Atul Gawande Challenges the Status Quo

 

Gawande can rightly be described as a superstar in the debate over national healthcare reform. His books on doctor performance and the complexity of medicine are bestsellers; his New Yorker article from this past June on the cost of healthcare was used by President Obama as a rallying cry for reform. 

 

Gawande’s visit was part of a lecture series hosted by Kaiser Permanente’s Center for Health Research. His presentation  focused less on the specifics of reform and more on the subjects of Gawande’s books: performance and complexity.

 

The biggest struggle facing the medical world, Gawande told the audience, is not money or malpractice, but how complex the profession has become. He listed statistics: There are now 13,600 diagnosable diseases, 6,000 prescription drugs and 4,000 medical procedures. But there are still broad gaps in coverage. Heart attack patients need to have stents implanted in their vessels within 90 minutes. Less than 50% of American hospitals meet that mark. The likelihood of a hospital getting blood cultures and using antibiotics on a pneumonia within the necessary six hours is about 60%. 

 

Gawande referenced a 33-year-old study that isolated two reasons for failure in the medical world: ignorance and ineptitude. Research is attempting to take care of the former; the latter, he said, is “the struggle of our time.” If the performance of hospitals in the United States is graphed, the data forms a bell curve with the majority of care centers falling in a broad center. Why are the few hospitals at the positive end of the graph doing so well?

 

Gawande described his experience at a hospital in Minnesota that treats cystic fibrosis patients. He walked away with a few simple answers. Care improves when an emphasis is placed on paying attention to details, proactive interaction with patients, transparency and teamwork.

 

Gawande is convinced Congress will enact healthcare reform this year. But, he lamented, there's no body of work exploring how to change the shape of the quality-of-care and health-care-cost bell curves. He pointed to a starting place: "The most important thing we can do is become curious about the positive outliers."

 

Look at Portland. On average, more than $400 is spent on hospice care and about $500 on ambulances in the last year of a patient's life. Compare that to a Texas county that Gawande studied, which spends $22 on care and $3,000 on ambulances.

 

His singling out of Portland had as much to do with the city being a "positive outlier" as it did with his emphasis on the idea that, as he put it, "all medicine is local."

 

Over the course of the night Gawande made it clear that he didn't think there was one answer to the myriad problems his profession faces. He's a proponent of the public option, but pragmatic about its future; he thinks the thorny topic of doctor pay should be addressed on a individual institutional basis. But when it comes to cutting through the complexity and improving the quality of care that patients receive, he spoke directly to the individuals who will make that happen.