Reith lecturer and rock-star doctor Atul Gawande on life, death and how to cure the NHS
The Today programme's Justin Webb talks to the US cancer surgeon about the terminal condition of living...
Face it: we are all suckers for a rock-star doctor. Prime ministers and presidents come and go. Film stars fade. Scientists seem sometimes to live in another world, or wish that they did.
But oh, the lure of a man or woman in a white coat who has also written an opera, been to the Moon, run a small country, published an important novel, farmed a hundred acres and can take one look at your stubbed toe and say, with a smile revealing perfect teeth, “You’ll be fine.”
Atul Gawande has not quite done these things, at least not yet. But he is a rock star for sure; one of an elite group of American doctors who has thought seriously about medicine and society and is helping us to think again about the whole idea of health. Born in Brooklyn, now 49, he’s a cancer surgeon, but among his extracurricular achievements, he’s a staff writer on The New Yorker, America’s highbrow magazine of ideas.
In other words, he can’t only walk the walk as a physician, he can also write, communicate, influence. He’s a handsome fellow too, but understated: where last year’s Reith lecturer (Grayson Perry) was all out there with his women’s clothes and stage make-up, Dr Gawande is a little more buttoned down, more med school than art school. But meet him for ten minutes and you’re left in no doubt that Gawande, while unlikely to dress in women’s clothes and do anything vibrant and shocking with clay, is nonetheless the ideal Reith lecturer for our times.
We’re entering a moment of neuralgia over health. It will be a huge issue at the general election next year. Hardly a day goes by without the news that the NHS is in trouble and must be rescued with this remedy or that. We are – rightly – intensely interested in the debate about how health services are delivered, how much it costs and how good the care can be. We’re worried, too, about how the health service treats us in our declining years.
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In other words we’re trying to be healthy and not thinking enough about what happens to us when, inevitably, we are not. As Gawande puts it, when I catch up with him, “Living is a terminal condition.” So as Dylan Thomas’s poetry rings in our ears this autumn, do we rage too much against the dying of the light?
In one respect the answer is no. One of the focuses of Atul Gawande’s thinking has been, he tells me, “delivering on the existing knowledge that we are not actually delivering on. We need to tackle the science of ineptitude.” Prime example: the thousands of people who go into hospital and come out with an infection. Here is medical progress waiting to happen: it requires no expensive laboratory experiments or fiendishly clever science. It’s about being clean.
That means tackling ineptitude among individual doctors – providing checklists, monitor- ing performance. But it means tackling ineptitude at the level of systems too – think of the scandals we’ve had in the NHS in recent years where poor care hasn’t been noticed and challenged sufficiently quickly. Here Atul Gawande speaks with the authority of a man who comes from a country where a full 20 per cent of GDP is spent on health but where actual outcomes vary staggeringly from place to place.
We tend to think, lazily, that the question is one of money: the Americans who get the biggest slice of health money have the best outcomes and the poorest get the worst. Not true. As Dr Gawande puts it, “The most expensive places are not the best places.” In fact, he says, “The American experience is that the best places to get treatment are often the cheapest because they’re the best organised.”
So can we relax about the NHS? Can we put the black hole in funding to the back of our minds? If we concentrate our organisation and efficiency, can we squeeze the funding further? Dr Gawande smiles. “The short answer,” he says, “is... maybe.” The problem is that you have to invest money to get the payoff. He gives the example of Scotland, where deaths in surgery were hugely reduced but the initial investment in training and monitoring cost money that had to be found up front. But his bigger point is that seeing health and the health budget as separate things is a mistake. It is a bureaucratic exercise, not a human one.
He tells the story of the vacuum cleaners of Boston. Doctors there noticed that children from homes with no vacuum cleaner had much higher rates of asthma. They could treat the asthma but the drugs and therapies are expensive. So they gave out vacuum cleaners instead of inhalers. One for every house. It cost money up front. And it was an eccentric way to spend a health budget. But a year later there was an 80 per cent drop in children being admitted to A&E departments in Boston with asthma attacks. Money was spent out of one budget and saved out of another.
His point is clear – if we’re to keep the cost of health under control, we have to find our equivalent of vacuum cleaners for many of our health problems. And we have to pay for them. But if we do, as Dr Gawande says, “We’re discovering means of improving people’s lives that are even more powerful than a drug or a device.” And it saved money in the longer term.
As for the drugs and the devices; well, Dr Gawande is perfectly happy to see them prescribed and used, but before you charge off to your specialist and demand the latest gizmo or specialised treatment, make sure you’re really in need. This, he says, is the strength of the British system. We’ve invested in primary care, in family doctors, who are the gatekeepers, the triage merchants. This doesn’t always seem very sensible when you have to fight to get an appoint- ment and your persistent cough is ignored, but actually, he claims, it works. It keeps costs down and stops the overuse of medical solutions.
A personal example: in my last year of working in the USA for the BBC I paid tribute to my sense of American-ness and went to a private MRI clinic in a shop- ping centre (they’re in lots of them) to have a full body scan. “See the future and alter it,” was the alluring message on the company website. But of course it was idiotic. They missed a couple of things that were wrong with me and decided that I had thyroid cancer, which, after several rounds of expensive tests, turned out to be wrong. Dr Gawande is surely right to warn us against a blindfaith in more being better. Health is more complicated than that.
Which brings him to a wider philosophical place: how should modern medicine be changed so that it can cope with the reality of modern life – that many of us will live a long time but will not be healthy at the end? At the moment medicine rages against the dying of the light just as much as we do as individuals – in fact more. Some of us do want to go gentle etc. But one more round of chemo gets in the way. Dr Gawande is clear: “We lose our way. We fail to recognise that people may have priorities in their lives besides just living longer. Even in very narrow times in their lives people have purposes that are bigger than they are. Medicine has to help them. We cannot be endlessly trying simply to preserve life. It has to have a purpose.
“It’s heartless to not offer people who have unbearable suffering an opportunity to alleviate it,” he says. But what then? Are we to offer death, as some would like? Assisted killing or suicide? If all else fails – all the efforts at palliative care – then yes: “You can properly give people a prescription to hasten their own death.” It happens in Washington and Oregon States in the US and, according to Dr Gawande, only half of the people who receive a prescription of drugs that would kill them actually use them. Possession is enough. It brings comfort. Might that be a job for the NHS in years to come?
Cradle to the grave including a final push if we want it? Dr Gawande is certainly not a trenchant “right to die” campaigner. But his thinking about public health represents a serious effort to address real ethical issues that modern medicine struggles with, and he acknowledges that this is one of them. We are desperate to be healthy. We have the means to be healthier for longer. But in the end, gently or otherwise, the goodnight calls. What then?
Paging the rock-star doctor. Even if you feel fine today, he has a message for you.
The first of Gawande's Reith Lectures was broadcast this morning on Radio 4 and will be repeated on Saturday at 10.15 pm. The Reith Lectures are also downloadable from the Radio 4 website