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May 4, 2018

Gawande: Health care is 'a freaking mess' and progress is an 'uphill battle'—but here's how we can do better

Daily Briefing

    Atul Gawande, a public health researcher and cancer surgeon, in a recent episode of Freakonomics Radio discussed why progress in the medical field can be an "uphill battle" and how simple solutions have the potential to improve health care delivery.

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    Why medical progress takes time

    When asked by Freakonomics' host Stephen Dubner why "good ideas often take a really long time to catch on in medicine," Gawande said the delay largely stems from the "difference between a visible and immediate effect … and … invisible delayed effects."

    As an example, he compared the difference between the health care industry's adoption of two transformational discoveries in the 19th century: anesthesia and antisepsis. According to Gawande, within two months discovering anesthesia, physicians across European capitals started to use it—even though news at the time was delivered "by boat and horse"—and, within six years, every U.S. hospitals was delivering anesthesia. In contrast, Gawande said, a "generation" after Joseph Lister discovered that antiseptic solutions used in conjunction with hand washing and instrument cleaning cut infections by 80%, not even "half of the profession [is] doing it."

    Why the difference? Gawande said anesthesia produced immediate and clear benefits for patients and physicians—resulting in a "win-win" scenario, whereas Lister's antiseptic solution, which was a carbolic acid, did not produce instant or obvious benefits. "Antisepsis was literally pain now for gain later," Gawande explained, adding, "You had to regulate it; you had to make hospitals do it. You had to change the culture of surgery to be antiseptic, and even today we still have to fight the uphill battle and figure out ways to make it easier to do the right thing."

    In a modern-day example, Gawande pointed to Viagra, which had an "immediate and visible effect" for patients and physicians, and nearly immediately became widespread. In comparison, the surgery checklist—which cut the mortality rate at hospitals by 22%, when compared with hospitals that did not use the list—has been "harder to sell." The checklist involves "making an investment now for a gain later for … problems which are often not immediately visible to people," Gawande said.

    How the US health care system can make "substantial" progress

    But Gawande said the U.S. health care system can realize substantial gains in improving health care delivery and reducing problems in the medical field, such as medical errors.

    For instance, Gawande in the episode recounted a time when he spoke to a manager at the Cheesecake Factory about how the manager would approach health care industry. The manager said he would learn what works best, find a way to make those strategies replicable, and examine performance to determine what improvements could be made—a straightforward strategy that has facilitated the restaurant chain's success at quality control, cost control, and innovation.

    While "the level of complexity and difficulty" is on a "whole [o]ther level" for hospitals, the health care industry can "make substantial progress" by breaking down the elements of health care and adopting a "Cheesecake Factory-like" approach toward standardization, Gawande said. There are certain health care encounters that everyone experiences "at one point or another," Gawande explained, such as birth, ED use, and end-of-life decisions.

    According to Gawande, figuring out how to make each process "work better" involves "breaking it down that way and recognizing you might need different payment models, different innovation for each of them," essentially asking the Cheesecake Factory-like questions, "'What are the best people doing? How do I distill that into a manageable recipe and enable it for as many people as possible?'"

    Health care ultimately progressing, Gawande says

    The health care industry, and particularly health insurance, is "a freaking mess," Gawande said—but he's hopeful "on the whole." For instance, he pointed out that "even in the short time that I've gotten to be a clinician—it's been about 14 years that I've been practicing as a surgeon—during that time, we've cut the number of uninsured by half." He continued, "It's not perfect, but a lot of our work in surgery—for example my field—we have cut the death rate by 30 to 40% in the time that I've been doing this work."

    He concluded, "So I've seen these things happen. I've gotten to participate in some of it, and there's a lot of continued problems we've got to work on. There are really big deals and big opportunities, but it’s not like we have failed to make progress. We've been moving the ball down the road" (Dubner, Freakonomics, 4/25).

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