Atul Gawande Does It Again

Atul Gawande, surgeon and staff writer for The New Yorker, is one of the most prominent voices speaking about patient safety in the United States.  Thanks to his frequent contributions to The New Yorker, Gawande has a bully pullpit,  and his ideas have become part of the current thinking about contemporary health policy and patient safety.  In spite of the fact that it is now unarguable that teamwork is critical to patient safety and that most medical errors and injuries result from failures in teamwork and team communication –what I call lack of  Team Intelligence — Gawande is both tone deaf and almost completely blind (I mix these metaphors deliberately) to the participation of non-physician actors to quality care.  His early books, Complications, Better and Checklist Manifesto, place him firmly in the tradition of the heroic medical narrative, where physicians — usually acting alone — battle illness and death.  In one particularly telling passage in the beginning of Better, Gawande states that:

“We (physicians) face daunting expectations. In medicine, our task is to cope with illness and to enable every human being to lead a life as long and free of frailty as science will allow. The steps are often uncertain. The knowledge to be mastered is both vast and incomplete. Yet we are expected to act with swiftness and consistency, even when the task requires marshalling hundreds of people – from laboratory technicians to the nurses on each change of shift to the engineers who keep the oxygen supply system working – for the care of a single person.”

What this neglects to acknowledge is that physicians don’t, in fact, marshall lab techs, or nurses, or shift engineers, nor does this personnel work directly for physicians.  Hospitals pay these people and most of them do not conceptualize their work as working for physicians but working for and with patients.  The kind of physician-centric view of the healthcare enterprise inhibits the kind of teamwork upon which safe patient care depends and instead turns hospital care into what I have called parellell play between intimate strangers.

In spite of the fact that Gawande is committed to greater safety and efficacy, his framing of healthcare activity ignores the fact that doctors are not an army of one but actually function as players on an inter-disciplinary team that includes multiple actors, each of whom has a contribution to make and ought to be consulted about  quality and safety improvements.  Healthcare, wherever it is delivered, requires what the linguistic anthropologist Edwin Hutchins calls “distributed cognition.”  As Hutchins explains it in Cognition in the Wild, “All divisions of labor, whether the labor is physical or cognitive in nature, require distributed cognition in order to coordinate the activities of the partcipants.  Even a simple system of two men driving a spike with a hammer requires some cognition on the part of each to coordinate his own activities with those of the other.  When labor that is distributed is cognitive labor, the system involves the distribution of two kinds of cognitive labor:  the cognition that is the task and the cognition that governs the coordination of the elements of the task.  In such a case, a group performing the cognitive task may have cognitive properties that differ from the cognitive properties of the individual.”  I have called those cognitive properties Team Intelligence — the ability of individuals working together to communicate, teach one another, think, learn, reason, critique, and cross-monitor together, irrespective of their position in the hierarchy.”

Gawande sadly seems unaware of the fact that other people around him actually may have something to contribute to both his individual performance or that of the entire team.  This is made painfully clear in his latest New Yorker contribution entitled, “Personal Best:  Should everyone have a coach?” The everyone in question here is, not surprisingly, the physician.  In this well-written piece (everything Gawande writes is well-written, which is why his not so hidden assumptions are so disturbing and problematic), Gawande ponders the question of whether physicians like himself should have the kind of personal coaches that are routine in the world of competitive sport.  In order to find out if he could improve his game, so to speak, Gawande asks one of the surgeons who served as his mentor during his training to come into the OR and observe him at work.  The senior physician –retired general surgeon Robert Osteen –agrees and watches Gawande in the OR.  When the two emerge, they debrief in the lounge and Osteen points to a number of small things that Gawande could do better.  Although neither surgeon mentions the word, most of Gawande’s problems have to do with his interaction with the team.  Acting as his usual army of one, Gawande has been oblivious to the fact that, “I had positioned and draped the patient perfectly for me, standing on his left side, but not for anyone else.  The draping hemmed in the surgical assistant across the table on the patient’s right side, restricting his left arm, and hampering his ability to pull the wound upward.  At one point in the operation, we found ourselves struggling to see up high enough in the neck on that side.  The draping also pushed the medical student off to the surgical assistant’s right, where he couldn’t help at all.  I should have made more room to the left, which would have allowed the student to hold the retractor and freed the surgical assistant’s left hand.”  Similar observations, apparently abounded, including the fact that the surgeon had not noticed the patient’s blood pressure problems that the anesthesiologist was continually tracking.

One wonders why Gawande needed to have a senior surgeon present to uncover these team problems.  Why didn’t anyone else in the room — medical student, surgical assistant, operating room nurse, anesthesiologist — mention these issues.  The answer seems to lie in Gawande’s view that only another physician — and a senior one at that — could possibly give him any tips.  As he puts it, “Yet the stranger thing, it occured to me, was that no senior colleague had come to observe me in the eight years since I’d established my surgical practice.  Like most work, medical practice is largely unseen by anyone who might raise one’s sight.  I’d had no outside ears and eyes.”

This is a truly amazing comment.  Gawande here argues that during his entire career there were no “outside ears and eyes,” observing him, and that his practice was “largely unseen by anyone who might raise one’s sights.”  In actual fact,  there literally hundreds of people have been observing him — and very closely — and many of them could have raised the surgeon’s sights and acted as  much needed “outside ears and eyes”  — and I might add brains  These people surround physicians and could help them make needed improvements.  To surgeons like Gawande, however, these people literally do not exist.  Surgical assistants whose access is blocked, med students who cannot help, nurses who have good ideas, these people are silenced by the kind of assumptions held by physician leaders like Gawande and others (for comments on Jerome Groopman and others, please see The Cure: Can Doctors Change How They Think, Boston Review).

In response to Gawande’s article, a former operating room staffer wrote a telling letter to the editor that should be required reading for those who read Gawande’s piece itself.   He pointed out that,

“like all surgeons, Gawande operates with other members of a surgical team, and his piece doesn’t explore the shared experience of his team members, all of whom are vitally aware of the progress of a surgery. I once worked in a lowly position in an operating room. I was never consulted about how any aspect of a procedure, however minor, might be improved, until the hospital was faced with a malpractice lawsuit.”

Atul Gawande concludes that doctors, like athletes, should indeed hire personal coaches.  I have a better idea.  How about hiring team coaches, people who can help recognize that improving patient care  not just about doing their “Personal Best.”  Yes, Robert Osteen taught his star pupil  to recognize his impact on those around him.  What he did not do is help  Gawande understand that patient safety and great performances are about how we all work, learn, think, and reason together.