Thursday, July 19, 2007

Atul Gawande: A Working Surgeon's Thoughts on America's Health Care System

Many of us have strong opinions about about our health care system. That doesn't mean we know what we are talking about (though that never stops me from sounding off about our health care system in this blog).

As patients, our views matter of course. But we don't see how the system works up close and real, day in and day out. We don't see what Atul Gawande, pictured here, sees and don't know what he knows.

As a surgeon, he lives health care. His patients have names, faces, lives, and health-care needs that he comes into contact with daily in the most intimate way possible.

Fortunately for us, Dr. Gawande is also a writer willing and able to give the rest of us his unobstructed view of our health-care system in actual practice. He writes not from a front row seat at our health-care drama but from the stage as a key player. He writes from daily experience. He also writes from the heart.

Dr. Gawande is a staff member of Brigham and Women's Hospital, the Dana Farber Cancer Institute, and the New Yorker magazine. He received his B.A.S. from Stanford University, M.A. (in politics, philosophy, and economics) from Oxford University as a Rhodes Scholar, M.D. from Harvard Medical School, and M.P.H. from the Harvard School of Public Health.

He served as a senior health policy advisor in the Clinton presidential campaign and White House from 1992 to 1993. His mother and father are both physicians. Not wanting to rotely follow in his parents' footsteps and thinking that he might like to be a professional philosopher, he resisted going into medicine -- until he could no longer resist.

Today, at 41, Dr. Gawande seemingly has everything. He is tall, devilishly handsome, has a wife and three children, and is now adding success as a writer to his success as a surgeon. Since 1998, he has been a staff writer for the New Yorker magazine.

I have read every one of his New Yorker articles and consider them must reading for anyone wanting a deeper understanding of our health-care system. In 2003, he completed his surgical residency at Brigham and Women's Hospital, Boston, and joined the faculty as a general and endocrine surgeon.

He is also Assistant Professor of Surgery at Harvard Medical School, Assistant Professor in the Department of Health Policy and Management at the Harvard School of Public Health, and Associate Director for the BWH Center for Surgery and Public Health.

He has published research studies in areas ranging from surgical technique, to US military care for the wounded, to error and performance in medicine. He is the director of the World Health Organization's Global Challenge for Safer Surgical Care.
In 2006, he received the MacArthur Award for his research and writing. His nonfiction writing has been selected to appear in the annual Best American Essays collection twice and in Best American Science Writing five of the last six years.

His book COMPLICATIONS: A SURGEON'S NOTES ON AN IMPERFECT SCIENCE was a finalist for the National Book Award in 2002 and is published in more than a hundred countries. He is editor of THE BEST AMERICAN SCIENCE WRITING 2006. His most recent book, BETTER: A SURGEON'S NOTES ON PERFORMANCE was published in April. It is mostly a compilation of his New Yorker Articles.
With all this, Dr. Gawande found time to serve recently as a guest columnist with The New York Times. His series of articles, all of which I read and saved, offer valuable insight into health-care issues. The articles are marked by something all too rare in the health-care debate -- an absence of idealogy.

Following are excerpts from The New York Times articles as well as one from Dr. Gawande's latest article (July 23) in The New Yorker. In the New Yorker article, Dr. Gawande offers his take on Michael Moore's new movie about health care, "Sicko." He and Mr. Moore have had some lively debates about the movie and our health-care system.

For the record, I think "Sicko" is terrific for what it is: a powerful, sad, funny, outraged, entertaining, broadside against everything that is wrong with America's health-care system. It is laced with wicked mean (forgive the local Worcester expression) sarcasm that I am ashamed to say I thoroughly enjoyed. It is also, as far as I am concerned, 100% right.
But then, that's only my opinion. You may be well advised to take more seriously what Dr. Gawande has to say about "Sicko." And now excerpts from Dr. Gawande's Times series and the July 23 New Yorker. First, what he says about Mr. Moore and "Sicko" in the latest New Yorker:

On "Sicko" Being Both Right and, Well, Sick

"The documentary filmmaker Michael Moore has more than a few insufferable traits. He is manipulative, smug, and self-righteous. He has no interest in complexity. And he mocks the weak as well as the powerful.... For all that, his movie about the American health-care system, "Sicko," is a revelation. And what makes this especially odd to say is that the movie brings to light nothing that the media haven't covered extensively for years..."

Referring to the many health-care horror stories in "Sicko," Dr. Gawande writes that "these have become ordinary tales in America. Just this year, in my own surgical practice, I have seen a college student who couldn't afford radiation treatment she needed for thyroid cancer, because her insurance coverage maxed out after the surgery; a breast-cancer patient who didn't have cash for the hormone therapy she needed; a man denied Medicare coverage for an ambulance ride, because the chest pain he thought was caused by a heart attack wasn't -- it was caused by a tumor.

"The universal human experience of falling ill and seeking treatment -- frightening and difficult enough -- has been warped by our dysfunctional insurance system.... "Sicko" doesn't really offer solutions.... It's an outrage machine. Moore hopes that once people grasp the inhumanity of our system, we will replace it. But will we?"

Excerpts from Dr. Gawande's Times series:

On Putting Off Seeing a Doctor

"As a surgeon, I've seen some pretty large tumors. I've excised fist-sized thyroid cancers from people's necks and abdominal masses bigger than your head. When I do, this is what almost invariably happens: the anesthesiologist puts the patient to sleep, the nurse unsnaps the gown, everyone takes a sharp breath, and someone blurts out, 'How could comeone let that thing get so huge?'

"I try to describe how slowly and imperceptibly it grew. But staring at the beast it has become, no one buys the explanation. Even the patients are mystified. One day they looked in the mirror, they'll say, and the mass seemed to have ballooned overnight. It hadn't, of course. Usually, it's been growing -- and, worse, sometimes spreading -- for years. Too often, by the time a patient finally seeks help, I can't help much."

On Being a Doctor and Treating Those Who Can't Pay

"It's one of those questions no one tells you about when you enter medical practice. What do you do when patients come who can't pay? Some doctors decline to see them. I have expenses to pay and a family to feed, they'll argue.

"But I grew up in a rural part of Ohio where an inordinate number of poor people live. My mother is a pediatrician there, and from the start, she could not imagine turning children away. Up to 20 percent of her patients have been without insurance, and more than half were on Medicaid, which paid terribly and was refused by other doctors.

"Some patients were not very grateful. Some were not as poor as they claimed. But we could count on my father's better-paying urology practice to cross-subsidize. So that's what she did.

"The message from my parents was straightforward: We are in medicine and that comes with certain moral obligations. So I've understood that part of my job is to see those who can't pay -- even if it sometimes hurts."

On Bad Medicine Sneaking Into Health Care

Recalling a patient he once saw, Dr. Gawande wrote that she was "a dancer in her 40s who had hobbled into the emergency room one October night with a painful, bulging mass in her groin. I gently put my fingers to it. It was beet-sized and firm. When I placed my stethoscope on it, I heard gurgling.

"This was, I told her, a strangulating hernia -- a rent in her abdominal wall had trapped a a loop of intestine. The swelling was the knot of bowel; the gurgling, the fluid inside. She was at risk of gangrene and agreed to an emergency hernia operation.

"It's not a complicated procedure. But there are still plenty of ways it can go wrong. Inside her, I found the hernia defect -- a one-inch gap in her muscle wall -- and, protruding through it, a choked-off, purple, six-inch length of bowel. I opened the gap wider, pushed the bowel back in, and thankfully it pinked back to life.

"We'd gotten there in time. I closed the hernia with a polypropylene mesh cut to size. It was like sewing a patch onto a torn couch cushion. The next day, she went home. I saw her two weeks later. No infection. No troubles. She'd done beautifully.

"Then I got an e-mail notice. The mesh manufacturer, Johnson&Johnson, was reporting that the mesh I'd put in was counterfeit. It was fake. Someone had infiltrated the supply chain chain somewhere between Sherman, Texas, where the authentic mesh was manufactured, and Boston, where I'd operated on the patient.... Somewhere along the way a counterfeiter replaced the lot with fake mesh packaged exactly like Johnson&Johnson's, right down to the lot number. It is believed this happened someplace in Asia. But no one really knows....

"I saw my patient and told her about the fake mesh. She was stunned. We then considered what to do. It wasn't clear the mesh would hold; and in many other patients, it became infected and had to be removed. But she had done all right so far, and redoing the repair is major surgery. So she decided to wait and see what happened. Given the alternative, doing noything and hoping for the best was a wise choice for her. But it's a bad choice for the rest of us."

On Rethinking Old Age and the Nursing Home

"This week I visited a woman who had just moved into a nursing home. She is 89 years old with congestive heart failure, disabling arthritis, and after a series of falls, little choice but to leave her condominium.

"Usually, it's the children who push for change, but in this case, she was the one who did. 'I fell twice in one week, and I told my daughter I don't belong at home anymore,' she said.

"She moved in a month ago. She picked the facility herself. It has excellent ratings, friendly staff, and her daughter lives nearby. She's glad to be in a safe place -- if there is anything a decent nursing home is built for, it is safety. But she is struggling.

"The trouble is -- and it's a possibility we've mostly ignored for the very old -- she expects more from life than safety. "I know I can't do what I used to,' she said, 'but this feels like a hospital, not a home.' And that is in fact the near-universal reality....

"Basic matters, like when she goes to bed, wakes up, dresses, and eats were put under the rigid schedule of institional life. Her main activities have become bingo, movies, and other forms of group entertainment. Is it any wonder that most people dread nursing homes?...

"The things she misses most, she told me, are her friendships, her privacy, and the purpose in her days. 'This is my last hurrah,' she told me. 'This room is where I'll die. But it won't be anytime soon.' And indeed, physically she's done well. All she needs now is a life worth living for."

On Why Reforming Health Care is so Damnably Difficult

Calling the American health insurance system "a slow-creeping ruin," Dr. Gawande writes that most of us resist large-scale reform "fearing that it could make some lives worse, even as it makes others better. And the truth is it could.

"There are two causes of human fallibility -- ignorance and ineptitude -- and health system change is at risk of both. We could err from ignorance, because we have never done anything remotely as ambitious as changing out a system that now involves 16 percent of our economy and every one of our lives.

"And we could err from ineptitude, underestimating the difficulties of even the most mundane tasks after reform -- like handling all the confused phone calls from those whose coverage has changed; ensuring that doctors' appointments and prescriptions don't fall tghrough; avoiding disastrous cost overruns.

"Health systems are nearly as complex as the body itself. they involve hospital care, mental health care, doctor visits, medications, ambulances, and everything else required to keep people alive and healthy. Experts have offered half a dozen more rational ways to finance all this than the wretched one we have. But we cannot change everything at once without causing harm. So we dawdle."

On Why Anything Is Better Than What We Have Right Now

"As a surgeon, I've worked with the veterans' health system, Medicare, Medicaid and private insurance companies. I've seen health care in Canada, Britain, Switzerland and the Netherlands. And I was in the Clinton administration when our plan for universal coverage failed. So, with a new health reform debate under way, what I want to tell you in my last column is this:

"First, there is not a place in this world that is not struggling to control health costs while providing high-quality, easily accessible care. No one -- no one -- has a great solution.

"But second, whether as a doctor or as a citizen, I would take almost any system -- from Medicare-for-all to a private voucher system over the one we now have.

"Job-based insurance is bleeding away the viability of American businesses -- even doctors complain about the cost of insuring employees. And it has left large numbers of patients without adequate coverage when they need it. In the last two years, for example, 51 percent of Americans surveyed did not fill a presecription or visit a doctor for a known medical issue because of cost.

"My worry is less about what happens if we change than what happens if we don't.... So we should not even consider a candidate withoput a plan capable of producing agreement. The ultimate measure of leadership, however, is not the plan. It is the capacity to take that plan and persuade people to find common ground in it. The politician who can is the one we want."

Thank you, Dr. Gawande.

So long and keep moving.