Dr. Atul Gawande: Teams at heart of better care

jprice@newsobserver.comMay 11, 2014 


Dr. Atul Gawande told UNC-Chapel Hill grads to believe in something bigger than themselves.

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— Dr. Atul Gawande received widespread attention after The New Yorker published his 2009 article about two Texas towns that were starkly different from each other in heath care costs and the culture of their medical communities.

In one, a culture of profit-making led doctors to over-treat patients. In the other, costs were significantly lower because the doctors worked more as teams when treating a patient and focused more on quality of care than money.

The clarity with which Gawande described the issues involved has made the article almost required reading for anyone working to solve the nation’s health care problems. That includes North Carolina doctors and politicians, and President Barack Obama, who cited the article as he pushed Congress to pass health care reform legislation.

Gawande, an associate professor at the Harvard University medical and public health schools and director of the World Health Organization’s program to reduce surgical deaths, was interviewed briefly after his UNC-Chapel Hill commencement address on Sunday. The interview has been edited for clarity and length.

Q: Your story on the Texas towns was in 2009. Five years later, how are we as a nation doing with the health care system?

A: We’ve come through this very contentious time, but we have embraced the idea that people belong in this health care system and the tenor of debate has really shifted. So, it’s no longer about whether we’re getting people in, it’s about how we get people in.

And that’s a tremendous shift. So where we are is about how you make it work, both how you make coverage work and be sustainable and how you make the system work, because the reality of our care is that as people encounter the health system who didn’t have insurance or who had it all long. We’re watching health care take away money for education – it’s the biggest competitor for the entire state budget – watching it take money out of people’s wallets and paychecks and creating debt at the national level.

The terrain has shifted so that now we’re in a place where we understand more is not better, and that spending more does not equal better care. We’re suddenly discovering that the 5 percent sickest patients account for half of our health care costs, and that the system doesn’t work for the sickest and the people with the greatest suffering.

A 20-minute office visit doesn’t work when you have five different problems and more than 10 different medications. Neither does the emergency room and neither does the hospital.

You really need a team of people who help you move through all of the needs that you have. And across the country, we’re watching health systems transform themselves into helping the people who are the sickest rather than just the people you can churn in and out of your office quickly.

I can tell you from a doctor’s point of view, it can be painful. We’re going through enormous changes. But it also connects you to many of the reasons why we went into medicine in the first place, which is being able help people, no matter how sick they are.

Q: I’m not sure all of your colleagues went into medicine solely with that motivation. Do you get pushback from doctors who say, “This is going to cost us?”

A: Absolutely. But I would say the biggest source of pushback and struggle, especially from colleagues, is less about the cost. It’s a new thing for us to suddenly be asked about our responsibility for costs. And that’s a source of both frustration and empowerment for some of my colleagues.

Second, we’ve moved to a place where so much knowledge and the skills are required that you can’t do it all yourself, and you really have to do this as teams. And that is a real struggle for many of my colleagues.

I find that the medical students graduating today, some of the residents and others, they’re completely at home in a world where they have to work with others to round out the care you’re trying to deliver. That wasn’t the case half a century ago, or even two decades ago. You were valued for how smart you were, how good your hands were.

Q: That’s the cowboy-versus-pit-crew metaphor you used in the Texas story.

A: Absolutely. You’re still seeing surveys with doctors saying “If I had known it was going to be like this I wouldn’t have gone into this profession.” And yet we’re having more applicants to medical school per seat than we have in decades.

Q: Where are some of the places this pit-crew approach is springing up?

A: It is in every state. You’re seeing primary care innovators pulling together, you know, people call it the medical home, but to me it’s the team ensuring that you’ve got the primary care that people have always thought about and talked about. It’s been enormously successful all over the country in reducing the likelihood that people end up in an emergency room or hospital.

A lot of this has been at places that were already on the lower end of the cost curve. So you see around the country enormous growth of these kinds of places in both coasts and along the upper Midwest, but in the lower Midwest and in the South, you have incredible pioneers. You have a number of great examples across Arkansas, and I know you have folks here in this Research Triangle area who have been creating teams.

I’m from a rural area in Ohio and our little county, the poorest in Ohio, has become a leader in creating services that go beyond what the doctor does, like they would take a health care worker, it doesn’t even have to be a nurse, who is kind of like a coach, and would come in and try to get everyone on a doctor’s panel to quit smoking and that has enormous consequences for health. A 20-minute doctor’s office visit doesn’t do that much. But a weekly touching base, trying to get you in, get this done, that has … we just wouldn’t have invested in that, even though it saves huge amounts of money and improves quality.

We haven’t figured out how to get the specialists there yet. It’s just starting to happen in some places, and the biggest chunk of the medical dollar is still on things like surgical procedures and non-surgical procedures like catheterization. And we’re only catching up to where that primary care change has started.

Q: Why are you still practicing? On the surface, that wouldn’t seem to be the highest and best use of your skill set.

A: It’s mostly selfish reasons, honestly. It’s my least stressful day of my week, being in an operating room, when there’s no email, no phone calls and you’re just doing one thing. And ironically, in the operating room, I can do it and 98 times out of 100 it’s gone right –a 2 percent complication rate. Anything else in daily life is actually not that predictable. That’s one.

The second part of it is, it’s a reality check. Every time I think I have explained the world and what we have to do, you meet another patient and it’s always more complicated than you think. You see how you’re making forward progress, but you also see all the things you didn’t think of.

Q: A lot of what you do is taking complex things and simplifying. Is there a process you go through to start burning through the fat and simplifying?

A: It’s always an invention process. So it starts with discovery. I never quite know whether it will turn out to be a piece of writing or research, or something that becomes a big project we have to carry out with a group of people, or a policy matter.

I’ll take a problem that we’re tackling now: Why are C-section procedures going through the roof? The most common procedure in the country now is a C-section. More than 35 percent of women who have delivery, it’s by C-section. And if you make a map of the country, the likelihood of having a C-section, depending on where you are, is from 7 to 70 percent.

So, my method is dig in deep, learn as much as I can, talk to lots of people, and maybe it’s going to become something I write about because it needs that kind of creative understanding. Maybe it turns out to be, as this case has turned out, an experiment, there isn’t enough information, people are guessing what the problem is. And so you don’t have a story to tell yet.

If so, one of my colleagues who is an obstetrician has decided well, let’s try gathering a bunch of data then trying some experiments. What’s the difference between a place at 10 percent versus 60? Is it the people? What is it?

It may become a whole project. We have a project in South Carolina trying to see if we can lower the surgical death rate following what came out (after) the book I wrote about using basic processes in health care.

It’s almost like a follow-on from the book.

This is a partnership between the (nonprofit) laboratory I have, the South Carolina Hospital Association, and it has been under way for about three years. We’ve also spent a little over a year partnering with the North Carolina hospital association bringing that here.

Some of the questions about health care can be answered by policy and things that people do in state legislatures and Washington. This stuff, how are you going to get the C-section rate down? How are you going to make it so that primary care really works? How are you going to take what we know already saves lives in surgery and make it work at a whole state level? I don’t think it’s really about whether you pass one law versus another law. It’s about building a professional culture, incentives and a system that comes together and works.

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