Since it takes a lot of reading in this post to get there, I wrote this all as a reaction to Gawande’s latest New Yorker piece, “Letting Go”, which is a phenomenal and heart-breaking read.
I am a huge fan of Atul Gawande. Here is how his website describes him:
A surgeon and a writer, Atul Gawande is a staff member of Brigham and Women’s Hospital, the Dana Farber Cancer Institute, and the New Yorker magazine.
The first time I remember reading something of his in the New Yorker was June 2008. He wrote about the reason we itch and scratch, and the science that is trying to figure it all out. It was so fascinating. I still think about it often when I find myself unable to resist scratching.
He also did an amazing piece on solitary confinement that everyone should read. It discusses how this type of punishment isn’t effective and is, more than anything, cruel.
But he hooked me with his coverage of health care in America.
In January 2009, he wrote a piece called “Getting There from Here”. In it he is trying to figure out how best to reform the broken health care system. Here are some great quotes:
There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have. […]
It will be no utopia. People will still face co-payments and premiums. There may still be agonizing disputes over coverage for non-standard treatments. Whatever the system’s contours, we will still find it exasperating, even disappointing. We’re not going to get perfection. But we can have transformation—which is to say, a health-care system that works. And there are ways to get there that start from where we are.
After reading this, I ran around quoting Atul Gawande to whomever wanted to talk about healthcare reform.
In June 2009, he wrote a piece about HOW we can minimize costs by focusing on the most expensive place in the US for healthcare (McAllen, TX) and on a model for efficient, productive, cooperative, and caring health care system (Rochester, MN – home of the Mayo Clinic). He ends the article this way:
Something even more worrisome is going on as well. In the war over the culture of medicine—the war over whether our country’s anchor model will be Mayo or McAllen—the Mayo model is losing. In the sharpest economic downturn that our health system has faced in half a century, many people in medicine don’t see why they should do the hard work of organizing themselves in ways that reduce waste and improve quality if it means sacrificing revenue. […]
As America struggles to extend health-care coverage while curbing health-care costs, we face a decision that is more important than whether we have a public-insurance option, more important than whether we will have a single-payer system in the long run or a mixture of public and private insurance, as we do now. The decision is whether we are going to reward the leaders who are trying to build a new generation of Mayos and Grand Junctions. If we don’t, McAllen won’t be an outlier. It will be our future.
There was such a negative response from some corners that he felt the need to clarify points on the New Yorker blog.
Then in December of 2009 he wrote another piece about health care legislation. This one argued that not having a master plan in the health care legislation for curbing costs is a good plan, in that there will need to be trial-and-error in this regard to find the best ways to cut costs:
Where we crave sweeping transformation, however, all the current bill offers is those pilot programs, a battery of small-scale experiments. The strategy seems hopelessly inadequate to solve a problem of this magnitude. And yet—here’s the interesting thing—history suggests otherwise.
He uses the history of the USDA to show how small-scale experiments in cost cutting led to much bigger programs in the end. Lots of programs failed but the ones that succeeded were incredibly successful. He thinks that health care can work in the same way.
One thing that I greatly appreciate from his writing is his ability to embrace the fact that the path forward through this mess will be, well, messy. And things will fail. But he also reminds us constantly that things will succeed. So we need to focus on the latter because the former will not get us anywhere at this point.
In April 2010, he responded to the historic passage of the new health care laws with a short piece entitled, “Now What?”
The most interesting, under-discussed, and potentially revolutionary aspect of the law is that it doesn’t pretend to have the answers. Instead, through a new Center for Medicare and Medicaid Innovation, it offers to free communities and local health systems from existing payment rules, and let them experiment with ways to deliver better care at lower costs. In large part, it entrusts the task of devising cost-saving health-care innovation to communities like Boise and Boston and Buffalo, rather than to the drug and device companies and the public and private insurers that have failed to do so. This is the way costs will come down—or not.
That’s the one truly scary thing about health reform: far from being a government takeover, it counts on local communities and clinicians for success. We are the ones to determine whether costs are controlled and health care improves—which is to say, whether reform survives and resistance is defeated. The voting is over, and the country has many other issues that clamor for attention. But, as L.B.J. would have recognized, the battle for health-care reform has only begun.
So, why I am writing ALL of this now? I started to read his latest New Yorker article last night. It from the August 2nd issue. It’s called “Letting Go” and it hit home. A doctor and medical journalist whose work and viewpoints I have come to admire and respect was writing about a situation that was personal and still painful and, once again, I felt like he was totally right.
In “Letting Go”, Dr. Gawande describes the end of life and how the medical community should respond to it. As technology gets better and better, doctors are able to always offer something, some kind of treatment until the very final moments of life (it even makes it hard for them to definitively say that someone is dying even if they are terminal – read the article because it makes more sense there). But for terminal patients, ending your days in an ICU are often not the way that any of us imagine our final days. And yet that is now where most people die. Not only is it sad and stressful, but it has led to extremely high costs. Here is what he writes:
If you were the one who had metastatic cancer—or, for that matter, a similarly advanced case of emphysema or congestive heart failure—what would you want your doctors to do?
The issue has become pressing, in recent years, for reasons of expense. The soaring cost of health care is the greatest threat to the country’s long-term solvency, and the terminally ill account for a lot of it. Twenty-five per cent of all Medicare spending is for the five per cent of patients who are in their final year of life, and most of that money goes for care in their last couple of months which is of little apparent benefit. […]
In 2008, the national Coping with Cancer project published a study showing that terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions, or admitted, near death, to intensive care had a substantially worse quality of life in their last week than those who received no such interventions. And, six months after their death, their caregivers were three times as likely to suffer major depression. Spending one’s final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or “It’s O.K.” or “I’m sorry” or “I love you.”
I highly suggest you read it. It will really make you think about how your want your own final moments to pass if and when you have the ability to control them (to a degree – much more so than dying all of a sudden in a car accident or from a brain hemorrhage).
I cried multiple times while reading it, thinking about very close loved ones who chose to be at home and to die in hospice. To have final words, final touches, and to be aware almost to the end.
Thank you to Atul Gawande for all his wonderful reporting that often reshapes the way I think about things in my world.