Saturday, May 05, 2007

Atul Gawande: Can This Patient Be Saved?

In a guest editorial in the New York Times, Atul Gawande, a general surgeon at Brigham and Women’s Hospital, a New Yorker staff writer and the author of the new book “Better” analogizes America's health care crisis to a patient who comes to him with a tumor too late to fix:

As a surgeon, I’ve seen some pretty large tumors. I’ve excised fist-size thyroid cancers from people’s necks and abdominal masses bigger than your head. When I do, this is what almost invariably happens: the anesthesiologist puts the patient to sleep, the nurse unsnaps the gown, everyone takes a sharp breath, and someone blurts out, “How could someone let that thing get so huge?”

I try to describe how slowly and imperceptibly it grew. But staring at the beast it has become, no one buys the explanation. Even the patients are mystified. One day they looked in the mirror, they’ll say, and the mass seemed to have ballooned overnight. It hadn’t, of course. Usually, it’s been growing — and, worse, sometimes spreading — for years.

Too often, by the time a patient finally seeks help, I can’t help much.


It’s as true of societies as of individuals. We did not muster the will to reform our long-broken banking system, for example, until it actually collapsed in the Great Depression.

This is, in a nutshell, the trouble with our health care crisis. Our health care system has eroded badly, but it has not collapsed. So we do nothing.

Gawande suspects the only way to get reform is for the health care system to collapse:

The only time the country has enacted a large-scale health system change was after a collapse. In 1965, when Medicare was created for the elderly and disabled, some 70 percent had no coverage for hospital costs. We’re not that badly off yet. Our health care system is like one of those tumors growing in my patients. The only questions are: When will it become bad enough to make us act? And will that be too late?

Reformers think we’re on the verge of waking up some morning, looking in the mirror and noticing the size of this tumor with enough alarm to do something radical about it. But isn’t it more likely we won’t?

Malcolm Gladwell has argued that when health care costs drive General Motors into bankruptcy, and 300,000 workers lose coverage overnight, that will be the next big crisis to prompt wholesale change. I thought so, too. But it now looks as if G.M. will instead wither slowly, shedding a plant here, a division there. And faced with a slow withering, we all just muddle on.

The case for sweeping reform — for severing health insurance from the workplace and creating a new system — is undeniable. But it’s going to be a long time before the large majority of Americans with decent coverage are persuaded to risk changing what they have. How then to cure a malignant health care system? Can we act before the patient collapses?

Gawande says "yes," but that, he wrote, will be his next column.

What's that saying? "An ounce of prevention is worth a pound of cure." But a pound of cure is so much more profitable. I suspect that is the real reason we are not seeing real reform.

Here is a link to Mr. Gawande's book on

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