Atul Gawande on regaining medical judgment

By Jeremy Manier

Dr. Atul Gawande’s authoritative New Yorker piece on health care costs has rightly drawn abundant praise from policy bloggers, Ezra Klein and Kevin Drum among them. Like the others, my comment comes with the caveat that you simply must read Gawande’s piece in full. It’s that good. I’ll also try to report back with a bit more wisdom from Gawande next Friday, when he’s giving the commencement address here at the University of Chicago’s Pritzker School of Medicine.

The question that Gawande’s piece raises is how to recover the medical judgment that he sees being eroded by constant incentives for physicians and hospitals to pursue profit and new revenue streams. He describes a medical culture that increasingly defaults to expensive options when guidelines are unclear, and a growing tendency of young physicians to rely on expensive tests. What’s often lacking, he says, is the willingness to do time-intensive evaluations:

Seeing a patient who has had uncomplicated, first-time gallstone pain requires some judgment. A surgeon has to provide reassurance (people are often scared and want to go straight to surgery), some education about gallstone disease and diet, perhaps a prescription for pain; in a few weeks, the surgeon might follow up. But increasingly, I was told, McAllen surgeons simply operate. The patient wasn’t going to moderate her diet, they tell themselves. The pain was just going to come back. And by operating they happen to make an extra seven hundred dollars.

But that readiness to operate isn’t making patients in the Texas town any healthier. More is not always better. Gawande then talks with the C.E.O. of the Mayo Clinic, who pithily sums up how that system has kept costs low and quality high: “More thinking, less testing.” Gawande proposes that medical communities should be more active in ensuring that patients get cheap but effective preventive care – like flu shots – while rooting out unnecessary operations and perverse financial incentives.

I recently talked with a physician who had another idea for how physicians can learn to cut costs: Try practicing medicine for a while in a developing nation.

Aisha Sethi, M.D., is a U. of C. dermotologist who spends one month each year at a dermatology clinic in Lilongwe, Malawi. The clinic has few resources for tests and imaging that would be routine at a U.S. hospital. But that’s not an entirely bad thing, Sethi said. With less technology to lean on, she and her colleagues rely more on their training and judgment. They tend to ask patients more questions, give longer exams, and give them offer more extensive counseling if expensive treatments are not available.

Sethi’s experience tracks with Gawande’s observations at Mayo, where he said physicians are willing to spend unusually long amounts of time with patients. “There was no churn—no shuttling patients in and out of rooms while the doctor bounces from one to the other.” Sethi said that in Malawi, physicians often don’t move from room to room at all; they sit comfortably in a central room where patients come to see them. Even that seemingly trivial difference seemed to make for a more relaxed environment.

No one has the silver bullet for reducing health care costs. But Sethi’s experience suggests that one way of teaching physicians to be more efficient may be to show them how much they can accomplish in settings where costly tools simply aren’t available.

Dr. Aisha Sethi with a young patient in Malawi

Dr. Aisha Sethi with a young patient in Malawi

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