The Velluvial Matrix
Stanford Medical School Commencement
Atul Gawande
June 12, 2010
Greetings to the graduating class of 2010. Thank you for inviting me back to this gorgeous place where I'd gone to college and worked in this school's laboratories—and even, in my sophomore dormitory, met my wife. But most of all thank you for letting me be part of this special occasion.
To take your place in those folding chairs, you have trod a long road. Many of you have worked for four solid years—or five, or six, or nine. And we are here to declare that, as of today, the twelfth of June, 2010, you officially know enough stuff to be called a graduate of the Stanford School of Medicine. You are Doctors of Medicine, Doctors of Philosophy, Masters of Science. It's been certified. Each of you is now an expert. Congratulations.
So why—in your heart of hearts—does it not quite feel that way?
The experience of a medical and scientific education is transformational. It is like moving to a new country. At first, you don't know the language, let alone the customs and concepts. But then, almost imperceptibly, that changes. Half the words you now routinely use, you did not know existed when you started: words like arterial blood gas, nasogastric tube, microarray, logistic regression, NMDA receptor, velluvial matrix.
Okay, I made that last one up. But the velluvial matrix sounds like something you should know about, doesn't it? And that's the problem. I will let you in on a little secret. You never stop wondering if there is a velluvial matrix you should know about.
Since I graduated from medical school, my family and friends have had their share of medical issues arise, just as you and your family will. And inevitably, they turn to the medical graduate in the house for advice and explanation. I remember one time when a friend came with a question.
"You're a doctor now," he said. "So tell me: where exactly is the solar plexus?"
I was stumped. It was not anywhere in the textbooks.
"I don't know," I finally confessed.
"What kind of doctor are you?" he said.
I didn't feel much better equipped when my wife had two miscarriages, or our first child was born with part of his aorta missing and we had to figure out what to do, or when my daughter had a fall with a dislocated elbow that I failed to recognize, or when my wife tore a ligament in her wrist that I'd never heard of—her velluvial matrix, I think it was.
This is a deeper, more fundamental problem than we acknowledge. The truth is that the volume and complexity of the knowledge we need to master in medicine and science has grown exponentially beyond our capacity as individuals. Worse, the fear is that the knowledge has grown beyond our capacity as a society. When we talk about the uncontrollable explosion in the costs of health care in America, for instance, about the reality that we in medicine are gradually bankrupting the country, we're not talking about a problem rooted in economics. We're talking about a problem rooted in scientific complexity.
Half a century ago, medicine was neither costly nor effective. Since then, however, science has combated our ignorance. It has enumerated and identified, according to the international disease classification system, more than 13,600 diagnoses, 13,600 different ways our bodies can fail. And for each, we've discovered beneficial remedies—remedies that can reduce suffering, extend lives, and sometimes stop a disease all together. But those remedies now include more than 6,000 drugs and 4,000 medical and surgical procedures—and growing. Our job in medicine is make sure all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive. And we're struggling. There is no industry in the world with 13,600 different service lines to deliver.
It should be no wonder that you have not mastered the understanding of them all. No one ever will. That's why we as doctors and scientists have become ever more finely specialized and super-specialized. If I can't handle 13,600 diagnoses, well maybe there are fifty of them I can handle—or just one I might focus my research upon. The result, however, is that we each find ourselves to be specialists worried almost exclusively about our particular niche and not the larger question of whether we as a group are making the whole system of care better for people.
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