June 13, 2005

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The Doctor's Advice: Talk to Strangers

Photo by Steve Gilbert Atul Gawande

Anyone who read Atul Gawande’s work, in The New Yorker or elsewhere, would recognize the voice in his keynote address at the 2005 HMS Class Day ceremony on June 9. Thoughtful, observant, and generous with his insight, he guided the graduates on a measured walk into their future as physicians, surgeons, and dentists. An HMS graduate himself (Class of ’95), Gawande is an HMS assistant professor of surgery at Brigham and Women’s Hospital, an HSPH assistant professor in health policy and management, and an author with a growing reputation.

First characterizing clinical practice as an activity bounded by numbers that readily becomes impersonal, he cautioned the practitioners-to-be not to let the system overwhelm them.

“As you become a white-coated cog in the machine, this remarkable and at the same time maddening factory of health care, how do you not disappear? How do you matter?” He then offered five rules to guide them in their passage.

His first rule is Ask an unscripted question. “Ours is a job of talking to strangers,” he said. “Why not learn something about them?” It doesn’t have to be an important question, just something simple like “Where did you grow up?” The response and the exchange that might follow bring enrichment beyond the clinical encounter.

Rule number 2 is Don’t whine. Though doctors have plenty to complain about, they should avoid falling into this tempting trap. “Resist it,” Gawande said. “It’s boring, and it will get you down. …Be prepared with something else to talk about: an interesting patient you saw, an idea you read about, even the weather if that’s all you’ve got.”

Rule number 3 is Count something. He himself has counted surgical instruments left inside patients, a rare event, but one that does happen about 1 in every 15,000 operations. By looking at the circumstances around these accidents, Gawande discovered that they usually occur during emergency procedures in which something unexpected arises. The solution, he said, has to be technological since the threat of punishment or lawsuits would not change the cause.

His fourth rule is Write something. Gawande cited the power of shared science to build collective knowledge far greater than any single person could muster. He also suggested that writing builds communities and establishes membership within them. This observation extended his theme of communication and the importance for doctors to “keep the conversation going.”

His last rule is Change. He urged his audience to be early adopters, not necessarily snagging every new thing that comes along, but taking advantage of new opportunities.

“Be willing to recognize the inadequacies in what we do and to seek out solutions,” he said. “As successful as medicine is, it remains replete with uncertainties and failure. This is what makes it human, at times painful, and also so worthwhile.”

—Robert Neal

Copyright 2005 by the President and Fellows of Harvard College