Wednesday, June 24, 2009

Krugman Catches Gawande Fever

Even the eminent Big Gov economist is referencing Atul Gawande's New Yorker article. Now it's official; every health policy wonk in America is now on record lauding the gloriousness and insight of the McAllen piece, as if it were a modern Revelation from above. God help us.

Let me be clear. Fundamentally I agree with Dr Gawande that physicians play a large role in running up health care costs. My issue is not with the "how" but rather the "why". Gawande very conspicuously attributes the exorbitant spending of McAllen to a "culture of money" that has infected its physicians. He rules out malpractice fears, defensive medicine, and the possibility of the higher quality/higher cost correlation. He then concludes that this leaves no other alternative but that doctors are ordering more and doing more just to line their own pockets. Then he extrapolates this to a national Either/Or paradigm of the Mayo model (collectivist, salaried, collaborationist physicians only doing what is right for the Patients, praise be their name) versus the McAllen model (greedy, self-referring, strip mall owning bastards). Read the article again. I urge all physicians.

There is another explanation. We certainly overutilize. We cut we radiate we probe we inject. There's this pressure to do something in American medicine that comes from a lot of different angles (patient pressures, the culture of modern medicine, the disconnect between the actual cost of medicine and those who prescribe/benefit from it). What I see in my everyday practice is overutilization, not from greed, generally, but from a lack of thinking. A lack of thought and clinical judgment. This is the heart of the trouble.

Last week I wrote about a 90 yo guy with metastatic pancreatic cancer who received a million dollar workup in the 2 days that he spent in the hospital. This week we were re-consulted on an older guy with CVA-induced dementia who keeps getting sent to the ER from his nursing home because of recurrent urinary tract infections. I reviewed his chart. Since April he has had two CT scans of his chest, two abdominal ultrasounds, two HIDA scans, three CT scan of his abdomen, an MRI of his brain, a PEG feeding tube, and a cystoscopy. In addition, he's been seen by general surgery, GI, ID, and neurology on each of his admissions. (We keep getting called because of fevers/sludge in gallbladder even though the guy has never complained of abdominal pain, nor is he tender, nor have any of the HIDA scans been positive.) Every time, he gets treated for his UTI and is sent back to the nursing home. The internist ordering all these exams/tests isn't making any money of it (although the radiology department loves her no doubt). She thinks she's simply being thorough, the patient's advocate.

Maybe there's a smaller role also being played by the threat of malpractice/defensive medicine, but mainly this is an ontologic failure of our profession. What does it mean to be a good physician? Is it ever enough to tell a patient that there's nothing more to be done? These are not easy questions. The culture of medicine has become poisoned by low reimbursements, malpractice litigation, high med school costs, less time available for individual patients. Doctors feel the need to do do do, to intervene, to prescribe, to operate. All this scrambling around and following up on tests and procedures leaves little time for actual thought. We've stopped thinking. And that's the essence of what is wrong in places like McAllen. Fixing it won't be easy. The causes are multifactorial and complex. But we have to start by re-assessing the way doctors are trained and the ethics that are inculcated in them. There isn't always a solution to a patient's sufferings and we need to stop interpreting this unfortunate reality as a source of failure.

Dr Gawande's article, interesting in the investigative, gotcha! sense, has been seized upon by our intellectual elites in Washington DC as a diagnosis and remedy for what ails American healthcare. It oversimplifies the problem (the way physicians process disease, patient expectations, and ever changing medical knowledge/technology) as one of pure and simple physician greed. Every practicing physician in America ought to be both offended and horrified by such an insinuation. We can certainly do better. We need to work harder and think more about what we are doing, especially with respect to how small decisions made on the local level affect the big picture. But let us not cede the terms of debate to people like Peter Orszag and Atul Gawande. Our profession has been characterized by selflessness, integrity, and intellectual curiosity for over a hundred years. Let us not allow allegations of physician greed in a southwestern Texas town be the cause celebre that defines us professionally as we head into the 21st century...


MissFifi said...

Have you seen the recent articles in Time Magazine re: Cleveland Clinic and Mayo clinic and how they keep costs low?,8599,1905340,00.html

They do have a great plan, but of course, they lose money and may have to stop doing what has been working for so long.
Our government needs to read the following Japanese proverb: Fix the Problem, not the blame

ER's Mom said...

There is so much wrong in American healthcare from a money perspective. Teasing out causes is futile.

1. Patients come to us for dumb stuff. And they don't use the cost-effective ways: See my post from a few days back on a woman who went to L&D (garnering a hospital charge) for a stupid yeast infection.
2. We order many (too many?) tests. Is it from lack of thinking, CYA'ing, standard of care...probably a mix of those and other reasons that I haven't even thought about.
3. We, as a country, have failed miserably in deciding what is important to us - quantity or quality of life. Hence your story of the pancreatic cancer in a 90 y.o.

Lots of thought bubbling through...

Anonymous said...

Very quite well said.

Anonymous said...


Been lurking for a while now, I am a second career nursing student. Love your way of getting your thoughts out there. Just common sense, what it is. You don't feel the need to get all existential.

I can learn a lot from you.

Decided to work forward from your archives this summer. I had the opportunity to observe (too much) surgery tableside last semester. Unusual and lucky. I say too much because I really feel a little weepy now that I didn't decide a different path many years ago. Don't think I could work OR without getting my hands "in there." I had to keep them behind my back during one surgery where another pair was needed, that was ridiculously hard for me to do. I am a A&P girl. I worry that the whole time I'm on the floor, I'll be wondering what you all are doing downstairs.


Anonymous said...

As an American living in Germany and using the German medical system which is excellent and costs a lot less than the US, I can offer one example why the cost of care in the US is out of bounds. I have very close friends in West Chester, PA and the husband there is getting the exact same type of shots in his knee I am getting here. Cost in Germany is 70 euros. The cost in PA (for the uninsured) is $2500. A knee brace in PA is $2000 which his insurance refused to pay. Mine cost not even 50 euros. I had a long chat with my doctor here about this. He was outraged at the prices in the US and claims there is no good reason for it. Even if companies want to make a very good profit on their drugs because of research etc., $300 - $350 a shot should be tops according to him. $2500 is a rip off.

DKV said...

Maybe it's a lack of physician empowerment.

I know that's a new-age, overused word, but it's the best I could think of.

I know (ie, like a fact) that my clinical judgement isn't worth a damn. I know this because patients will demand their antibiotics, their ankle x-rays, even a second opinion (in the ER!), regardless of what I explain to them. I know that their customer satisfaction is important (Hello, Mr. Press-Gainey.) and that they won't be satisfied until they get what they want. I know that clinical judgement stands up a lot better in court if there are 1, 2, or 3 objective tests corroborating that judgement.

So I use come clinical judgement, and coat it with tests, like inch-thick icing on a child's birthday cake.

Expectations have to change.

Anonymous said...

selflessness, integrity, and intellectual curiosity for over a hundred years- also greed.

One question: if there is say 20 per cent unnecessary treatment and we eliminate it we will then have too many doctors?