Harvard Magazine has a nice profile of surgeon and writer Atul Gawande that talks about, among other things, his constant state of flow.
Gawande had seen that part of the man's colon was ischemic -- dead and gangrenous -- and had ceased to move waste out of the body. He wasn't sure about the cause, but suspected a blood clot. One thing was clear: without immediate surgery, the colon would rupture.
After examining the patient, Gawande conferred with the resident in the corridor outside the man's room. He went through a familiar and well-practiced set of actions that he seemed to do without thinking: slipping his ring finger into his mouth to moisten it, working his wedding band off, unbuckling his watchband, threading it through the ring, and refastening it, all the while carrying on a conversation about stopping the patient's anti-clotting medication and getting a vascular surgeon to assist.
Atul Gawande and some colleagues searched the US for healthcare successes -- hospitals and clinics where costs are relatively low and quality of care is high -- and came up with a few lessons.
If the rest of America could achieve the performances of regions like these, our health care cost crisis would be over. Their quality scores are well above average. Yet they spend more than $1,500 (16 percent) less per Medicare patient than the national average and have a slower real annual growth rate (3 percent versus 3.5 percent nationwide).
I wanted this article to be much longer than it was with breakouts of each of the ten lessons with lengthy explanations.
I've got two follow-ups to share with you regarding Atul Gawande's New Yorker piece about healthcare costs in the US (kottke.org post). In the Wall Street Journal, Abraham Verghese argues that in order for a healthcare reform plan to be successful, it has to include cost cutting.
I recently came on a phrase in an article in the journal "Annals of Internal Medicine" about an axiom of medical economics: a dollar spent on medical care is a dollar of income for someone. I have been reciting this as a mantra ever since. It may be the single most important fact about health care in America that you or I need to know. It means that all of us -- doctors, hospitals, pharmacists, drug companies, nurses, home health agencies, and so many others -- are drinking at the same trough which happens to hold $2.1 trillion, or 16% of our GDP. Every group who feeds at this trough has its lobbyists and has made contributions to Congressional campaigns to try to keep their spot and their share of the grub. Why not? -- it's hog heaven. But reform cannot happen without cutting costs, without turning people away from the trough and having them eat less. If you do that, you have to be prepared for the buzz saw of protest that dissuaded Roosevelt, defeated Truman's plan and scuttled Hillary Clinton's proposal.
In Gawande's example, what Verghese is saying is that you can't just make McAllen's healthcare system adopt an El Paso type of system without a whole lot of pain.
Gawande addressed some of the criticisms of his article on the New Yorker site. One of the major criticisms was that McAllen's higher costs were associated with higher levels of poverty and unhealthiness:
As I noted in the piece, McAllen is indeed in the poorest county in the country, with a relatively unhealthy population and the problems of being a border city. They have a very low physician supply. The struggles the people and medical community face there are huge. But they are just as huge in El Paso -- its residents are barely less poor or unhealthy or under-supplied with physicians than McAllen, and certainly not enough so to account for the enormous cost differences. The population in McAllen also has more hospital beds than four out of five American cities.
On Friday, Atul Gawande gave the commencement address at the University of Chicago Pritzker School of Medicine. The address touched on some of the same themes as his recent piece on the differing costs of healthcare across the US. He began with an anecdote about how observation of well-nourished children in poor Vietnamese villages led to village-wide improvments in curbing malnutrition.
The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children's mothers were breaking with the locally accepted wisdom in all sorts of ways -- feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet-potato greens to the children's rice despite its being considered a low-class food. The ideas spread and took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped sixty-five to eighty-five per cent in every village the Sternins had been to.
And I don't know why, but I've always thought of surgery as primarily a cerebral pursuit; a great surgeon is so because he's clever and smart. A short passage from Gawande's address reveals that perhaps that's not the case:
In surgery, for instance, I know that I have more I can learn in mastering the operations I do. So what does a surgeon like me do? We look to those who are unusually successful -- the positive deviants. We watch them operate and learn their tricks, the moves they make that we can take home.
So surgeons learn surgery in the same way that kids learn Kobe Bryant's post moves from SportsCenter highlights?
Obama read Atul Gawande's article about the differences in healthcare costs in different parts of the US and was so taken by it that he had a meeting about it with his aides and mentioned the piece in a meeting with a group of Democratic senators.
As part of the larger effort to overhaul health care, lawmakers are trying to address the problem that intrigues Mr. Obama so much -- the huge geographic variations in Medicare spending per beneficiary. Two decades of research suggests that the higher spending does not produce better results for patients but may be evidence of inefficiency.
Obama is indeed reading this guy's stuff. (thx, cliff)
Atul Gawande discovered that McAllen, Texas spends more per person on healthcare than El Paso (which is demographically similar to McAllen) and set out to find out why. Along the way, he encounters a curious relationship between the amount spent on healthcare and the quality of that care: higher spending does not correlate with better care.
When you look across the spectrum from Grand Junction to McAllen -- and the almost threefold difference in the costs of care -- you come to realize that we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.
There is no insurance system that will make the two aims match perfectly. But having a system that does so much to misalign them has proved disastrous. As economists have often pointed out, we pay doctors for quantity, not quality. As they point out less often, we also pay them as individuals, rather than as members of a team working together for their patients. Both practices have made for serious problems.
Obama, you're reading this guy's stuff, yes? Get him on the team.
Update: Dr. Peter Orszag is the Director of the Office of Management and Budget for the White House and is working on some of the problems that Gawande talks about in this article. Here's a 40-minute video of Orszag speaking on "Health Care - Capturing the Opportunity in the Nation's Core Fiscal Challenge". (thx, todd)
I changed the bit in the first paragraph about El Paso and McAllen being "nearby". Funny, I thought 800 miles in Texas *was* nearby. (thx, stephen)
I also changed "lower spending correlates with better care" to "higher spending does not correlate with better care"...those two statements are not the same. I misread the results of one of the studies that Gawande mentions. (thx, patrick)
Atul Gawande branches out from his usual excellent writing on medicine and turns his attention to solitary confinement in America's prison system. Gawande likens extended solitary time to torture.
This is the dark side of American exceptionalism. With little concern or demurral, we have consigned tens of thousands of our own citizens to conditions that horrified our highest court a century ago. Our willingness to discard these standards for American prisoners made it easy to discard the Geneva Conventions prohibiting similar treatment of foreign prisoners of war, to the detriment of America's moral stature in the world. In much the same way that a previous generation of Americans countenanced legalized segregation, ours has countenanced legalized torture. And there is no clearer manifestation of this than our routine use of solitary confinement-on our own people, in our own communities, in a supermax prison, for example, that is a thirty-minute drive from my door.
This likely will not change until Americans start to believe that rehabilitation and not punishment is the primary goal of prisons. So, probably never.
From the New Yorker last week, Atul Gawande on how the US should nationalize healthcare. His answer: nationalize slowly, use what's already in place, and don't rebuild the whole system from scratch.
Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.
As usual, Gawande makes a lot of sense. Whatever the solution, we should be doing all we can to avoid something like this from ever happening again:
"When I heard that I was losing my insurance, I was scared," Darling told the Times. Her husband had been laid off from his job, too. "I remember that the bill for my son's delivery in 2005 was about $9,000, and I knew I would never be able to pay that by myself." So she prevailed on her midwife to induce labor while she still had insurance coverage. During labor, Darling began bleeding profusely, and needed a Cesarean section. Mother and baby pulled through. But the insurer denied Darling's claim for coverage. The couple ended up owing more than seventeen thousand dollars.
I try not to miss any of Atul Gawande's New Yorker articles, but his piece on itching from this week's issue is possibly the most interesting thing I've read in the magazine in a long time. He begins by focusing on a specific patient for whom compulsive itching has become a very serious problem. (Warning, this quote is pretty disturbing...but don't let it deter you from reading the article.)
...the itching was so torturous, and the area so numb, that her scratching began to go through the skin. At a later office visit, her doctor found a silver-dollar-size patch of scalp where skin had been replaced by scab. M. tried bandaging her head, wearing caps to bed. But her fingernails would always find a way to her flesh, especially while she slept.
One morning, after she was awakened by her bedside alarm, she sat up and, she recalled, "this fluid came down my face, this greenish liquid." She pressed a square of gauze to her head and went to see her doctor again. M. showed the doctor the fluid on the dressing. The doctor looked closely at the wound. She shined a light on it and in M.'s eyes. Then she walked out of the room and called an ambulance. Only in the Emergency Department at Massachusetts General Hospital, after the doctors started swarming, and one told her she needed surgery now, did M. learn what had happened. She had scratched through her skull during the night -- and all the way into her brain.
From there, Gawande pulls out to tell us about itching/scratching (the two are inseparable), then about a recent theory of how our brains perceive the world ("visual perception is more than ninety per cent memory and less than ten per cent sensory nerve signals"), and finally about a fascinating therapy initially developed for those who experience phantom limb pain called mirror treatment.
Among them is an experiment that Ramachandran performed with volunteers who had phantom pain in an amputated arm. They put their surviving arm through a hole in the side of a box with a mirror inside, so that, peering through the open top, they would see their arm and its mirror image, as if they had two arms. Ramachandran then asked them to move both their intact arm and, in their mind, their phantom arm-to pretend that they were conducting an orchestra, say. The patients had the sense that they had two arms again. Even though they knew it was an illusion, it provided immediate relief. People who for years had been unable to unclench their phantom fist suddenly felt their hand open; phantom arms in painfully contorted positions could relax. With daily use of the mirror box over weeks, patients sensed their phantom limbs actually shrink into their stumps and, in several instances, completely vanish. Researchers at Walter Reed Army Medical Center recently published the results of a randomized trial of mirror therapy for soldiers with phantom-limb pain, showing dramatic success.
Crazy! Gawande documents and speculates about other applications of this treatment, including using virtual reality representations instead of mirrors and utilizing multiple mirrors for treatment of M.'s itchy scalp. Anyway, read the whole thing...highly recommended.
Atul Gawande on the state of health care for the elderly. "Mainstream doctors are turned off by geriatrics, and that's because they do not have the faculties to cope with the Old Crock. The Old Crock is deaf. The Old Crock has poor vision. The Old Crock's memory might be somewhat impaired. With the Old Crock, you have to slow down, because he asks you to repeat what you are saying or asking. And the Old Crock doesn't just have a chief complaint -- the Old Crock has fifteen chief complaints. How in the world are you going to cope with all of them? You're overwhelmed." This article depressed the hell out of me.
Short profile of Atul Gawande, surgeon and writer, one of the few New Yorker contributers I make a point of reading every single time I see his byline. "I now feel like writing is the most important thing I do. In some ways, it's harder than surgery. But I do think I've found a theme in trying to understand failure and what it means in the world we live in, and how we can improve at what we do."
Atul Gawande on the rise in Cesarean deliveries in the US, which soon may become safer than natural childbirth: "We are losing our connection to yet another natural process of life. And we are seeing the waning of the art of childbirth. The skill required to bring a child in trouble safely through a vaginal delivery, however unevenly distributed, has been nurtured over centuries. In the medical mainstream, it will soon be lost."
I was somewhat disappointed in the 2003 edition of this collection, especially after enjoying so much the last three editions. Perhaps Oliver Sacks and I disagree on what makes science writing good. The two best articles were 1491 by Charles Mann about what the Americas were like before Columbus landed and the effect of the European arrival:
In North America, Indian torches had their biggest impact on the Midwestern prairie, much or most of which was created and maintained by fire. Millennia of exuberant burning shaped the plains into vast buffalo farms. When Indian societies disintegrated, forest invaded savannah in Wisconsin, Illinois, Kansas, Nebraska, and the Texas Hill Country. Is it possible that the Indians changed the Americas more than the invading Europeans did? "The answer is probably yes for most regions for the next 250 years or so" after Columbus, William Denevan wrote, "and for some regions right up to the present time."
and Atul Gawande's The Learning Curve, an article on how doctors need to learn on the job (while potentially making costly mistakes) in order to become more effective overall:
In medicine, there has long been a conflict betwenn the imperative to give patients the best possible care and the need to provide novices with expericne. Residencies attempt to mitigate potential harm through supervision and graduated responsibility. And there is reason to think that patients actually benefit from teaching. But there is no avoiding those first few unsteady times a young physician tries to put in a central line, removes a breast cancer, or sew together two segments of colon. No matter how many protections are in place, on average these cases go less well with the novice than with someone experienced.
