Another Side of Atul Gawande

I’ve been pretty hard on Dr. Atul Gawande over the years.

During the Obamacare deliberations he wrote an article in the New Yorker about McAllen, Texas  that became mandatory reading in the White House. It purported to show that for some unexplained reason McAllen had much higher costs than other locations in the United States. This was evidence, the White House said, that physicians are greedy and need to be controlled by bureaucrats. It was a poorly researched article that relied solely on Medicare data and failed to account for unique conditions in that city. As it turned out, when you include non-elderly spending, McAllen isn’t particularly costly and the area has an extreme shortage of physicians, so people tend to go to the emergency room instead.

A few years later he wrote another article in the New Yorker about how marvelously efficient the Cheesecake factory is, and bemoaning that American hospitals can’t do likewise. I posted some comments about how mistaken the analogy is on the NCPA Blog.

So I was prepared for the worst when I sat down to read his latest, an excerpt from his new book published in Slate. It was about end-of-life care, and after Zeke Emanuel’s writing about his determination to die at age 75, I expected to read more about how old folks aren’t worth spending a lot of money on.

In fact, the article is a moving and sympathetic telling of the case of one woman with metastatic ovarian cancer. She is a wonderful, cheerful 72-year old lady with profound problems. Gawande has many treatment options available to him, and he works with her to find the best match of what he can do with her own priorities – fears, hopes, level of comfort.

There are no sweeping generalities, no implicit policy prescriptions, no judgments about her. It is a love story between a caring physician and his patient. She is depicted as a whole person whose emotions are far more important than lab tests. I urge you to read the article for an example of medicine at its best.

This isn’t the first time I’ve encountered this phenomenon – a doctor who is wonderful with his patients who goes completely off the rails when it comes to public policy. Don Berwick is another. As I wrote in another NCPA post about a speech he gave at a graduation ceremony at Yale Medical School —

“Here is a lovely and loving man, someone who treasures the dignity of the people he cares for, who recognizes and honors their humanity and their sovereignty. How could this man be the same one who, as CMS Administrator, advocated locking physicians into an “evidence-based medicine” regimen that treats patients like mere statistics and confines personal knowledge of them to variables of age, race, and gender (like the Dartmouth Atlas does)? How could he push for the adoption of a program that assigns patients to an Accountable Care Organization without their knowledge or consent?”

I’ve written also about Berwick’s fine little book, “Escape Fire”  and been just as puzzled. For example, he writes –

“Interactions … begin with this assumption: The patient is the source of all control. We act only when the patient grants that privilege, each time.

“Control begins in the hands of the people we serve. If we caregivers wish to take it, we must ask. If a patient denies control, then we must accept their will as a matter of right. We are not hosts in our organizations so much as we are guests in our patients’ lives.”

These physicians are at their absolute best when they are dealing with actual patients. They are the epitome of health “care.” But once they sit down to write policy, they turn from Dr. Jekyll to Mr. Hyde. Which reminds me, one again, that for all the talk of Accountable Care Organizations, Bundled Payments, Interoperable Health Records, and Population Health Management, the essential, irreplaceable transaction in medicine is between one doctor and one patient. Nothing else comes close.