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Atul Gawande at Stanford: the medical-industrial complex cometh**

Efficient and seamless functioning parts

Efficient and seamless functioning parts

Atul Gawande, the surgeon and writer of much-deserved acclaim, reveals his spectacularly technocratic vision of the future world of medicine, a vision of a true medico-industrial complex.  This is from Gawande’s address to the Stanford medical school graduating class, and the emphases are mine:

Why does anyone receive suboptimal care? After all, society could not have given us people with more talent, more dedication, and more training than the people in medical science have—than you have. I think the answer is that we have not grappled with the fact that the complexity of science has changed medicine fundamentally. This can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door. We have to be more like engineers building a mechanism whose parts actually fit together, whose workings are ever more finely tuned and tweaked for ever better performance in providing aid and comfort to human beings.

You come into medicine and science at a time of radical transition. You have met the older doctors and scientists who tell the pollsters that they wouldn’t choose their profession if they were given the choice all over again. But you are the generation that was wise enough to ignore them: for what you are hearing is the pain of people experiencing an utter transformation of their world. Doctors and scientists are now being asked to accept a new understanding of what great medicine requires. It is not just the focus of an individual artisan-specialist, however skilled and caring. And it is not just the discovery of a new drug or operation, however effective it may seem in an isolated trial. Great medicine requires the innovation of entire packages of care—with medicines and technologies and clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually, and shown to produce ever better service and results for people at the lowest possible cost for society.

Wow.  I’m appalled.

Not because I think that Gawande’s efficient, techno-industrial future world wouldn’t be a huge improvement on the status quo, which is currently rife with waste, graft, corruption, error, and greed.  I’m appalled because this is such an archetypal expression of a way of seeing the world that we rely on too much, to our detriment.  It’s almost a perfect example of what the agrarian viewpoint is not.  If you want to know what agrarianism is, it’s not too simplistic to say that it is exactly the opposite of what Gawande describes.

I could mine this speech for tens of posts about agrarianism generally, but today I’ll limit myself to first impressions.

According to Gawande’s vision, physician autonomy is dead.  At the very least, it’s nothing like the kind of autonomy that most doctors and medical students have in mind.  In place of craftsmen physicians who use their training and judgment to treat patients, we have “… clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually…”  Think about what this means.

It means that clinicians — doctors, nurses, PAs, NPs — no matter how highly trained or well paid, must not exercise individual judgment but instead must conform, “seamlessly” to a medical system in which they are merely another mechanism alongside the inanimate mechanisms of “technologies” and “medicines.”  What else could Gawande mean?  He says: “This can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door.”  And he’s explicit that clinicians, as well as technologies and medicines, must be “monitored carefully” and “adjusted perpetually.”  If we actually relied on the judgment of clinicians, how could they then “fit together seamlessly” with the rest of the medico-industrial system?

Setting aside the reasonable question of whether this is even possible, I wonder how many graduating Stanford medical students heard that and swelled up their chests, proud of the knowledge that they were entering upon a career where the highest they can ask of themselves is that they fit seamlessly into a system that will “adjust” them perpetually in the name of efficiency.  And I wonder if some of them didn’t worry just a bit over whether robotic technology might improve enough during their careers to make David E. Williams’ vision come true — not just robotic nurses but robotic doctors as well.  Better hope you have your student loans paid off by then, folks, or you’ll be competing for those Starbucks jobs when you’re forty like too many of us in other decaying professions are already.

I’m not saying that this is somehow dystopian — compared with our current system we would probably get better medical care for less money after being processed by Gawande’s system.  But I doubt that Gawande’s prescription is the only way to improve upon our current mess.  But if not, I wonder who would sign up to be a doctor in this system?  Plenty of people, certainly, but probably not all the graduating medical students listening to Gawande’s speech.

I suppose there are possibilities in Atul Gawande’s world for a rich and rewarding career for those who like to exercise personal judgment.  Just make sure that you are one of the “engineers building a mechanism whose parts actually fit together” instead of just a doctor.  Gawande misleads when he suggests that doctors generally need to be more like engineers; under his system most doctors will be more like the part than the part-maker; they will be the objects of the “tweaking” that only a very few of them will have the opportunity to do.  And for those lucky enough to be a tweaker instead of a tweaked, what they do won’t bear much resemblance to anything like what most of the graduates imagine when they think about “practicing medicine.”  Yes, for the select few, the way is still open in Gawande’s system to become a respected bureaucrat.

Worse, though, than the horrifying thought of doctors suffering through unrewarding careers is the likelihood that Gawande’s medico-industrial utopia will encourage most of us working in that industry to take even less responsibility for its outcomes than we do now.  Gawande hints that he thinks this failure to take responsibility is a problem when he bemoans the tendency of specialists  to worry “almost exclusively about our particular niche, and not the larger question of whether we as a group are making the whole system of care better for people.”

His solution — to assign responsibility for the whole to a small number of those specialists — is the same solution that the financial industry implemented (and which failed) and that the oil industry implemented (and which failed).  If only a few people are assigned responsibility for an enormously complex system of specialists, one over which they cannot possibly know enough about what is going on to accurately forecast the risks and take the proper precautions, the result is the collapse of AIG and the Deepwater Horizon spill.  These are both industrial catastrophes — large-scale and difficult to fix because the cause is often hard to identify and to understand.

But we’ll forgive Gawande; he’s just offering up a very conventional vision of improvement from an industrial mind-set; he was probably on a deadline.  Like most conventional visions of this sort, the vision is appealing: a social organization that functions like a well-oiled machine!  One that works, and works efficiently!  The problem is that implementation of such a vision is always such a bitch.  Easy to imagine, hard to do.

** Apologies to Arnold Relman.

One Comment

  1. kayvon wrote:


    First I think Gawande was blowing alot of hot air into the lungs of these new grads. I mean what system really runs seamlessly? Surely not medicine, and surely not in the near future. I think alot of this speech was lip service, which is my impression of Gawande from reading some of his writings. I don’t think he really intends everything in the practice of medicine to run as smooth as the gas flow in the fuel injection of a lexus or the power seats in a BMW (do BMWs have power seats?). I really think he is trying to portray a vision of the implementation, regulation and monitoring of quality in medicine across all providers, hospitals, technology and pharmacy.
    His reference to the “Individual craftsmen brewing plans for whatever patient comes through the door,” I believe is referring to physician accountability. For example recall that less than 5% of what we do in medicine is truly evidence based-this allows providers a wide scope to practice medicine, some of which is borderline malpractice. Thus to implement and regulate a range of the standard of care within the realm of known evidence is reasonable (for example practice guidelines with the review of the current literature). However by no means would this be a perfect system, and likely would be fraught with many holes that even the best seamstress or surgeon would not be able to mend.
    One problem I have with his essay, and what I personally feel is the root of our medical systems’ flaw is its intrinsic conflict between profit and patient care. Gawande states technology and science have changed medicine-sure. However, it was money and profit earned from the sick that fueled the technology and science in the early 20th century, and still does to date. These two opposing endpoints (profit and the welfare of the patient), cannot and will not be in harmony, and thus we will always struggle with efficiency and accountability despite our best efforts to improve quality by normalizing/intergrating our goal-directed therapies

    Sunday, June 20, 2010 at 6:07 pm | Permalink

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