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Surgeon Gawande Seeks More ‘Rational Care’ in Medicine

September 3, 2009 at 2:16 PM EDT
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In a continuing series of conversations with key players in the health care debate, Ray Suarez speaks with surgeon and writer Atul Gawande about spreading the concept of "rational care" in medicine.

JIM LEHRER: Now another in our conversation series on health reform, and to Ray Suarez.

RAY SUAREZ: Some of our previous conversations have gauged the views of a hospital executive, the CEO of a major insurer, and advocates from both sides.

Tonight, we speak with a cancer surgeon and well-known writer whose essays and reports have influenced the debate. Dr. Atul Gawande directs the Center for Surgery and Public Health at Brigham and Women’s Hospital in Boston. He is also a staff writer at The New Yorker.

And, Doctor, the president is going bat himself before a joint session of Congress to stump for health care reform next week. Congress is returning to work. When final versions of these bills are finally circulated in the House and Senate, what for you is the make or break? What has to be in those proposals?

DR. ATUL GAWANDE: Well, first of all, what I would want to see is that there are final versions in the House and Senate.

My — my great fear here is that nothing will come through. The debate has become so torn that we’re losing sight of the fact that we do have some central problems we have to fix for our country, both people who are losing insurance or have insurance that doesn’t cover basic needs, and then our struggles with the cost of the system.

And I think that’s what’s got to be there, is an effort to really make a lifeboat that covers people when they lose coverage, gets rid of preexisting condition exclusions for their coverage, and then also begins making the deposit of working on the — the deep, hard problem of our costs.

RAY SUAREZ: Congress went on recess, and the version of a national conversation began. What’s been missing in that? What important conversations haven’t been included in the debate thus far?

Must move forward with proposals

DR. ATUL GAWANDE: Well, the disappointing part of all is that it hasn't really had that can-do spirit behind the idea that we can solve our problems.

There is great contention about what we do to handle a problem that's a sixth of our economy. It affects every single person in our country. It feels so complex and enormous, that we can't imagine being happy with anything that might come out of it.

But I do think that there is a strong sense that it's sort of like some of my patients. I mean, if we do nothing, we may have a 50 percent chance or worse that this system will simply fail upon us.

And moving forward will be far better than doing nothing. It may have aspects like an operation that -- that not all of us will be happy with. But it will be a much better, brighter outlook for us if we have covered people and if we are starting the hard work, which we keep putting off, of actually making the care of higher quality, while getting the costs down.

RAY SUAREZ: Well, on the subject of cost containment, you went on a reporting trip to the Texas border and contrasted spending and results in two border communities, McAllen and El Paso. What did you find?

DR. ATUL GAWANDE: Well, I went partly because I was confused about what we can really do on health care costs. And so I thought one place to find it would be to go to one of the most expensive counties for health care in the country, and that's in McAllen, and then look at it compared to another border community with very similar fairly sick populations.

But what we found was that, in one community, we're spending $15,000 per person per year on Medicare, and, in the other, they're spending half of that, $7,500 per person. And, yet, there is no difference in the quality of care between the two places. If anything, the quality was better in El Paso than the more expensive McAllen.

And, so, I talked to the doctors there, my colleagues, to ask them what their perspective was on it. Some of them were surprised. Some didn't think there was a problem at all. They thought maybe all the rest of the country should spend the way they are.

But many saw a problem where medical care was poorly organized, duplicate testing, poor prevention. And then, also, some saw Medicare -- medical care being placed as a business, ahead of needs of patients, doctors sometimes owning imaging centers, surgical centers, and then finding themselves in a bind, where, to keep the business going, you have to bring more people in.

It wasn't a community that looked at itself and said, wow, we're costing a lot for our employers and for our patients. What can we do to make the care more sensible? Perhaps begin doing -- avoiding problems, like they -- they might -- they do five times as much home nursing visits, without any clear benefit from them.

Fewer options might be better

RAY SUAREZ: But you have conceded in your journalism and in your life as a physician that Americans, in many parts of their lives, perceive that more is better.

And one of the hallmarks of the debate that has been going on over the past several weeks is that, when you talk about cost containment, people hear that as limiting, rationing, taking away things that they have.

How do you talk about cost containment to people who are already insured and hear that as losing something they already possess?

DR. ATUL GAWANDE: Yes. You know, the hardest part, I mean, idea that more must be better and less couldn't possibly be better. An example here, we're doing 62 million of the -- 62 million C.T. scans for a population of 300 million. And there was one community at a conference where I met the doctors from Cedar Rapids, Iowa, and they looked and they saw in their own community those exact numbers for a town of 300,000, in one year, they had done 52,000 C.T. scans.

And that alarmed them, and it embarrassed them, because, first of all, those scans have 1,000 times the radiation of a regular chest X-ray. They know they're increasing risks of cancer there. And they recognize that a lot of them were unnecessary.

This was an enormous cost for their community. And, so, they started working on how to reduce it. Now, if you want to say, look anything over 40,000 scans, and no more scans, that's rationing, and -- and we would all find that horrendous.

But the way people are approaching these kinds of problems, for example, at my hospital, we decided that, for example, if you have a normal headache, a lot of people automatically are getting C.T. scans, when it's actually dangerous to do that, because of the radiation, and finding that there are good guidelines for helping us decide when is it worrisome to have -- what are the features that make it worrisome for a headache?

And, so, our, hospital adopted a system where we -- if we didn't meet the usual guidelines, we didn't have an insurance bureaucrat coming down on us. We just were asked to talk to the radiologist and discuss the case.

And we found, within a year, we had reduced uses -- unnecessary uses of C.T. scans by 15 percent and saved a lot of money.

'No magical bullets'

RAY SUAREZ: In closing, you wrote over two years ago, looking ahead to this debate that's going on now, "The debate will become angry and murky and mind-numbingly complicated, and the temptation will be to put off reform yet again."

Are you still worried about that? And are you in a position now where you will take a bill, and postpone tinkering with it, instead of no bill at all?

DR. ATUL GAWANDE: Yes. You know, this is what happens when -- when we come to grips with a really, really hard problem. There are no magical bullets or white knight solutions.

I'm personally very skeptical of grand schemes to completely remake every way that people get their health care. The kind of bills that are moving through Congress right now are ones that leave most people -- leave -- leave everybody, pretty much, in the insurance plans they have if they're happy with them, but offer a lifeboat for those who have inadequate coverage or are laid off, a lifeboat they can have which gives them coverage.

And then they start doing the hard work of changing some of the ways that -- offering some -- some experiments with how to pay doctors differently, so it's for quality, and not quantity, and start us down the road of really working on what's going to be a problem that will take us some years to solve, improving our quality, making a better health care system, but also quite manageable, at lower cost.

RAY SUAREZ: Dr. Atul Gawande, thanks for joining us.

DR. ATUL GAWANDE: Thank you.