Patients love Atul Gawande. A surgeon, writer and broadcaster, he talks about medicine in ways that make sense to the non scientist. We read his words and punctuate ‘yes’, ‘exactly!’ ‘that, that’s what I mean’. He talks so clearly of our experience we forget that he’s a radical- a medic calling for transformation. Health systems hear the voice of doctors before they hear the rest of us (my current fantasy Phd topic).
Yesterday we were talking to final year medical students. 200 bodies crammed into a big lecture theatre. They’d been there all day, as part of a preparation for practice programme. The room was hot and stuffy, and there was almost a conveyor belt of speakers, each trying to convey the importance of their particular issue. We were all about hearing personal stories, listening to patients, recognising expertise. The usual messages from us, structured to make sense to them. I referenced Gawande, and just about resisted opening his book Being Mortal at page 1 and reading it all out loud.
A hint of what you missed …
In the end, a person doesn’t view his life as merely the average of its moments—which, after all, is mostly nothing much, plus some sleep. Life is meaningful because it is a story, and a story’s arc is determined by the moments when something happens. Unlike your experiencing self, which is absorbed in the moment, your remembering self is attempting to recognize not only the peaks of joy and valleys of misery but also how the story works out as a whole. That is profoundly affected by how things ultimately turn out. Football fans will let a few flubbed minutes at the end of a game ruin three hours of bliss—because a football game is a story, and in stories, endings matter.
Jewel Douglass didn’t know if she was willing to face the suffering that surgery might inflict and feared being left worse off. “I don’t want to take risky chances,” she said. She didn’t want to take a high-stakes gamble on how her story would end. Suddenly I realized, she was telling me everything I needed to know.
We should go to surgery, I told her, but with the directions she’d just spelled out—to do what I could to enable her to return home to her family while not taking “risky chances.” I’d put in a small laparoscope. I’d look around. And I’d attempt to unblock her intestine only if I saw that I could do it fairly easily. If it looked risky, I’d just put in tubes to drain her backed-up pipes. I’d aim for what might sound like a contradiction in terms: a palliative operation—an operation whose overriding priority was to do only what was likely to make her feel immediately better.
No one ever really has control; physics and biology and accident ultimately have their way in our lives. But as Jewel Douglass taught me, we are not helpless either—and courage is the strength to recognize both of those realities. We have room to act and shape our stories—although as we get older, we do so within narrower and narrower confines.
That makes a few conclusions clear: that our most cruel failure in how we treat the sick and the aged is the failure to recognize that they have priorities beyond merely being safe and living longer; that the chance to shape one’s story is essential to sustaining meaning in life; and that we have the opportunity to refashion our institutions, culture, and conversations to transform the possibilities for the last chapters of all of our lives.
from Being Mortal, Atul Gawande