues in one of the later Reith Lectures.  Can't wait!

Oh, and it's Atul Gawande's 7x7th birthday today. Let them eat cake!