Monday, May 30, 2011

The Most Uninspiring Med School Graduation Speech Ever

Atul Gawande's recent commencement speech to Harvard Medical School is here. Read it if you like. It won't exactly send chills down your spine, to say the least.

His essential message is this: Healthcare is far too complex for any one doctor anymore. So gear up to be an interchangeable part, a faceless drone who performs menial tasks according to checklists and algorithms that Really Smart People will provide for you. Don't be a Cowboy (in the romanticized, individualistic sense of a bygone era) unless you want to be like a real live lower-case "c" cowboy in Wyoming who functions as part of a team and follows protocols (Dr Gawande talked to one himself, it's true!). All that debt you've taken on to be a physician? It's so you can be an anonymous member of an integrated Team. Like a Pit Crew. Who doesn't get jacked up to join a pit crew? I sure do!!!

Is it any wonder that Dr Gawande is the very Messiah of future healthcare delivery to people like Maggie Mahar and Ezra Klein? Not a word about being a better physician, about recapturing the old ethic of patient ownership. Nothing about the challenges individual doctors face to stay on top of new medical developments and how they can be surmounted. Nothing about personal accountability. Nothing about putting your heart and soul into this noble calling.

31 comments:

Anonymous said...

A bit off topic. But a friend of mine a new RN but already in healthcare (2nd heatlhcare degree), who had worked with a very well known (and liked) doc for a few years sought him out as an important reference to land that great internship. He not only wrote a stellar letter of reference but actually took the walk over to personally represent for her. She not only did not get an interview, but was in so many words told at a later date that a doc's reference no longer holds any weight in this world. Now if she knew corporate administration that well things would be different.

-SCRN

Anonymous said...

it distresses me to see how much praise this dude gets and is refreshing to see people out there like yourself that share my healthy distrust of him.

Anonymous said...

Umm Buckeye, for someone who thinks "Dotting the I" is the Mecca of College Athletics, you've got some nerve...
I don't even remember who spoke at my Med School graduation, we didnt get our real diplomas till a few days later when they made sure you'd paid all your library/parking fines...
and it was so bogus, cause you couldn't even check out any of the books, if you wanted Stolting's "Basics of Anesthesia" you had to Xerox it a page at a time...
and the really good books they kept chained to the desk like a grimy Gas Station Men's Room key...
thats right, we had unlimited Xerox priveleges until some a-hole starting copying Harrison's, Cecil's, and DSM-3(OK, I'm old)for the suckers, I mean residents who couldn't afford the real thang on there $18,000/yr salary...
the great thing is they couldn't even complain when they found out you'd only photocopied the first 20 pages of Harrison's, and then 800 copies of page 21...

Frank

Kellie (General Surgeon) said...

I haven't been overwhelmed with Dr. Gawande either. He seems a bit too "political". If he didn't have such "great ideas" about cutting costs, he'd not be doing much. (Oh, that and his books). His WHO guidelines to improve surgical outcomes work well in countries where they don't even have a pulse oximeter, but not sure they are going to do much to change outcomes here.

Thanks for the post.

Anonymous said...

He has an article of psychobabble in the most recent JACS.

Anonymous said...

This shows why his name is pronounced, "a tool."

Dr Ruth Livingstone said...

Hmm, well I would rather fly in a plane where the pilot uses a checklist before taking off. Wouldn't you?

And I would rather have my appendix removed by a surgical team who take the time and trouble to make sure they have the right patient, are going to remove the right part, have the right equipment, know who everybody is and who is doing what - before they start cutting me open. Wouldn't you?

Anonymous said...

For buckeye,

Do you then not believe in ATLS guidelines? Or ACLS? or PALS?

tom e said...

Odd that he would pursue
Surgery as his actions suggest more of an Internal Medicine orientation.

The opportunity to speak at any commencement ceremony should obligate the speaker to affirm the graduates and their accomplishments. Anything less is in effect say, "you are all fools; you have sacrificed a good deal for this day and it is all for naught.

You will soon join a cadre of workers whose life is more of an existance rather than living. Seek not to explore,and differentiate yourselves, rather seek to fit in. Seek not the vivid colors of individual and professional success in favor of the gray's of conformance and medocrity.

Finally for the class of 2011, I leave you with this thought-since its formation in 1782, Harvard Medical School has educated individuals who imbued the philosophy of "a physician is who I am"; that is no longer the case. It is now "a physician is what I do".

Buckeye Surgeon said...

Anon 1:31pm and Ruth Livingstone-
That is a straw man response in the highest sense. I am not, nor is any other reasonable physician, opposed to guidelines and core safety measures. Gawande's message of "get used to being an interchangeable part of the Glorious Groupthink Whole" is the point of contention here. His address was dismissive and condescending toward a group of young people who have achieved something worthy and commendatory. "Excited about being a Doctor eh? Well don't get too effervescent kids. Because the real work of health care is being done by Superior Geniuses with PhD's and MBA's and Super Doctors churning out papers in academia." It was just a lousy address. Deflating and unnecessary.

Yitz said...

I'm a med student. When I read his first book years ago, part of what inspired me to go into medicine was the way he described the never ending battle to learn more, be a better doctor.
Now I see that all I need to do is just get a bunch of algorithms and checklists.
My admiration for him didn't last long.

Anonymous said...

So I take it Dr. Gawande Won't be interviewing for the Ohio State head coaching vacany...

minimumnz said...

"get used to being an interchangeable part of the Glorious Groupthink Whole"

Strawman calling a strawman a strawman much?

Anonymous said...

After a few years of dealing with oncologists on behalf of a family member, I'm damned glad there's one less med school class entering the profession with romantic dreams that don't include ensuring that treatment is the most effective available or bothering with simple proven safety measures.

You write of the pit crew as if it was comprised of mindless drones checking off items with no real understanding of the interventions or the patient. That's also a straw man argument.

Working as part of a team and following established protocol doesn't prevent doctors (or nurses) from focusing on the patient and making careful and considered decisions on the finer points of care, especially as they concern that specific patient.

You might even think doctors would have more time for that when the other pieces have becomes routine. That's certainly what we found after we fled the oncology cowboys.

I can see potential problems in leaving protocol decisions to a insular group of experts, certainly, but that doesn't seem to be your complaint.

The one thing that's sacrificed here is the doctor's ego. I understand why that bothers you but from the patient's perspective? No loss. None at all.

Anonymous said...

there is so much more to being a good doctor than acting as if you have true autonomy.

Buckeye Surgeon said...

Um, the pit crew analogy was used by Gawande himself. Pit crews (for the Nascar-deficient) are comprised of similarly outfitted drones who swarm the race car when it pulls in for a pitstop, each with a highly specialized assignment (unbolt tires, bring new tire, wash windows, check oil, etc) This is Gawande's ideal apparently. It is an era of super specialization wherein only the Fellowship-trained Thyroid surgeons take out thyroids and colorectal surgeons take out colon cancers and only endocrinologists can manage diabetes and all patients with "indigestion" get sent straight to the gastroenterologist. It is asking individual doctors to be less responsible for the patient as a whole.

This has nothing to do with ego. I know it's fun to bash the stereotype of the Arrogant Physician, but how does inculcating into young doctors an ethic of patient responsibility/ownership reflect poorly on those who wish to promote it? I don't get it, honestly.

Anonymous said...

But what improves patient outcomes the most? Really, I'm asking. Because none of it matters when fallible humans (that are doctors) err (when it could have been simply prevented) and a patient dies.

Anonymous said...

I could not disagree with your comments more. All of the world is evolving and most all jobs today are more complex than they were just a decade ago - requiring all of us to be better team members. Not just physicians.

Referencing protocols or guidelines does not diminish the role of the physician, but rather demonstrates the importance of science in the practice of medicine. Scientific evidence should be the primary guide to helping patients achieve better health.

But that's not to say that patients don't need the guidance of a wise physician.

big tuna said...

The pit crew analogy is not used by Gawande to suggest that every person act as a cog in machine, or drone as you put it. To say so is simply demagoguery. The pit crew analogy is used to show how communication, team-work, and coordination are applied in many different settings, and that doing so in medicine could result in better care for patients.

Anonymous said...

anyone here ever WATCH a Nascar race???
those guys crash all the time, its the only thang that makes the races watchable...
I remember the good ole days, before those commie restrictor plates when you had to pay attention or you might have #3's Monte Carlo in your lap...

Frank "Dale Earnhardt Jr Sucks" Drackman

Anonymous said...

Being a member of that kind of "pit crew" only means that Buckeye, Frank, and I went to the same class about what checkboxes to click so electronically the patient received excellent care. This way we can remind each other of missed checkboxes so we don't get "dinged". And we, like all other providers will have given the most excellent care always. The checkboxes say we did.

-SCRN

Anonymous said...

Wow. I cant believe how many people totally missed the point of this post. Dr. Buckeye, they should have had you give the speech highlighting your last blog post which included a sample case that was "solved" not by protocols or algorithms, but by wisdom, experience, critical thinking, & some old fashioned common sense. While protocols & algorithms augment safety & decision making processes, the challenge & excitement of medicine manifests itself in the physicians ability to think, which algorithms cannot do.

Regards,
PrecordialThump

Carol Cassella said...

Reading these comments I am most struck by the fact that nearly all are posted anonymously. Perhaps you should state your names as clearly and publicly as Dr. Gawande and stand up for the personal missles? Healthcare is changing and not all for the better. Maybe more doctors should find a visible platform and speak out.

Joe Says said...

I took exception to Mahar's comment "Buckeye's contempt for the patient", but of course she deleted my comment on her blog. I find it outrageous that any wonk could make such a charge.

http://www.healthbeatblog.com/2011/05/doctors-heroes-or-members-of-a-pit-crew.html#comments

Why is it these health wonk types go right for hitting below the belt. Maybe they need a little liability for their actions and they may see the world a little more realistically.

Mark Graban said...

Trying a 3rd time:

I'll assume a glitch caused my first comment attempt to not appear here... so I'll try again.

Dr. Gawande makes it quite clear in his book that checklists are to be developed by those doing the work, that they are NOT supposed to be handed down from on high. You're arguing against a straw man of your own creation.

Did you actually read his book or the New Yorker article on which it was based?

Are surgeons more interested in what's exciting or what's proven to be most effective for patients? @Kellie - the WHO proved checklists to be effective in Michigan, not just third world countries.

Why would it be mutually exclusive to have checklists to ensure that you have the right patient and right site, but then be as creative as necessary during an actual procedure?

Anonymous said...

Mark, sweetie, we already do those checks, FYI. But, we'll just let you make the important decisions from now on due to your vast surgical/nursing experience trumping ours. That way you can get busy suing yourself.

-SCRN

#1 Dinosaur said...

Regarding the pit crew analogy, my response is, "Time and place." Not every car is a race car driving a NASCAR race. Not all car maintenance needs to happen in 30 seconds or less. Not all doctors need to be super-specialists taking care of diseases and conditions of the left nostril while referring out problems of the right. Knowing when that super-specialized care is appropriate for a particular patient and reserving it for those occasions is the real secret to containing health care costs.

BTW, I agree with Buckeye.

Anonymous said...

I can't figure out, is Graban a doctor?

MFS47 said...

So tell me who else is sticking their neck out to solve real problems. Inspire me.

MFS47 said...

Who else is sticking their neck out to find solutions. Stop whining guys a new day has dawned.

Anonymous said...

You guys are pathetic. Look at the outcomes. That is what matters. --An emergency doctor