The first time I ever read anything by Dr. Atul Gawande was about 7 years ago when I read an article in The New Yorker. The article was not only well written but also educational and sparked a desire in me to improve my “clinical” skills and understanding through reading, however, not through traditional textbooks. Instinctively, I called my grandfather "Popeye," who practiced Neurology for close to 50 years. I asked him to read it; he too enjoyed the article and after hearing his response and opinions. I knew that I had found something, a passion for both medicine but also literature. Several years later, I was asked to write a blog. Sometime down the road, I reached out to a podcaster and inquired about shared interests. There was an uncanny association to a blog I had written and a presentation she had recently given. We discussed a collaboration; however, it, unfortunately, fell through. But there is a light at the end of the tunnel, I have completed it and publishing it on a blog and podcast site that started three-months ago, with a friend and paramedic. It has been shortened quite a bit to ensure that I do not muddy the waters and ruin the book if you choose to read it.
Complications, a book that discusses medicine from the perspective of a surgical resident. Atul Gawande. Dr. Gawande is a remarkable author who has done an exceptional job of bringing the reader into the hospital. What I find most intriguing about the book is its relatability to all types of medicine, including prehospital and critical care transport. Of course, Dr. Gawande is a surgeon, but his ideas and experiences are easily translated into what a paramedic might experience. Although this is the second time I have read the book, I spent more time analyzing and taking notes in the margins – so to speak. I call this the Bill Gates Affect, it allows me to recall specific ideas from the paragraphs, chapters, and pages that turn so quickly through my anxious fingers (Bariso). I do not write in the margins (sometimes I do, just do not tell my son); however, I do use it post-it-notes to “earmark” pages. I want to be able to return to quickly if asked a question or, in this case, write a blog.
Dr. Gawande breaks down the practice of medicine and alludes (passive-aggressive he does suggest and directly) to the idea that as humans, there is an expectation for doctors to be perfect. This construct is what I imagine our patients helicopter think, they presume that they are in the best hands available. But the reality is, this is nearly impossible. To be perfect would make us robots and hinder our ability to be compassionate providers who are empathetic to our patients' needs and care. I guess we have to weigh which is more important our ability to provide empathy and compassion or become errorless robots.
Making mistakes, or as Gawande puts it being fallible, is a part of the process. We learn through our mistakes, and through this process, we, as emergency medical technicians and paramedics, become better providers.
Gawande discussed a scenario when he was first learning to put in a central line and the anxiety it provoked in him, he made mistakes, and needed guidance from a senior resident, at one point the chief resident had to take over for Gawande. Ultimately, Gawande learned from his errors and, through repetition, became a proficient provider, who still makes minor mistakes, not nearly as many, but always learning. This is very similar to skills we learn and practice and become more proficient at.
As unnerving as this makes us feel, it is part of becoming a better practitioner. Dr. Gawande does describe how repetition might just be the key to be a better clinician. My favorite part of the book is where he describes a hernia surgical center, an outpatient clinic in Canada, where only hernia repairs are performed. Their success rates are the best in the world but also some of the least expensive. The reason for this is that these physicians only perform hernia repairs and have them down to a machine-like accuracy. Is this possible in prehospital medicine?
Another example in the book Gawande writes about a Swedish physician who went up against a machine. The physician is considered an expert at reading 12-leads, something we as medics like to think about ourselves. He was asked to look at thousands of 12-leads and try and determine if a patient was having a myocardial infarction (MI) by reading only the 12-lead. On the other side of the room was a machine that had been programmed to read 12-leads and identify a patient having an active MI the machine won the battle versus man and proved that robot-like preciseness is a critical component of patient care. This made me think deeply about how I could improve this skill while continuing to use a patient-centered approach for the patient experiences MI like signs and symptoms. Obviously, the machine was not going to do that for the patient.
Machines may not be the answer to all of our problems in medicine. But according to Dr. Gawande implementing devices to perform a particular task may reduce medical errors. We all complain about autonomy, but it seems like the hernia repair facility and the machine that reads 12-leads may be the future. Utilizing algorithms and checklists for patient care might be just the solution to reducing medical errors. I do not believe Dr. Gawande is suggesting that we remove the clinician altogether, but instead, we improve our practice by putting controls in place to prevent unwanted errors.
Dr. Gawande further discusses human error and how its impact is not entirely avoidable instead of an expected result from time to time. The key take away from this is that we accept responsibility for our mistakes, learn from them, and mitigate further injury to our patients. I think about this frequently when administering medications, performing intubations, and even placing a tourniquet. There will be complications. However, it is possible to reduce these by merely putting in place controls that force us to challenge and check ourselves (checklists, CQI’s).
Dr. Gawande mentions the use of Morbidity and Mortality conferences, more commonly referred to as an M&M. These M&Ms allow physicians to discuss errors in a "judgment" free zone where they are not held in litigation, this forum allows them the freedom to discuss their mistakes and learn from them. These conferences are necessary because, without them, it is believed that physicians would not report their errors, and ultimately patient care would be harmed. Implementing a structured means of follow up and critical analysis of an error is, without a doubt, in my mind, something the practice of medicine cannot do without. I pause to think about how this process might be applied to prehospital medicine. Are our Audit and Reviews enough? What else can we do to ensure that paramedics do no harm or better yet reduce our errors and improve patient outcomes?
Briefly, I want to finish with a topic Gawande mentions several times and clarifies that without the human factor, medicine would not be what it is. He talks about controls and processes to prevent errors but also autonomy. Understanding this concept is critical to furthering medicine. Technology advancements are essential, but so is allowing for paramedics and EMTs to act with gestalt. Merging these together is what makes an excellent clinician. For instance, recognizing when to use technology, but also knowing when to use your gut to treat a sick patient who at first glance appears and according to the monitor is stable.
This blog barely touches the surface of this book, and much of its contents are pertinent to our practice in prehospital medicine. Do not be fooled humans make mistakes. However, we can learn from those errors through understanding that we are fallible. By applying discipline to knowledge, repetition, and consistent checks and balances, like checklists and M&Ms, we can improve our skillset and set our profession up for success, advancing EMTs and paramedics into the realm of unlimited potential.
Regards, and as always be safe, and PragMedic,
Bariso, J. (n.d.). Bill Gates follows these 4 rules to get the most from his reading. Inc.