One of the ways Picker Institute supports patient-centered care is by recognizing significant contributions to achieving patient-centered care nationwide.
“Conversations with Leaders in the Field of Patient-Centered Care” is a regular feature that highlights these contributions. This Conversation is with Dr. Atul Gawande, a winner of the 2010 Picker Award for Excellence® in the Advancement of Patient-Centered Care.
Dr. Atul Gawande
Dr. Atul Gawande is a general surgeon in Boston, Mass., and the author of several internationally best-selling books on modern medicine, including, most recently, The Checklist Manifesto, which reached the New York Times’s nonfiction bestseller list in 2010. He has also been a staff writer at The New Yorker magazine since 1998, and many of the pieces published there about his life as a surgical resident have played a larger role in clinical and political developments in the healthcare industry.
At the Institute for Healthcare Improvement’s 22nd Annual National Forum on Quality Improvement in Health Care, you participated in a discussion of the “triple aim”: lower costs and higher quality resulting in better healthcare. As a surgeon and a writer, how do you approach this issue?
I don’t understand abstractions, as a surgeon or as a writer. In both modes, I need to understand a situation through knowing what happens to a particular individual. Let me give you an example: Not too long ago I attended a parent-teacher conference at my son’s school. I was interested in meeting the new school superintendent and asking him what he was working on. I thought he’d say educational reform, how to restructure the educational system. But what he spends his time on, he said, is healthcare. As a result of property tax reform in Massachusetts, his budget for teachers has been slashed. At the same time, the cost of medical benefits for teachers has risen by 9 percent. What is he to do?
A little later I was talking to my son’s math teacher. He couldn’t quite remember where my son was. With 35 students in the class and one teacher, my son was disappearing somewhere in the middle.
As I left the classroom, I ran across a teacher whom I’d operated on for lymphoma. She was tough–she’d survived. But 5 percent of teachers account for 60 percent of teachers’ total healthcare costs, and I suddenly realized that I was part of the reason my child was being neglected.
Seeing these issues in terms of the community where they were happening, I could understand the problem: Does great healthcare for this teacher have to bankrupt my son’s future?
Do you have an answer for that question?
I think hope lies in the bell curve for healthcare costs. There’s a very wide variation, with most people grouped in the mediocre middle. The same is true of quality outcomes: Most people are in the middle. Where I see hope in those facts is that the best results often come at the least expense, and the least expensive care often achieves the best results.
You’re mentioned “community” several times. How important is community, as a concept and as a fact, in achieving the triple goal?
Community matters. There’s always a tension between maximizing revenues and meeting the needs of the community. In the end, all medicine—like all politics—is local. The communities that have healthcare systems rather than fragments of care are getting better results at lower costs.
Central to achieving the triple aim is improving results divided by lowering costs: reducing emergency room visits, eliminating unnecessary imaging and surgery. The teacher I treated—can we take care of her lymphoma by doing less, by making it easier for her to live her life and at the same time giving her the best chance of surviving?
What do you think of President Obama’s healthcare legislation?
I think it creates great opportunities for developing systems. However much it is attacked, it provides the tools we need, and the question for us is how do we want to use these tools? Do we want to use them to drive up revenues—and there are a lot of people saying that—or do we want to use them to create better healthcare systems in communities so healthcare for teachers doesn’t mean sacrificing our children’s future? How do we lower costs without compromising the quality of care?
We can set goals, but is it remotely possible that we can succeed? I’m a little skeptical that a community of 10,000 people can come together and develop a master plan, and we’re a nation of more than 300 million. But if we start at the local level, we may just succeed.
How?
At the turn of the last century, a major problem facing this country was the cost of food. Forty percent of a family’s budget went for food, and 50 percent of the workforce was involved in producing it. It was a fragmented system in which the evidence of how to put better food on the table at a lower cost was largely ignored. Farmers for the most part repudiated what they called “book farming.”
In 1903 a man named Seamon Knapp, whom we would deride as a bureaucrat, defied this logic by making a very simple, very small change: He persuaded a community of farmers to choose one of their number to try scientific farming, with the proviso that if the experiment failed the farmer would be reimbursed for his losses. Not only did the experiment not fail, but when the community was hit by the boll weevil, the experimental farm survived and thrived. Guided by this demonstrable success, farmers followed suit, and by 1930 there were 750,000 demonstration farms. A hodge-podge had come together as a success.
There were four elements that made this possible:
- Making it possible for farmers to own their own land.
- Adding to the store of available knowledge with experimental/research farms
- Collecting data: weather information, crop reporting, grading systems.
- Sharing information through broadcasts, mailers, meetings.
This was not a case of the government taking control but of local farming communities trying to bend the bell curve of food costs. And it worked. By 1930 food was down to 24 percent of the family budget, and the workforce in food production was down to 20 percent. By the 1950s, both proportions were less than 10 percent.
These results were beyond imagining. The abundance in our supermarkets became the best argument for the American way of life and was critical to our becoming a superpower, with the attendant responsibilities. There were some painful dislocations, but no vast foreclosures and social unrest. The system was created by trial and error, and by focusing on results rather than ideologies.
I believe this is a road we can replicate. Like the food industry, healthcare is comprised of hundreds of thousand s of local entities. All of them want to provide great care, but they’re measuring success by revenues.
We’re at a time when hope and belief are sapped out of society. There is a lack of belief in the collective possibility of where we can go. With the wrong incentives, the results have been disastrous. Can it be fixed? No one knows.
In order to transform the food system everywhere, we needed to transform it somewhere. That is what we can do with healthcare, learning from it in the same way, through
- Experiments in financing
- Collecting data. The scarcity of reliable healthcare data is a total embarrassment—we know more about cows than we do about how many people died after surgery in the last four years.
- Innovation
- Sharing what we learn
I don’t know if the government will step up to the plate. But we became the envy of the world with what we can do with food, and we can do the same in healthcare. It does not seem like it now, but all those small efforts we are making add up to being the accountable local community, the caring local community, the organized local community.