Atul Gawande

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The Artery: Atul Gawande On How We Want To Die

Dr. Atul Gawande is a general surgeon at Brigham and Women’s Hospital and a professor at Harvard Medical School and the Harvard School of Public Health. (Courtesy)

Dr. Atul Gawande (Courtesy)

First, just to restate what I posted on CommonHealth’s Facebook page on Friday in response to Dr. Atul Gawande’s superb and reassuring New Yorker piece, “The Ebola Epidemic Is Stoppable”:

Who here agrees that Dr. Mehmet Oz should be stripped of his “America’s doctor” title and it should be given to Dr. Atul Gawande?

Fifty readers “Liked” the idea, and here’s some more ammunition for that proposition: Dr. Gawande’s latest book, “Being Mortal: Medicine And What Matters Most In the End.” It’s reviewed on WBUR’s arts blog, The Artery, here, with the conclusion:

Perhaps surprisingly, geriatric doctors and hospice social workers have found that refusing extreme medical procedures does not mean refusing life. Unlike a 30-something patient with one fixable problem, an elderly patient has a spectrum of problems that cannot be fixed, only managed. Making small but key changes, like simplifying medications, controlling arthritis, ensuring good meals and maintaining social connections, can be more effective in prolonging life than some extreme medical measures.

“Being Mortal” is a valuable work, and a timely one. By 2044, there will be as many people in the world who are over 80 as there are under 50. Gawande reflects that, “It is not death that the very old fear …. It is what happens short of death — losing their hearing, their memory, their best friends, their way of life.” These are what matter in the end.

Read the full review on The Artery.

Atul Gawande, Renowned Surgeon And Writer, Launches Innovation Lab

In some ways, the name Dr. Atul Gawande chose for his new health care innovation center — Ariadne Labs — says it all.

“Ariadne is the myth of the Greek goddess who showed Theseus the way out of the labyrinth with a simple thread,” Gawande explained. “We’re in the simple-threads business to show our way out of the labyrinth of health care complexity.”

Surgeon/writer Atul Gawande is opening Ariadne Labs, a center, for health care innovation. (Photo: Fred Field)

Surgeon and writer Atul Gawande is opening Ariadne Labs, a center for health care innovation. (Courtesy Fred Field)

Gawande, a surgeon at Brigham and Women’s Hospital, has been named one of the world’s most influential thinkers. The surgical checklist he promotes has been gaining traction worldwide since 2008, when it’s use in a World Health Organization project reduced deaths during surgery by nearly 50 percent. The list is a set of questions everyone in an operating room answers, starting with: Do we have the correct patient? What operation are we performing? And is the site marked?

Now, Gawande is expanding his focus from surgery to two other big health care moments: childbirth and death.

“We think in the course of a person’s life that you will turn to the health system for a few high-risk, high-failure health care moments, and also some of the highest-cost moments in that system,” Gawande said. It starts with childbirth and surgery — the average person has seven operations in their lifetime — all the way to the end of life.

“We know that almost 90 percent of patients say they want to die at home, yet less than 50 percent do,” Dr. Rachelle Bernacki tells an audience gathered for the first research meeting on end-of-life care at Ariadne Labs’ new office.

Boston can be the Silicon Valley of health care innovations.

– Atul Gawande

Bernacki is testing a set of questions that aim to make sure doctors understand the wishes of patients who face a prognosis of death within six months. “We start all conversations with, ‘What’s your understanding of where you are with your illness now?'” Bernacki explained. She is analyzing patients’ responses to seven questions and training doctors to have these difficult conversations.

Some health care experts who’ve wrestled with the end-of-life issue for years — like Stuart Altman, who has worked on health care reform at the state and national level for 45 years —  are thrilled to hear Gawande’s lab is taking it on.

“Atul Gawande is a true find,” Altman said. “There are few people — no, as a matter of fact, I don’t know anybody who really has a better insight into how our system works and where it doesn’t work and how it could be better.”

But Gawande knows there are hurdles ahead. Continue reading

Atul Gawande Responds To Critics Of Three Different Stripes

Local surgeon and health-care writer supreme Atul Gawande recently had a typically superb piece in The New Yorker, about projects to improve care — and cut costs — for the sickest, most expensive patients. (You can now read it without a subscription.) Now he’s responding to three different stripes of criticism that the piece raised.

The piece prompted objections from “defeatists,” “catastrophists” and “triumphalists,”he writes here on the New Yorker’s site. The defeatists don’t believe that the high-intensity methods he describes will ever be widely applied in the health care system. The catastrophists think the increased medical hand-holding he writes about can amount to unacceptable government intrusion in people’s lives. And “the triumphalists” think this intense style of care should be offered to everyone, not just the sickest patients.

(Below, an oldie but goodie)

Atul Gawande’s Latest, On The Most Expensive Patients

Honest, we don’t get any commissions from The New Yorker for getting more people to subscribe, but maybe Atul Gawande should. His incisive pieces on aspects of the health care system ranging from end-of-life care to medical costs are must-reads for their mix of analysis and humanity.

His latest is just about to come out in the Jan. 24 issue (see the New Yorker link and summary here.) It’s titled “The Hot-Spotters” and describes innovative efforts to improve care for the super-expensive patients whose complex needs suck up a huge portion of the health care budget.

The New Yorker has put up a digital pay-wall, so you can’t read the whole article online without subscribing. But I can spill that it has a small local angle: a mention of a Massachusetts General Hospital program led by Dr. Tim Ferris that has found ways to improve care and cut costs for some of their most expensive Medicare patients. And The New Yorker site is advertising a live chat on medical costs this Thursday at 1 p.m. Here’s another little teaser from the magazine’s summary of the piece:

Writer tells about Jeffrey Brenner, a physician in Camden, New Jersey, who has used data mining and statistical analysis to map health-care use and expenses. His calculations revealed that just one per cent of the hundred thousand people who made use of Camden’s medical facilities accounted for thirty per cent of its costs. That’s only a thousand people—about half the size of a typical family physician’s panel of patients. In his experience the people with the highest medical costs—the people cycling in and out of the hospital—were usually the people receiving the worst care. If he could find the people whose use of medical care was highest, he figured, he could do something to help them. If he helped them, he would also be lowering their health-care costs.

Here’s Atul Gawande at a recent appearance at WBUR.

Atul Gawande: On Dressing For Tennis (And Payment Reform)

Influential surgeon, writer and thinker Atul Gawande was at WBUR today and spoke eloquently about the great political, financial and emotional obstacles facing health care reform during the program “On Point.” (He said we’re in the midst of a “fight for the soul” of health care in the U.S.)

I caught up with Dr. Gawande after the show and asked him to provide some motivational words to get people to exercise (he looks pretty fit, and I assumed he’d share with me his detailed, daily workout routine.) I was wrong. Turns out even the guy the president turns to for deep thinking on health care has trouble motivating himself to get out there and break a sweat. You can listen to his response here, but there’s a catch: first, you must hear what he has to say about payment reform in Massachusetts.

McAllen, TX: Health Care’s Bad Boy Town May Not Be So Bad

Surgeon/writer Atul Gawande made McAllen the poster child for overpriced health care. But is it?

Kaiser Health News today asks: Did McAllen Get a Bum Rap?

A June 2009 New Yorker article by Atul Gawande attributed the high spending to a culture of doctors that ‘came to treat patients the way sub-prime mortgage lenders treated home buyers: as profit centers.’ The article became required reading in the White House and Congress during the health care debate and turned McAllen into shorthand for America’s decadent medical spending problem.” But a Health Affairs study “contradicts one of Gawande’s assertions: that McAllen doctors over-treat everyone. The study looked at claims data from the private insurer Blue Cross and Blue Shield of Texas. It found Blue Cross paid McAllen 7 percent less for the care of the average McAllen patient than it did for an average patient in El Paso, 800 miles up the Rio Grande. The New Yorker article repeatedly held up El Paso as an example of a place where medicine is practiced correctly.”

Gawande, in his own post commenting on the Health Affairs study writes:

For members fifty or older, McAllen was indeed significantly more expensive than El Paso. But for those under fifty, McAllen was downright ordinary—even less costly than El Paso. They had escaped high-cost care.

It’s true that employees younger than fifty with Blue Cross coverage are a somewhat distinctive group. They are healthier than average and account for only a small percentage of local health costs. Nationally, people older than fifty account for about seventy per cent of total spending; among people under fifty, the poor and disabled account for much of the rest. The overall cost problem remains. But there is an important revelation here: not all the health care in a high-cost community has to be out of whack. The questions we then must ask are why the pattern is different for some groups of people, and whether such differences suggest ways to change the pattern for everyone.

There are two main explanations for the discrepancy: McAllen doctors could simply offer a lower-cost care for the kinds of conditions people under fifty have (pregnancies and traumatic injuries tend to be the big-ticket items); or Blue Cross could be particularly effective at restricting overspending. It’s hard to know which is the answer. Looking at the evidence available, we can’t be sure. But I am rooting for the idea that Blue Cross is making a difference.