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How Atul Gawande is Being Misunderstood

Everyone is reading Atul Gawande’s article in the New Yorker about health care costs. But I think most people misunderstand Gawande’s major point.

Everyones At It

Everyone’s At It

The conventional wisdom on Gawande’s piece is this: our problems are caused by bad incentives in our health care system. They encourage doctors to overprescribe care. McAllen, Texas is the poster child of this problem. If we can change the economic incentives, doctors will behave better. They will follow medical evidence, not their bottom lines, and from this will emerge a rational, affordable system.

This isn’t what Gawande is saying.

Gawande went to McAllen expecting to see a microcosm of the American health care system. As expected, he found excessive, even abusive spending, and a culture that encouraged both. But he also found that in nearby El Paso, Texas, medicine wasn’t practiced this way, nor in most other places in the country. And so he came up with a surprising insight. Yes, McAllen is a reflection of what can happen based on the incentives in the system. But if every incentive works this way, why is McAllen such an outlier?

Gawande concluded it had to do with the “culture” of medicine in each community. Most doctors go into medicine to help patients. In Gawande’s visit to McAllen, he heard stories that money had become more important than quality care. What Gawande realized was how important this question of “culture” was to how McAllen became McAllen. It made him think of places that had a completely different culture, like the Mayo Clinic.

The doctors of the Mayo Clinic decided, some decades ago, to put medicine first:

The core tenet of the Mayo Clinic is “The needs of the patient come first” — not the convenience of the doctors, not their revenues. The doctors and the nurses, and even the janitors, sat in meetings almost weekly, working on ideas to make the service and the care better, not to get more money out of patients. . . . Mayo promoted leaders who focused first on what was best for patients, and then on how to make this financially feasible.

Gawande couldn’t believe how much time doctors at the Mayo clinic spent with each patient, and how readily they could interact with colleagues on difficult problems. While it is true, the Mayo Clinic has financial arrangements that make this easier, it is the culture of patient care that dominates, not questions of pay:

No one there actually intends to do fewer expensive scans and procedures than is done elsewhere in the country. The aim is to raise quality and to help doctors and other staff members work as a team. But almost by happenstance, the result has been lower costs.

“When doctors put their heads together in a room, when they share expertise, you get more thinking and less testing,” [Denis] Cortes [CEO of the Mayo Clinic] told me

And this is where Gawande is being misunderstood.

The “cost conundrum” that Gawande talks about is not about how to cut costs, or how to change who pays for health care and how much. It’s deeper than that. Gawande’s point is that we have been fixated for so long on the question of money in health care that we are starting to forget about medicine. By focusing on ever more clever ways to pay doctors, we have systematically undervalued everything that makes for high quality medicine. Things like time with your patient, thinking about his or her problems, consulting with colleagues, and coming up with sound advice.

We discount what he calls the “astonishing” accomplishments of the Mayo Clinic on this score. And instead of designing health care reform around ways to help more hospitals become like the Mayo Clinic, we choose instead to think about money, to focus our attention on how to cut costs in places like McAllen.

Politically, it makes sense – it’s convenient to have a poster child like McAllen to explain why one reform plan or another should become law. But the pity is that in this important time of reform we’re not talking about trying to put the needs of the patients first – to put medicine back in the center of health care. The pity is that in spite of the fact that everyone’s reading Gawande’s article, his most important insight is being misunderstood.

If we continue to be focused on money over medicine, we will lose the “war over the culture of medicine – the war over whether our country’s anchor model with be Mayo or McAllen.”

*This blog post was originally published at See First Blog*


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4 Responses to “How Atul Gawande is Being Misunderstood”

  1. Roy says:

    Excellent re-take on this issue, Evan!

  2. Ben Stanger, MD says:

    Falchuk's comments nicely frame the “cultural” changes that could benefit both quality of care and out-of-control costs. The Mayo model provides a good balance that would improve both measures. However, Mayo is exceptional for many reasons — including characteristics of individual practitioners, malpractice concerns, and other features — even among academic medical centers.

    Reform that refocuses attention on the care provided to patients, rather than on reimbursement, is critical for a functioning and affordable health care system. However, I this distinction will be too subtle for policymakers, whose job it is to REGULATE. In the end, I fear the result of reform will be practice (and spending) requirements that only increase the complexity of medical care. One of the secrets of success of the Mayo program is that under that system, physicians have the freedom to do what they think is necessary (and only what they think is necessary) for good care.

  3. Evan Falchuk says:

    Thanks for the comments!

    I agree, Dr. Sanger, reform is going to end up focused on reimbursement. The insistence on seeing everything through a financial lens makes it easy to do things like misread Gawande's piece.

    In this sense, the health care reform debate is over. Some big reform bill will be signed and it will focus on new ways to pay for care. These fundamental issues of how care is actually delivered – which have everything to do with the quality and cost of care – will continue to be left to doctors and patients to figure out on their own.

    We need a cultural shift in how we think of health care to move things in this direction. It will take time, but we have to keep at it, day by day.

  4. Evan Falchuk says:

    Thanks for the comments!

    I agree, Dr. Sanger, reform is going to end up focused on reimbursement. The insistence on seeing everything through a financial lens makes it easy to do things like misread Gawande's piece.

    In this sense, the health care reform debate is over. Some big reform bill will be signed and it will focus on new ways to pay for care. These fundamental issues of how care is actually delivered – which have everything to do with the quality and cost of care – will continue to be left to doctors and patients to figure out on their own.

    We need a cultural shift in how we think of health care to move things in this direction. It will take time, but we have to keep at it, day by day.

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