Why does medicine fail ? – Ignorance, Ineptitude, Hubris
This week the first of four Reith lectures will be broadcast by Radio 4 featuring Atul Gawande. These are well worth a listen as Gawande has a rare ability to recognise and articulate what holds back modern medicine. He also has unquestionable credibility as he is a practising endocrine surgeon.
I first heard of Atul Gawande in 2009 when I was invited to an event at the Cromwell Hospital in London’s Kensington to launch the Cromwell’s adoption of the World Health Organisation (WHO) Surgical Safety Checklist, one of the first hospitals in the UK to do so. I met Martin Bromiley, an airline pilot who last lost his wife 4 years earlier during routine surgery when she lost her airway and suffered unrecoverable brain damage. Understandably, Martin wanted to understand what had happened; it turned out that a problem had arisen – ‘can’t intubate, can’t ventilate’ – but that established procedures for such an emergency hadn’t been followed.
One of the reasons was the hierarchical culture within the NHS and a culture where mistakes were not openly acknowledged so they could be learned from. Contrast this with the airline industry where incidents are routinely investigated to learn from mistakes. Martin has since campaigned for the NHS to transform its culture with regard to accepting that mistakes are inevitable and they should be learned from, not covered up or punished.
The idea of the Surgical Safety Checklist is to adopt practices from fields like aviation that use checklists all the time to reduce the risks of things being forgotten or risks being overlooked through human fallibility, and to engender a stronger sense of teamwork within operating theatre teams. Atul Gawande has written books called ‘Complications’, ‘ Better’ and ‘The Checklist Manifesto’, where he combines story telling with insightful analysis of the dilemmas and limitations of modern medicine.
Why Doctors Fail
In the trailers for the upcoming lectures, Gawande asks ‘‘Why doctors fail’, and suggests there are 3 reasons:-
Ignorance – the knowledge doesn’t exist yet
Ineptitude – the knowledge exists but an individual or individuals fail to apply it
Hubris – we don’t understand that we all have areas of ignorance and always will have
The problem Neurofeedback faces right now is ineptitude – most of the professionals whose job is to treat the symptoms Neurofeedback can help with, don’t know about Neurofeedback. So they don’t use it or refer their clients/patients to those who do.
When we overcome the ineptitide through education, we encounter hubris: when I am a professional at the top of my field, it is hard to accept that there is something (Neurofeedback) that is better than I offer, that isn’t new, and I don’t know about. Regardless of what it is, any such idea is a threat to my sense of identity, a threat to my beliefs about myself. As a professional at the top of my field. So my beliefs won’t let me accept it, and I will go to extraordinary lengths to resist it and hold onto my beliefs.
BUT we can take heart from the fact that these barriers have been the same throughout history, and if anything this realisation is a validation that we are onto something.
Stuart Black, November 2014. Updated November 2019.
P.S. I had the same sinus surgery that Elaine Bromiley had 18 months after I met Martin Bromiley. The theatre team used the Checklist.
P.P.S. A few years later (2015), Mathew Syed opened and closed his book “Black Box Thinking’ with the story of Martin Bromiley and his wife.