Variation and cost

I’ve always enjoyed Atul Gawande’s essays, both in the format of his New Yorker articles as well as in his books. A former Rhodes scholar and presidential health care policy advisor, and now surgeon at the Brigham and Women’s Hospital in Boston, Gawande writes engagingly and persuasively about health care policy and quality.

As accomplished as Dr. Gawande may be, his most recent article in The New Yorker, “The Cost Conundrum,” has generated so much buzz that I wanted to point it out to all of you as an important and worthwhile read. For those of you with specific policy interests, I would also point you to the Health Affairs blog and a follow-up roundtable discussion with Bob Berenson, Elliott Fisher, Bob Galvin and Gail Wilensky.

In his article, Dr. Gawande describes his visit to the town of McAllen, Texas, which comes to symbolize — through his colorful anecdotes and insightful analysis — everything that is wrong with current health care in America. He talks about the profit incentives that encourage overuse of health care in McAllen and says that more care is not necessarily better care. One of my favorite analogies from the article comes when he reflects, “Providing health care is like building a house. The task requires experts, expensive equipment and materials, and a huge amount of coordination. Imagine that instead of paying a contractor to pull a team together and keep them on track, you paid an electrician for every outlet he recommends, a plumber for every faucet, and a carpenter for every cabinet. Would you be surprised if you got a house with a thousand outlets, faucets and cabinets, at three times the cost you expected, and the whole thing fell apart a couple of years later?”

As the policy commentators in the Health Affairs blog point out, the issues that Dr. Gawande points out aren’t new, so it’s interesting to see how much traction this article has gotten (It was forwarded to me by several different friends within a few days of publication, and the town of McAllen is one of the most talked about places in the U.S. Congress these days). I think that part of it has to do with the urgency in Dr. Gawande’s words and the disturbing ethical implications he raises in the midst of a national debate about health care reform. As he writes, “… we are witnessing a battle for the soul of American medicine. Somewhere in the United States at this moment, a patient with chest pain or a tumor or a cough is seeing a doctor. And the damning question we have to ask is whether the doctor is set up to meet the needs of the patient, first and foremost, or to maximize revenue.”

There will be some uncomfortable questions that will continue to come up in the wake of this article, questions about how medicine has evolved in the year 2009 and how faithfully we, as a profession of doctors, are fulfilling our Hippocratic Oaths. Sometimes, though, critical self-reflection can lead us to an important opportunity for growth.