Gawande: 'Heroic' medicine isn't enough

Long-term, incremental care is undervalued, he says

Editor's note: This popular story from the Daily Briefing's archives was republished on July 23, 2019.

The health care system rewards "heroic" care—like the surgeon who gives a patient a new heart—while undervaluing "incremental" care, such as the long-term management of chronic conditions, to the detriment of overall health, Atul Gawande writes in The New Yorker.

10 imperatives for primary care today

Gawande, a renowned Brigham and Women's Hospital surgeon, author, researcher, and now CEO of Haven, the Amazon-Berkshire Hathaway- JP Morgan joint venture, has firsthand experience with the drama of the OR. Patients are cut open, their wounds are fixed, or an organ is removed, and frequently patients' lives are saved. This, Gawande says, is "heroic" care, and it's what most people see as the true miracle of modern medicine.

By comparison, primary-care medicine seems "squishy and uncertain," Gawande writes. Getting patients to take their medication, show up for annual physicals, manage their weight, or adapt to long-term chronic conditions such as diabetes, isn't exciting—and these efforts require patience.

But the evidence that access to primary care improves long-term health outcomes is decisive, Gawande notes. For instance, multiple studies have found that areas with higher rates of primary care physicians have lower rates of general mortality, infant mortality, and mortality from common conditions such as heart disease.

And other studies have found that "people with a primary-care physician as their usual source of care [have] lower subsequent five-year mortality rates than others, regardless of their initial health."

Incremental care in action

Gawande visited a Boston-area clinic run by his colleague Asaf Bitton, an expert on primary care, to see the value of long-term, incremental care firsthand.

The clinic was small but busy. "At any given moment, [clinicians] might be suturing a laceration, lancing an abscess, aspirating a gouty joint, biopsying a suspicious skin lesion, managing a bipolar-disorder crisis … or stabilizing a patient who'd had an asthma attack," Gawande writes. "Asaf and his colleagues can deliver on-the-spot care for hundreds of conditions and guidance for thousands more. They run a medical general store."

But Asaf told Gawande the real value of the clinic came from long-term, relationship-based care. It was a place where front-desk staff knew patients by name and some patients had seen the same doctor for years.  

These long-term relationships improve care in several ways, Gawande explains. For instance, studies show that patients are less likely to delay care if have a trusting, familiar relationship with their doctors, which improves patients' health outcomes. And doctors are free to take an incremental, methodical, and long-term approach to treating their patients.

In fact, some doctors at the clinic told Gawande that learning to wait was an important part of being a primary care doctor. "Most of the time people will get better on their own, without intervention or extensive workup," Katherine Rose, a physician, told Gawande. "And, if they don't get better, then usually more clues to the diagnosis will emerge, and the steps will be clearer."

Primary care doctors and other "incrementalists," such as non-interventional cardiologists, "focus on the course of a person's health over time," Gawande writes. They develop a comprehensive but evolving picture of their patients' health and use it to provide personalized and preventive care.

Picking the right priorities

Despite the enormous benefits of incremental care, the health care system consistently favors heroic care, Gawande says. For instance, a 2016 survey shows that orthopedic surgeons and other interventionists earn significantly more than family medicine doctors or internists.

And heroic care can typically draw on more resources. "As an American surgeon, I have a battalion of people and millions of dollars of equipment on hand when I arrive in my operating room," Gawande writes, adding, "Incrementalists are lucky if they can hire a nurse."

Gawande says this mismatch in resources "is not just shortsighted—it's immoral." For instance, he writes that "more than a quarter of Americans and Europeans who die before the age of 75 would not have died so soon if they'd received appropriate medical care for their conditions, most of which were chronic."

But there are signs that things are starting to change, Gawande writes. More sources of information now help providers predict "health and well-being over time." These resources, from genomics to remote monitoring, are shifting the focus of health care from high-cost, episodic care to long-term, incremental, and personalized care, Gawande argues.

"In this era of advancing information, it will become evident that, for everyone, life is a preexisting condition waiting to happen," Gawande writes. This poses "a problem for our health care system," which "doesn't put great value on care that takes time to pay off," Gawande says.

But it also presents an opportunity "to transform the course of our lives" by "discovering the heroism of the incremental." According to Gawande, "That means not only continuing our work to make sure everyone has health insurance but also accelerating efforts begun under health reform to restructure the way we deliver and pay for health care."

"We can give up an antiquated set of priorities and shift our focus from rescue medicine to lifelong incremental care," Gawande concludes. "Or we can leave millions of people to suffer and die from conditions that, increasingly, can be predicted and managed. This isn’t a bloodless policy choice; it’s a medical emergency" (Gawande, New Yorker, 1/23).

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