Gawande Article About Healthcare

I’ve mentioned before my disdain for mainstream science and health reporting. One of the reasons I started blogging to help fill the gap myself is the writings of Atul Gawande. He’s a surgeon who has written two excellent books about medicine: Complications, and Better. Today I noticed an excellent article by Dr Gawande in the New Yorker about healthcare, cost, and the soul of medicine.

Discussion below the fold.

As I’ve said elsewhere, I’m not in medicine for the money. I think that the best doctors aren’t, though admittedly, I’m biased. Gawande seems to feel similarly. Not everyone agrees. As Gawande discusses in this article

…we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain, or a tumor, or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.

The article is a discussion of McCallen Texas, which is one of the most expensive healthcare markets in the country. It’s a discussion of why McCallen is so expensive, and how that might tell us how to us reduce healthcare costs without “rationing” healthcare.

I’ll leave you all to read the article rather than summarize it here. Go.


I’ll wait here.

When you’re done keep reading here and I’ll toss out a couple of quick thoughts about the article.





My favorite thing about this article is that Gawande does something only a doctor can: he puts the responsibility back squarely on our shoulders.

It’s true, in the end, most medical decisions that costs alot of money is made by a doctor. Gawande points out that the incentives in the system are set up to favor doctors putting excess cost into the system. In my own meager experience I’ve seen issues with this.

I’ve seen a doctor order X-rays (at 200-400 bucks a pop) to appease a patient rather than spend an extra 10 minutes explaining that it’s unnecessary, and invoking the old CYA, “don’t get sued, just do what the patient demands” argument, just to name one example.

Gawande sees this all as an issue relating to cost control. He points out that healthcare rationing isn’t necessarily the end point to fix our medical system. Rochester, Minnesota is one of the cheapest healthcare markets in America despite being home to the Mayo clinic system. As is pointed out in the article, Mayo’s system is set up to benefit patients. Not hospitals, not physicians checkbooks, not insurance companies.

When incentives are to revenue stream, rather than responsible stewardship, we do not benefit the patients. When we do not benefit our patients, we do not deserve the responsbilities we are granted.

Despite this, in the end this is where I think that responsbility really should lie with doctors. Doctors should be the ones responsible to decide what tests are appropriate. Not insurance companies, not patients. Yet if this is appropriately our responsbility, it’s also our job to steward the system’s resources appropriately.

An attending I worked with recently said “Three things should never be for profit: religion, government, and medicine.” Reasonable people may disagree with that, but not with the statement’s intent. When our incentives force us to be profit minded, rather than patient minded, everyone suffers.

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12 Comments on “Gawande Article About Healthcare”

  1. Stepan Says:

    Wow, the article is chilling. I’ve been following with dread and fascination the medical care my dad is receiving in Switzerland and how it would compare if he lived here (US).

    He’s been generally healthy and robust, but a month ago sudden abdominal pain turned out to be caused by a large kidney tumor and a subsequent CT scan revealed another tumor (unrelated) in his large intestine. His surgeons were planing to take care of both tumors in a single operation, but during a preliminary colonoscopy, which also uncovered a large polyp, his tumor got perforated and he had to have an emergency abdominal surgery (16″ of his large intestine was removed). Luckily he fought his infection and recovered enough to have his kidney taken out today.

    I found it fascinating seeing my relatives’ attitude about the emergency surgery (“these things sometimes happen”) compared to the almost-reflexive American attitude (“malpractice!”). From what I can tell the Dr. wasn’t negligent and was horrified (and apologizing profusely) when it happened.

    The second thing was the relatively small financial impact this will have on my parents. I don’t know what the cost of one week in ICU and another in recovery would be here in the US, but my dad was saying something about his bill listing a (regular) hospital day at $230 (I’ve paid more for a hotel stay!), and I’m looking forward to learning what the total bill will be. Apparently he’s responsible for 10% of his costs, but his co-pay maxes out at $650.

    Note that Switzerland has universal health care and everyone is required to carry basic health insurance; I think my parents have some kind of basic+plus insurance, but nothing fancy. He’s being taken care of in a public hospital and when it’s all said and done will have spent 3-4 weeks there, including maybe 10 days in the ICU. I don’t want to think about how costs would have affected my parents’ “golden years” if they were living here.

  2. Lisa J Says:

    As someone recently diagnosed with a chronic illness, I was very frustrated to go to a specialist’s office only to have him refer me to a different specialist after reviewing my case. I had had an appointment scheduled with that previous (referred-to) specialist and my ever-vigilant, wonderful GP told me the guy had a reputation for being “pricey.”

    I followed my GP’s advice because I’d received the preliminary packet from that specialist in the mail, and was dismayed to discover that there were two appointments worth of mandatory testing (including repeating tests already used in my diagnosis) before I would be evaluated on the THIRD appointment by the doctor. As a cash-pay patient, the $400 dollar estimate for the first visit alone, and the knowledge that the second visit included a cystoscopy and would probably not be cheaper was daunting.

    My GP has told me that he has an “extensive practice” in the city, and it includes all the latest bells and whistles. Part of me suspected that the mandatory testing was a way to make sure he paid for and expanded this type of practice, regardless of prudent practice or what the patient might need.

    This article only further underlines my suspicion. I am going to continue to endeavor to find competent, interested care for my condition, even if it is “more complex” than the first specialist. Wish me luck! I can’t continue to afford $200 office visits where a doctor reads my file and says, “You’d be better off at the really expensive place.”

    • To all the denialists: Never let it be said that I only ever represent the “medical establishment.” I’m more critical of MD’s and DO’s because I hold us to a higher standard.

      @Lisa J
      I’m sorry to hear of your chronic illness. In many ways, they’re worse than acute illnesses – their time course often removes appropriate sympathy from ones support network, and in many cases, wreak as much mental pain as physical pain. Good luck with your medical journey, and I can only hope your next specialist is better than your last.

      I hope that by policing our selves better, punishing those that break the rules, that are deceptive in exactly the way you describe, doctors can regain the world’s trust, and our own self respect.

      On the other hand, you’re very lucky to have what appears to be a very good primary care doctor.clearly had your best interest in mind, and looked out for you. That’s an important part of a a PCP’s job.

      Is s/he really a GP? that’s rare these days, a GP is a doctor who has not completed a residency. the vast vast majority of primary care doctors complete a residency in either internal medicine, or family practice and become board certified in these specialities. Some board certified doctors find the term GP to be an insult, as they’ve gone through years of extra training.

      • Lisa J Says:

        I did not KNOW that – I had adopted it because it is used so much by people when they describe their primary care physician/gatekeeper. Thank you for that information! The last thing I would EVER want to do is insult my regular doctor. He is an MD, and I think a family practitioner. I know he completed a residency, because when I went to see him after my divorce to be checked for STD’s (ex had been cheating) he mentioned dealing with women in abuse situations during residency.

        Unlike the stereotype of a lot of patients, I honestly don’t TRUST my body/instincts (my step-mother was completing her master’s in psychology/counseling as I was an adolescent, and NOTHING was an accident, any pain was psychosomatic, etc.). If it weren’t for my doctor’s insistence and encouragement, I would have quit looking for reasons for the pain and sickness when the first referral came back without a reason for the problem, assuring myself it was “all in my head” and I should “tough it out.” Yes, patients like that DO exist.

        Since he had treated me for seven years at that point, never had me request pain medication or ever come to him for a problem that WASN’T evident and verifiable, he encouraged further referrals, and when I didn’t like the approach of the next referral, he insisted I get a second opinion. I honestly believe he holds my health foremost, and he is probably my “favorite” doctor.

        Thank you SO MUCH for that bit of education, and the way you’ve presented it! Also, thank you for the encouragement. Since I am uninsured, my doctor is willing to take over supervision of my illness if a specialist will design a treatment protocol he can follow (i.e., if this doesn’t work, try plan B; if this complication arises use X). At $47 for a cash visit, he is much more affordable than a specialist. I’m very touched by that, because in my research about my illness I’ve found actual professional papers written on how to make ends meet treating a patient with my illness, because we take up more time/resources than they usually get back in fees.

  3. ShortWoman Says:

    You know, it would be nice if doctors didn’t have to be businessmen, true. But the fact is that by the time you and your classmates graduate med school, your average student loan debt will be 6 figures. You will have 10 years to pay it back. Thanks to the original Bush Administration, interest will accrue immediately should you defer it until after internship and residency.

    Thus, your classmates will have to pay this off at a time when their spouses are pressuring them to buy a home and start a family. Anyone who thinks doctors make too much needs to start by fixing how we pay for medical school.

    Your malpractice insurance will likely run something like $20,000 per year, assuming a low risk specialty. This is money that has to be paid before you can earn a dime. Of course if you work for a big group, you won’t ever see the bill, but the administrators who run the office know this number. They also know that they will be lucky to be reimbursed half of what they bill the health insurance companies.

    You will also be paying over $1000 per year for expenses associated with being a doctor: dues paid to your certifying board; testing fees; state medical license; DEA registration; continuing medical education. More costs of doing business. Again, a big group might pick up these costs for you, but they are still part of their cost of doing business.

    These are all issues that need to be addressed if you think that doctors are part of the problem of rising health costs.

    I on the other hand think that for profit health insurance companies and the system they represent are a far bigger part of the problem.

    • Lisa J Says:

      You know, Short Woman, I HATE insurance companies. I have never seen an insurance company that DIDN’T make money hand-over-fist. I have never begrudged a doctor who was acting in a patient’s best interest.

      That being said, I would suggest that in most metropolitan areas you can find doctors who are going beyond making ends meet to absolute, unabashed profiteering. Greed exists in the hearts of most men, to one level or another, and if a person with the wrong scruples and the right opportunity is bound to exploit others. It happens all the time.

      Many of the doctors discussed in that article were profiteering, not providing good medical care, and that abuse will also need to be addressed if we are to create an affordable, manageable health care system for everyone.

    • ddw11 Says:

      If you’d like to rail against insurance (or drug) companies, you’ll get no opposition from me. Same goes for med school tuition, I just finished taking out my loans for third year, ouch!!! But in the context of this article, the doctors are to blame for the absurd discrepancy in health care expenditures between neighboring towns. Research suggests that doctors who are salaried see less patients, see their patients for longer, order less tests and procedures and employ more preventative strategies. This is associated with more efficient health care expenditure and more satisfied patients.

      • Lisa J Says:

        Exactly, DDW. And I am so happy that it is coming from a med student who is taking out those student loans! There is no excuse for the exploitation that is discussed within the article.

      • ddw11 Says:

        BTW, if anyone is interested in our possible healthcare future, denialism blog has been running a series on other country’s systems and how aspects of each could be integrated into our own reforms.

        • Denialism’s coverage has been great. I found it pretty informative myself.

          But be warned, noone can give neutral information on this subject. my impression is that Mark seems pretty wedded to the idea that “doctor’s are innocent in this mess”, if you read the comments here

          I asked about this article, specifically in the context of physician stewardship of resources, and Mark gave me a straw man about how the Mayo clinic is a bad comparison.
          But it’s clear that Mayo isn’t the point of the article and I didn’t ask about Mayo.

          ddw clearly caught the meat of the article: McAllen spends much more than El Paso, a demographically, insurance coverage matched area.

          So go, read about our options at denialism blog, but remember that everyone has some sort of agenda.

        • ddw11 Says:

          WCTs, you are all over the internet, do you read everything I do?

          You’re right, MarkH didn’t address your actual question, but rather took you to be asking whether a Mayo model could be applied across the country in all populations. For the record, if you had asked that, I would have agreed with him, at least as far as the clinic in Minnesota is concerned. The same may not necessarily be true in their other two clinics, which certainly must have more diverse populations.

          It is my personal hope that national health care reform will result in everyone having at least basic insurance, which will in turn allow a mayo clinic like, “patient first” model to be more widely adopted. Hopefully such reforms will remove the financial burden of dealing with the un/under insured and resolve the crazy physician compensation systems that motivate the present “finance first” model.

          The article talks about anchor tenants shaping the economic culture of their surrounding area, it is basically my hope that large scale, national health reform will serve this “anchor tenant” role. I hope that a “patient first” system will not only allow doctors (private or public) to be “patient first,” but actively encourage it.

  4. ddw –

    For the record, I’m a huge junky, and I suspect that most people who read Orac, also read PalMD and denialism.

    I’d like to think my question was clear, certainly didn’t mention Mayo in my initial qustion. Even if it wasn’t as initially written, I rewrote it, and Markh has responded to other comments since then. I rather think he won’t be addressing my actual concern. It’s a little disappointing, as I’ve greatly respected the blogging on denialism. I think it’s obvious that Mayo’s system isn’t applicable, that’s a trivial question, and it’s difficult to believe he thought I was actually asking that.

    I agree with Mark’s overall point that once you reduce the incentive to practice defensive medicine, and pay us to think instead of run a ton of tests and procedures, and make cover universal so we aren’t having a stealth tax to cover the uninsured, we can bring cost down alot.

    I like the analogy of anchor tenants, but I suspect that local thought leaders will influence the culture to a large degree as well. And I don’t think the two are identical.

    In my area, some of the most common “And this is how we do this” protocols come from local doctors who are very well respected, either in private practice, or on faculty. As they go, so go the community.

    Either way, I suspect that universality and a few other reforms will allow us to move back to our roots as patient first. I’m cautiously optimistic.

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