In best-selling books and award-winning articles, surgeon and journalist Dr. Atul Gawande chronicles the daily failings of American medicine. The problems — spiraling costs, poor coordination of care, refusal to accept patient mortality or clinician fallibility — are unwieldy and entrenched. But Gawande also provides a road map for change, exploring new ideas that save lives and celebrating clinicians and systems that dare to challenge the status quo.
"We're now in this amazing experiment, and there's nothing like it," said Gawande. "All of this is about whether we can produce a health care system that actually takes better care of people and manages to lower the health costs. That hasn't been accomplished in any one community. Once we have one, then the others will follow."
Gawande is a keynote speaker at the 2011 Catholic Health Assembly, June 5-7 in Atlanta. Peter R. Orszag, former budget director in the Obama White House, and Dr. Donald Berwick, administrator for the Centers for Medicare and Medicaid Services, also will address the assembly.
Gawande is a surgeon at Brigham and Women's Hospital in Boston, a staff writer for The New Yorker magazine and author of The New York Times best-selling titles Complications: A Surgeon's Notes on an Imperfect Science; Better: A Surgeon's Notes on Performance; and The Checklist Manifesto: How To Get Things Right. Gawande also is a former White House advisor and a past recipient of the MacArthur "genius" grant. TIME named him as one world's top 100 influential thinkers.
Gawande did not set out to be an author. He only started writing after a friend asked him to write about life as a resident for an internet magazine, using a style now called a blog. But as the internet grew, so did his audience. A New Yorker editor read his work and asked him to write for the weekly magazine. Today Gawande finds more doctors read his New Yorker pieces than his scholarly research articles.
"What people often imagine is that I write to explain things to people, and I'm actually not," said Gawande, who is 45. "I'm mostly interested in the problems that are puzzling to me as much as anybody else. How do we control health care costs? What is itching? Why do we take such bad care of people facing terminal illness? And why have I done it so badly at times? I'm writing for citizens whether they are doctors or not doctors. People who are wondering, like I am, how do we understand the world of health care and how do we do better."
One of Gawande's recent New Yorker articles, "Letting Go. What should medicine do when it can't save your life?" takes a painful and honest look at the lung cancer death of a young mother who continued aggressive, and almost certainly futile treatments with debilitating side effects, almost to the day of her death. The story, a National Magazine Awards finalist, asks how caregivers can better care for patients in the final stage of life. The question will be the subject of his fourth book, Being Mortal, which Gawande hopes to complete within two years.
"It's hard to have those conversations" on end-of-life care, said Gawande. "They are hard for the patients who must contemplate their own death. They are hard for families who must confront the emotional anxieties. And they are really difficult for clinicians because you feel you're supposed to be powerful and here is the ultimate proof that you are not.
"We have been so focused for the past half-century on defeating death that we have lost the skills of helping people cope with sickness that will not be cured," he said. "I also think in the past 50 years we've made this enormous change: Mortality used to be in the domain of patients, families, communities and religion and now medicine has laid claim to it — 'This is our turf, not yours.' Everybody else has been asked to take a back seat." The health care system never equipped clinicians to deal well with impending death, and there is no guarantee medical providers will become good at it, he said.
Gawande is dismayed the Patient Protection and Affordable Care Act did not do more to promote important end-of-life conversations between physicians and patients. A provision that would have reimbursed physicians for having consultations with patients covered by Medicare about hospice care and other end-of-life services fueled a political backlash. Health reform critics equated the proposed consultations with sanctioning "death panels" and the language was removed as the legislation was being shaped.
Gawande said that ultimately, though, caregivers must find the courage to confront death and, in doing so, give patients "a good death."
"If Washington can't even talk about it, then it is our responsibility in medicine to talk about it and to be able to provide solutions that make people's lives better," said Gawande. "We're good at extending people's lives but we're not good at addressing the concerns that people have, which are: not suffering, being able to be in control of their lives, being able to be home. All of those are areas where we are failing people."
Other aspects of the Affordable Care Act, however, encourage Gawande. He hopes the prospect of consistent care fixes the "broken relationship" so many working-class and lower-income patients have with health care.
But success also depends on the health system's ability to control costs. In "The Cost Conundrum. What a Texas town can teach us about health care," published in the New Yorker in 2009, Gawande challenged the fee-for-service model that generates profits but not necessarily good health outcomes. He was prepared for some backlash from that report, but his peers largely accepted his findings.
"It's not that the topics aren't upsetting, but I think we know that the way we go about things is neither sustainable nor effective," he said. "We are individuals who are trying to make something that really requires an entire organization to work, and we're all in organizations that don't foster that. It's not because the organizations aren't trying. Many leaders are trying to make this enormous transition from
specialist-based care to care that ensures that a group of people are able to work together. Medicine's complexity has reached a point where individual physicians can't do it by themselves anymore."
Gawande believes the Affordable Care Act provides caregivers the tools and the freedom to make that transition while maintaining quality.
"Whether we are successful depends on whether we in medicine take seriously the obligation to redefine the way we are paid and redesign the way we deliver care," he said. "It's opened the door to say the way that we pay people hasn't worked. Fee-for-service — rewarding for quantity — has not generated the kind of quality we are aiming for or the responsible finances. With the creation of ACOs (accountable care organizations), bundling and other things, what it says is this isn't business as usual.
"We can try to create organizations with physicians on salary," Gawande said. "We can try putting checklists in place. We can try making systems of care. It opens up the creative potential to think about, and even be rewarded, by thinking about how they get costs down while ensuring they don't harm a soul."
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