Ignorance is not the first word that comes to mind when meeting someone who manages to function as surgeon, bestselling author, Harvard professor and this year’s BBC Reith lecturer simultaneously. But the limits of human ability form the backbone of Atul Gawande’s work.
Take what he suggests we should teach the doctors of the future on their first day of class. One: they are never going to know everything. “The knowledge that exists to help people exceeds what you’re going to be able to hold in your head,” he says. Two: they are never going to be able to fix everything. “You’re going to see people who are becoming frail and are only getting frailer; you’re going to see people with terminal illness and have to be able to manage death.” He stops and laughs. “It’s a big, long day, isn’t it?”
Gawande, 49, is a fixer, a fervent believer in systems and results. As precise in his language as you might expect from someone who wields a scalpel for a living, his work The science interview: Atul Gawande, Reith lecturer whether in the operating theatre or on the page – is about finding answers. “Most of the time I’m just trying to write to figure out something that’s confusing or bothering me,” he says. Each point he makes arrives neatly backed up by statistics and studies. This is a man who has written an entire book championing the life-saving merits of a checklist. So it’s slightly surprising that, in his latest work, Gawande grapples with something that has no obvious solution: death.
Being Mortal deals with end-of-life care: the dilemmas of nursing homes, final treatment options and when doctor or patient should declare that enough is enough. Our end may be unfixable but Gawande firmly believes that the way we get there is not. As the baby boomers come of age, a generation that thought it might live for ever is having to face the question of how they want their final decades to take shape. For many, this means avoiding an institutionalised end as much as possible. “In a war that you cannot win, you don’t want a general who fights to the point of total annihilation,” Gawande writes. “You want . . . someone who knew how to fight for territory when he could and how to surrender it when he couldn’t.”
What Gawande wants the medical professionals of the future to take on board is the idea that wellbeing means more than survival. Each of us has different priorities that make our lives worth living. “Since [doctors] have the capacity to keep trying not just to relieve pain but . . . keep you on machines and extend life, we lose sight of what people might want to be alive for,” he says. For Gawande, as long as his brain is still working, he’s happy to be kept going. In one of the stories he relates, an elderly man only wants to stay alive if he is able to continue eating chocolate ice cream and watching football.
Gawande’s own father, also a doctor, was diagnosed with a slow-growing mass in his spinal cord just as his son started doing research for what would become Being Mortal, and his decline became an essential part of the book. “It became clearer and clearer that this was going to limit his life,” says Gawande. For him, medical intervention was worth it if it meant that he could continue to interact with people and be in charge of his world. With this in mind he chose to undergo what was, for a time, successful surgery. But, as Gawande writes, “the choices don’t stop.” His father did not live to see Being Mortal published but died “never having to sacrifice his loyalties or who he was”. The importance of this opportunity for everyone echoes throughout the book.
Medicine was not always the obvious path for Gawande. He studied PPE as a Rhodes scholar at Oxford and worked for Bill Clinton’s campaign before deciding to finish medical school. Along the way he found he had a habit of making friends with writers, including Malcolm Gladwell and Jacob Weisberg, former editor of online magazine Slate. Perhaps inevitably, he began to write too. “I feared people saying, ‘Who do you think you are to even be writing about these subjects?’” he says. “I was always careful to write about things from the perspective of – all I’m trying to learn is how do I get good at what I do . . . Although I’ve feared the backlash, it really didn’t come.”
Instead he enjoyed it. “My editors would be just as blunt as my surgical professors,” he says. “I had 30 columns writing for Slate and it was like doing 30 gallbladders in a row.” He read Oliver Sacks, Abraham Verghese and other doctors-turned-writers voraciously. “They feel to me like they opened a door towards the idea that I could treat medicine as a subject in this way.” Outside his own sphere, the surgeon favours authors such as Tolstoy and Hemingway, who “manage to be both very economical in their writing but also manage to capture large swathes of experience along the way”.
Gawande’s own work is a frontline bulletin calling for new tactics. Sixty years ago, most humans would have died at home. Today, the “world has medicalised the experience of mortality” and the majority end up in institutions. In the final phase of our lives, doctors – and their patients – will experiment with one thing after another, trying to extend the quantity of life with little thought as to the quality. “The wisest surgeons I know are the ones who've been in practice for a while,” says Gawande. “Certainly my younger surgeon self was sure I could get myself out of certain situations. As I have now reached my middle-age surgeon self, I think I recognise the wisdom that older surgeons have . . . when they simply say, ‘I’m not doing any good here.’”
When all of us were at risk of dying in infancy or childbirth, things were different: “[Humans] recognised that there were ideals in life besides just living longer,” Gawande says. Now, “we can spend 70 years of our life basically not having to worry about our mortality.” Some of the more efficient among us will work through an end-of-life checklist: making wills and funeral arrangements. In his own work, Gawande is trialling a similar approach for doctors. They talk through questions that deal with the patient’s fears and goals, what outcomes are unacceptable to them and what trade-offs they might be willing – or not willing – to make as their end nears. At what point do they say “enough”? The key is trying to make such a conversation routine, almost part of the paperwork. “The act of answering these kinds of questions as a patient is very powerful,” says Gawande. “People don’t come to grips with their anxieties because they hear a lot of facts. They come to grips with them because they get to voice what they think and what they want to do in their own words.”
The advantages could be many. Not only does hospice care save money and reduce suffering, studies show it can also extend lives. The problem is that geriatrics and palliative care are often not sexy – or well-paid – branches of medicine. As a result, they lack recruits. “You become a surgeon because you want to be the hero, you want to have a nicely clean, fixable problem,” says Gawande. But those who specialise in end-of-life care deal with messiness. There is a memorable scene in Being Mortal where a geriatrician examines a woman’s feet for calluses, sores and unclipped toenails. These could determine whether she falls or not – and whether she falls or not may determine how long she survives. Forty per cent of the 350,000 Americans who fall and break a hip each year will end up in a nursing home.
Gawande believes that medicine has much to learn from other professions when it comes to systems and solutions. The airline and construction industries routinely use checklists to ensure that planes stay up and buildings don’t collapse. “Discipline makes daring possible,” says Gawande in an upcoming Reith Lecture: an idea that his 2009 book, The Checklist Manifesto, elaborates on. He worked with the World Health Organisation on the safe surgery list, which cut patient deaths by 47 per cent in a trial and can now be found in hospitals across the world. Gawande routinely uses it in his own operating theatre, where it flags issues from medication allergies to forgetting to pad someone’s bad back. “I’d say on a weekly basis we’re catching something . . . and maybe once every month or two it’s something really substantial.”
His team has also extended the idea to cover crisis situations – from fires in operating theatres to the risk of spreading Ebola. “We increasingly treat Ebola like it’s a special case but the truth is we have 4 million people who pick up infections in US and European hospitals every year,” he says. “The fact that . . . nurses and doctors don’t know how to put on a gown and gloves and then take them off without contaminating themselves or others – these are basic things.” Gawande’s team has advised the Centers for Disease Control and Prevention. “Part of it was just helping them recognise how to simplify it so that any triage nurse, transport worker, anybody who comes into contact with people who might even be suspected of Ebola, can know what the key steps are.”
Still, even such an extensive knowledge of checklists hasn’t quite done the trick when it comes to Gawande’s own time management. “I have not figured out how to balance it. It’s not ideal,” he says. “The writing ends up being nights, weekends. I squeeze it into the schedule here and there.” Being Mortal was finished while he and his wife were on a 20th anniversary trip to Italy.
The results of all this hard work have drawn the attention of the public and presidents alike – Barack Obama reportedly recommended a New Yorker piece on the costs of American healthcare to senators. And – given the problems affecting health systems across the world – there are many more articles still to write.
“I’m drawn to often very simple ideas . . . the checklist, conversations at the end of life, the nature of the cost of healthcare,” Gawande says. “And I feel like the more simple the question… the more the attention and reaction often has been.” The surgeons of the future will have some 6,000 medicines and 4,000 procedures to choose from. But sometimes they only need one solution.
Atul Gawande’s BBC Reith Lectures start on Radio 4 on Tuesday November 25 at 9am, and will also be available to listen to on BBC World Service and online.
‘Being Mortal’ is published by Profile Books and Wellcome Collection, £15.99.
Photographs: Maja Daniels; Erik Jacobs/Eyevine
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