Atul Gawande: America’s Doctor

Who is Atul Gawande and why is he having a bigger impact on your life than any physician in America who is not treating you?
Gawande is a cancer surgeon in Boston. A Rhodes Scholar and the recipient of a MacArthur “genius grant”, he trained at Harvard, and Stanford and grabbed a Masters in Public Health along the way. He has a sharp sense of public policy and worked for the campaigns of Gary Hart and Al Gore, on the staff of Congressman Jim Cooper (D-TN), and as Bill Clinton’s
health care lieutenant during the 1992 campaign.

More importantly, Atul Gawande writes. He writes so well that he has become a staff writer for The New Yorker — as unlikely for a full-time physician as for a full-time CEO or lawyer. His writing is stunning. Says fellow writer Malcom Gladwell: “Every subject Atul Gawande touches is probed and dissected and turned inside out with such deftness and feeling and counter intuitive insight that the reader is left breathless.”

Son of an immigrant pediatrician and a urologist, Gawande wanted to be a rock star in college (he still performs surgery with the Decemberists, Tom Petty, and Springsteen on his iPod). He soon gave up his guitar for a word processor however and did something few doctors would ever consider doing: he published a collection of his medical mistakes in Slate, where Gawande first emerged as a major writing talent. He has published three books: The Checklist Manifesto (2009), Better: A Surgeon’s Notes on Performance (2007), and Complications: A Surgeon’s Notes on an Imperfect Science (2002).

But this year Gawande broke loose. He has become hugely influential because of three articles he published on health care reform in the New Yorker. Each has caused a national sensation. The first two were required reading in the Obama White House. Not suggested reading — Obama expected everyone working on health care to know these articles cold. I have no question that the third and in many ways most subtle article, just published, will enjoy the same status.

All three articles are brief and a delight to read. I will summarize them here and comment on them briefly, and link to them. Read them — they are educational, insightful, and important.

Gawande opened the year with Getting There From Here: how Obama should reform health care a mildly heretical essay on how to think about health care reform. The not obvious idea: health care systems evolve and are highly path dependent. Where you end up, depends hugely on where you have been. Gawande does a wonderful job of summarizing the impact of specific social reforms on the health care systems of Germany, France, and England. He argues that

“accepting the path-dependent nature of our health-care system—recognizing that we had better build on what we’ve got—doesn’t mean that we have to curtail our ambitions. The overarching goal of health-care reform is to establish a system that has three basic attributes. It should leave no one uncovered—medical debt must disappear as a cause of personal bankruptcy in America. It should no longer be an economic catastrophe for employers. And it should hold doctors, nurses, hospitals, drug and device companies, and insurers collectively responsible for making care better, safer, and less costly.”

He spelled out the message to policymakers: you cannot remake a sixth of the US economy from scratch — you have to build on what has worked to date. Sound obvious? Tell it to Hillary Clinton or to the dozens of elected officials dreaming about legislating single payer health care in 2009.

In June, Gawande published The Cost Conundrum: what a Texas town can teach us about health care. He reports on McAllen, Texas, the town with the distinction of having the highest health care costs in America. Were they healthier for all the spending? No, they weren’t. Were they spending because they were unhealthier — perhaps the Tex-Mex diet and nearly 40% obesity rate? Nope, El Paso is next door and just as fat, but spends a lot less. Did they have better technologies?

“there’s no evidence that the treatments and technologies available at McAllen are better than those found elsewhere in the country. The annual reports that hospitals file with Medicare show that those in McAllen and El Paso offer comparable technologies—neonatal intensive-care units, advanced cardiac services, PET scans, and so on. Public statistics show no difference in the supply of doctors. Hidalgo County actually has fewer specialists than the national average.

“Nor does the care given in McAllen stand out for its quality. Medicare ranks hospitals on twenty-five metrics of care. On all but two of these, McAllen’s five largest hospitals performed worse, on average, than El Paso’s. McAllen costs Medicare seven thousand dollars more per person each year than does the average city in America. But not, so far as one can tell, because it’s delivering better health care.”

The article was smashing because it was so careful. It looked at the problem from the perspective of a physician, a patient, and a payer. Take this conversation:

“One afternoon in McAllen, I rode down McColl Road with Lester Dyke, the cardiac surgeon, and we passed a series of office plazas that seemed to be nothing but home-health agencies, imaging centers, and medical-equipment stores. “Medicine has become a pig trough here,” he muttered.

“Dyke is among the few vocal critics of what’s happened in McAllen. “We took a wrong turn when doctors stopped being doctors and became businessmen,” he said. We began talking about the various proposals being touted in Washington to fix the cost problem. I asked him whether expanding public-insurance programs like Medicare and shrinking the role of insurance companies would do the trick in McAllen. “I don’t have a problem with it,” he said. “But it won’t make a difference.” In McAllen, government payers already predominate—not many people have jobs with private insurance.

“How about doing the opposite and increasing the role of big insurance companies? “What good would that do?” Dyke asked. The third class of health-cost proposals, I explained, would push people to use medical savings accounts and hold high-deductible insurance policies: “They’d have more of their own money on the line, and that’d drive them to bargain with you and other surgeons, right?”

“He gave me a quizzical look. We tried to imagine the scenario. A cardiologist tells an elderly woman that she needs bypass surgery and has Dr. Dyke see her. They discuss the blockages in her heart, the operation, the risks. And now they’re supposed to haggle over the price as if he were selling a rug in a souk? “I’ll do three vessels for thirty thousand, but if you take four I’ll throw in an extra night in the I.C.U.”—that sort of thing? Dyke shook his head. “Who comes up with this stuff?” he asked. “Any plan that relies on the sheep to negotiate with the wolves is doomed to failure.”

Gawande concludes

“Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coördination. Imagine that, instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets, and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later?

Getting the country’s best electrician on the job (he trained at Harvard, somebody tells you) isn’t going to solve this problem. Nor will changing the person who writes him the check.”

This week, Gawande came out with what may be his finest piece yet — Testing, Testing: The health-care bill has no master plan for curbing costs. Is that a bad thing? “Cost is the spectre haunting health reform. For many decades, the great flaw in the American health-care system was its unconscionable gaps in coverage. Those gaps have widened to become graves—resulting in an estimated forty-five thousand premature deaths each year—and have forced more than a million people into bankruptcy. The emerging health-reform package has a master plan for this problem. By establishing insurance exchanges, mandates, and tax credits, it would guarantee that at least ninety-four per cent of Americans had decent medical coverage. This is historic, and it is necessary. But the
legislation has no master plan for dealing with the problem of soaring medical costs. And this is a source of deep unease.”

Gawande summarizes the paralyzing effect of health care costs on our economy an then proceeds to tell an amazing story about how at

“the start of the twentieth century, another indispensable but unmanageably costly sector was strangling the country: agriculture. In
1900, more than forty per cent of a family’s income went to paying for food. At the same time, farming was hugely labor-intensive, tying up almost half the American workforce. We were, partly as a result, still a poor nation. Only by improving the productivity of farming could we raise our standard of living and emerge as an industrial power. We had to reduce food costs, so that families could spend money on other goods, and resources could flow to other economic sectors. And we had to make farming less labor-dependent, so that more of the population could enter non-farming occupations and support economic growth and
development.”

He then makes the case for a lot of testing and for a subtle role for government based on the experience of the Department of Agriculture’s Extension Service. The last time I read a plea for a government agency based the experience of agricultural extension agents who tested, learned, and taught their way to high productivity, I was advocating to the Clinton Administration for what became the Department of Labor’s Office of the American Workplace. I wish I had known as much as Gawande has learned on the topic however. He not only understands the subtleties of the government role, but of the role of the legislature as well. And he makes a compelling case for learning our way to reducing medical costs and for learning from the astonishing success of our Agricultural Extension agents as we do so.

These three articles, published during Gawande’s annus mirabilas, may do more to shape the future of American health care than any others. Gawande has made such extraordinary contributions to our current debate that we should grant the man his life’s wish: let’s make him into a rock star. He has earned it, he always wanted to be one, and he has a message that will leave all of us much better off.

Gawande maintains links to his New Yorker articles here. I recommend them highly.