Reith Lectures: The Future of Medicine
The Reith Lectures return to the subject of health care: Professor Atul Gawande presents his view on ‘The Future of Medicine’
First broadcast in 1948, the Reith Lectures were created to advance public understanding of significant issues of the day through high-profile speakers and to act ‘as a stimulus to thought and contribution to knowledge’. They were named in honour of Lord Reith, the BBC’s first director general, who maintained that broadcasting should be a public service that would enrich the intellectual and cultural life of the nation. Previous lecturers include the philosopher Bertrand Russell, ‘father of the atomic bomb’ J. Robert Oppenheimer, and pianist and conductor Daniel Barenboim. More than 240 Reith Lectures are available to download as podcasts.
In 2014 Professor Atul Gawande, a practising surgeon at Brigham and Women’s Hospital, USA and Professor at both the Harvard School of Public Health and Harvard Medical School. presented a series of four lectures on ‘The Future of Medicine’, where he explored the nature of progress and failure in medicine, a field defined by what he calls ‘the messy intersection of science and human fallibility’.
In this report, Professor Littlejohns (Professor of Public Health, King’s College London) summarises the key messages from the lectures and what he thinks the whole series means for the NHS. He does not go into the detail of each talk as you can hear them live on the BBC website (www.bbc.co.uk/programmes/b00729d9; they are also available as a transcript),
Professor Gawande’s background
The first thing to note is that Atul is no ordinary doctor. He was born in Brooklyn, New York, in 1965, to Indian migrants to the United States, both doctors. He obtained an undergraduate degree from Stanford University in 1987 and then became a Rhodes Scholar, earning a degree in Philosophy, Politics and Economics from Balliol, Oxford, in 1989. He graduated from Harvard Medical School in 1995. However, during this period, 2 years into his course, he left medical school to become Bill Clinton’s healthcare adviser during the 1992 presidential campaign and a senior adviser in the Department of Health and Human Sciences after Clinton became president. He directed one of the three committees of the (ultimately unsuccessful) Clinton Health Care Task Force.
His medical credentials are completed with a Masters in Public Health degree from the Harvard School of Public Health in 1999. However, he is also a prolific writer both for the New Yorker and academic journals. His June 2009 New Yorker essay compared the healthcare of two towns in Texas to show why healthcare was more expensive in one town than the other. Using the town of McAllen as an example, it argued that a revenue-maximising businessman-like culture (which can provide substantial amounts of unnecessary care) was an important factor in driving up costs, unlike a culture of low-cost high-quality care as provided by the Mayo Clinic and other efficient health systems. The article was cited by Obama during the introduction of his health reforms.
Atul published his first book, Complications: A Surgeon’s Notes on an Imperfect Science, in 2002. His second book, Better: A Surgeon’s Notes on Performance, in 2007 and his third The Checklist Manifesto: How to Get Things Right in 2009. His latest book, Being Mortal: Medicine and What Matters in the End, was released in October 2014.
Summary of the first lecture: Why do doctors fail?
Atul’s first lecture was recorded at the John F. Kennedy Presidential Library and Museum in Boston. Not surprisingly, as a popular writer Atul knows the power of the single story. While he may be an advocate of science-informed medicine, he does not devalue the importance of the ‘case study’.
He uses the medical history of his first son, Walker, who had a congenital heart lesion diagnosed at 11 days but who was ultimately successfully treated (although there were some tense moments along the way, including some misdiagnoses), to highlight what he considers two forms of failure in health care – ignorance, that is where the knowledge does not exist, and ineptitude, where knowledge exists but is not applied. In the context of heart surgery he relates what are for him the two key scientific breakthroughs relevant to his son’s condition – the first in 1628 when William Harvey deduced that the heart was a pump and the second, when Werner Forssmann performed the first human cardiac catheterisation on himself in 1929, ignoring the advice of his department chief. While supposedly losing his job, he did pick up the Nobel Prize for Medicine in 1956.
Atul then adds a third cause of failure, which he calls necessary infallibility. He switches the analogy to the physical environment for inspiration. Scientists can never predict absolutely when and where hurricanes develop or even, when they exist, what will happen to them. This is because they are based on many complex physical laws with uncertainty inevitable – however, you always know that if you put an ice cube into a fire it will melt. Human physiology and responses to disease are more like a hurricane than an ice cube.
Returning to his child’s story, he raised the issue of consistency and fairness in healthcare (given this unpredictability) when he refers to another child in the same ward with the same condition as Walker but who had been referred too late for effective treatment. So what is the solution – because the development of the science and delivery of healthcare is ‘messy’, involving individuals and systems; he is an advocate for complete ‘transparency’ and it is a duty to remove the veil of secrecy often seen within healthcare.
The lectures are followed by questions: the issue of how to assess a good doctor was raised and also how can we incentivise ‘transparency’ when it is often the case that the opposite is the norm in the systems in which we work.
Summary of the second lecture: The Century of the System
The second lecture sees Atul moving to London to the Wellcome Building at Euston. Sir Henry Wellcome was a medical pioneer who died in 1938. His legacy was the Wellcome Trust (worth £16.6 billion), which aims ‘to achieve extraordinary improvements in human and animal health’. In this lecture Atul explores the impact that the development of systems has had – and should have in the future – on medicine and overcoming failures of ineptitude.
Atul starts with a slightly different take on the universal challenge facing all health systems – how to deliver effective healthcare to all. Not surprisingly since he practises in the USA, rather than dwelling on the usual trilogy of too much that can be done to an aging population with multiple morbidities with limited resources, he feels people are couching the problem too much around money, excessive business modelling and too much regulation, which eventually makes health political. His response is to introduce what he considers is the main challenge facing health care today – complexity. He illustrates this with a case study of a drowning girl in Austria who eventually returns to lead a normal life having been under the ice of a frozen lake for 30 minutes. He goes carefully and eloquently through all the high-tech procedures required to save the girl, including heart lung bypass and extracorporeal membrane oxygenation. For him the story highlights two key issues: first the previous impossibility of saving such a girl and how this is now made possible through the sophistication of new treatments; and second how everyone in the team has to get everything just right – the sheer complexity of it all.
He deviates slightly here to refer to what is often considered the major achievement of modern medicine, the discovery of penicillin. But he claims that we were fooled by it. We were seduced into thinking that the future was going to be as simple as give an antibiotic and see the patient saved. The reality is more like trying to save a drowning girl. He argues that faced with this complexity people are not rising to the challenge. He refers to what has become known in the UK as the second translational gap, ie we know what to do but it just does not get done. He highlights evidence of poor practice and variation in care (especially treatment of hypertension) and considers our response as being ‘primitive’ – we just give out more and more information. He refers to ‘medieval’ guidelines, regulations and incentives (both positive and negative) and, while they have helped a little, we still have a long way to go for best practice to be the ‘norm’.
He refers to a friend stating that while the last century was the one of the molecule, this one is going to be that of the system. He tells the story of his involvement with the WHO surgical ‘checklist’ as a way to make sense of a complex system. He highlights the role of the ‘checklist’ as being a stimulus for discussion between teams as much as having intrinsic value. Like all good communicators he uses humour to make his point. They undertook a survey 3 months after its introduction and 20% of surgeons really disliked it: ‘it’s more paper work …a pain in the butt’. However, when asked if they were to have an operation would they like the team to use it, 94% said that they would.
He returns to the drowned girl story and relates how he contacted the authors of the paper because he was so impressed and wanted to know how they had done it. He learnt that this hospital had had many similar cases previously, mainly from snow avalanches, and the patients had mostly died. The hospital had learnt that the secret was the co-ordination of all the high-powered specialists who were required to be there quickly and they introduced a protocol. The management of the girl was its first practical test. However, the punch line was that we learn that it was the telephone operator with a checklist who had the responsibility to instigate the system.
A strength of the Reith Lectures is that questions can be asked by the studio audience. However, this one had not just walked into the Wellcome Building from the Euston road. The UK audience proved to be a little more challenging than those in Boston. Sally Davies, the Chief Medical Officer for England, said that she was ‘profoundly uncomfortable on a number of counts by what she had heard this evening’. First that people would think that everyone not breathing for 30 minutes could be saved, highlighting that his patients had been drawn from ‘frozen water’. Secondly she pointed out that the examples of poor practice he used did not apply to the UK because of good primary care and, thirdly, while as a surgeon he dealt with the sick, she was worried more about preventing sickness. She finished with ‘so how do you bring your century of the system out to play to have a big impact on that?’. With perfect charm and political ease Atul thanked Sally for her ‘cautionary notes’ and laid out his plans. The compere for the evening Sue Lawley (of Desert Island Discs fame) asked Professor Davies whether she was content with the answer. Dame Sally was in benevolent mood, her response being ‘I think that you are beginning to get there in those last few comments.’ Other questions came from Maureen Baker, President of the Royal College of GPs on multi-morbidity, Nick Black on patient involvement and Ali Parsa on artificial intelligence. The final question came from Clare Marx, President of the Royal College of Surgeons on how did this approach ensure ‘compassion’ – which was the perfect cue for Atul to introduce his next lecture, which is to be entirely on this issue. So the second lecture ended. When eminent surgeons from the USA and UK talk about ‘systems applied with compassion’, we are certainly entering a new world.
Summary of the third lecture: The problem of Hubris
The third lecture took place at the Royal Society in Edinburgh, a city famous for John Hunter, father of modern surgery and Alexander Fleming the discoverer of Penicillin.
In this lecture Atul comes closest to challenging the direction modern medicine has taken, illustrating his concerns with how a certain group of patients are managed – those who are close to death. He again uses case studies to exlore the importance of dying with dignity. The first is his daughter’s music teacher who suffered with a leukaemia-type illness caused by the chemotherapy that she had received for a sarcoma. The second, his father with a brain tumour. We learn how he realises that there is a middle way between doing everything that modern care can offer at all costs or ‘giving up’. Ironically he said that his medical training could not help him discover how he should manage such people, ‘So I approached this the way I know how to approach these kinds of questions. I decided to approach it as a writer. And what I do when I write is I talk to lots of people and so I interviewed… I ultimately lost count after 200 people. I interviewed more than 200 families and family members and patients about their experiences with serious illness with ageing, with frailty. And I also met and interviewed and observed scores of palliative care doctors, frontline nursing home workers, geriatricians and others.’ Of course this approach is not as unscientific as Atul would have us believe, he had merely switched paradigms from a ‘medical model’ of research that he was trained in to a ‘social one’, equally legitimate.
From the palliative care experts he learnt three lessons. Firstly, ‘Medicine seems to have failed to recognise that people have priorities, priorities they want us to serve besides just living longer. It seems obvious. We aren’t just people who want to live to be pulsing organisms lying on a bed doing nothing, but what are the priorities that people have? And people have priorities that can range from, you know, wanting us to help make sure that their cognitive function is intact or wanting us to make sure that they’re able to spend more time at home than in the hospital or wanting to make sure that they can just be with their dog.’ Secondly ‘I learned that the most reliable way to learn what people’s priorities are – and there are highly technical studies on this – the most reliable way to learn is to ask. And we don’t ask. In studies for example of cancer patients in a very advanced stage – in one study it was just a group of people who lived on average only 4 months after they started the study – less than a third of them had had a conversation with their physician.’ And thirdly, of course if you ask you also need to listen and he uses humour when he describes how he thought that he only talked about 50% in his consultations until it was actually measured and he talked for 90% of the time. We are taken through the last few months of Meg’s life, which reached a climax with a farewell concert in her living room of all her students.
Following the talk the questions quickly moved from debating dying with dignity to assisted death.
Summary of the fourth lecture: The idea of wellbeing
The fourth lecture took place at the India International Centre, New Delhi. Atul’s parents were both doctors from India who moved to the USA. His father came from a poor rural background where his grandfather lived to be 109 years.
Atul starts this lecture with the importance of primary care (the four Cs: contact, continuity, comprehensive and co-ordination), but highlights the difficulty of poor access and variability of quality internationally; he even highlights the UK as having a specific problem in this regard. He then moves onto the improvement of mortality in childbirth that occured with the introduction of hospitalised service provision. but then quickly gives a severe warning that all too often new interventons lead to overuse – in this case high caesarian section rates. He introduces the childbirth checklist, but highlights that the implementation of good practice remains a challenge. There may be many barriers to it being widely implemented. but he dwells on the fact that so often no one cares if practice is good – only if it is substandard. Overmedicalising health care and no one caring leads into a discussion of how the elderly are treated and he contrasts the situation of his grandfather at the head of the family table, a revered wise man, and how the elderly were treated back in the USA. But he suggests that India is now moving that way – giving the younger generation greater freedom comes at a cost. As in his other talks he suggests that wellbeing is far more than the delivery of medical interventions and feels that the only way it can be delivered is through the design and implementation of complex systems. He finishes with a story of the care 100 homeless old people receive in New Delhi dellivered by the charitable sector.
The post lecture questions allow him to voice his concerns over excessive pharmaceutical profits through ‘secondary patenting’ and how research should be targeted on prevention and managing patients’ wellbeing and not endlessly searching for a cure of their disease.
What does this mean for the NHS?
So what lessons can be drawn out for the NHS? Well, the tension between supporting innovation at the same time as not overmedicalising health care is an obvious one, particularly as the coalition government see the pharmaceutical industry as a key creator of wealth for the UK and there are daily announcements of innovations such as genetic profiling that will solve the Treasury’s as well as the Department of Health’s problems. Secondly, you neglect primary care at your peril and thirdly, caring for (as well as treating) patients remains a challenge when hospitals are full and human and financial resources are tight.
Professor of Public Health, King’s College London