According to Gawande, Systematizing the Right Care Is Key to Advancing Health

June 22, 2018

A day after making headlines as he was announced CEO of the new joint healthcare company formed by Amazon, Berkshire Hathaway, and JPMorgan Chase, Atul Gawande, MD, took the stage at the America's Health Insurance Plans Institute & Expo to deliver a talk on the importance of thoughtful care, particularly at the end of life, and how it can be incorporated into a better healthcare system.

A day after making headlines as he was announced CEO of the new joint healthcare company formed by Amazon, Berkshire Hathaway, and JPMorgan Chase, Atul Gawande, MD, took the stage at the America's Health Insurance Plans (AHIP) Institute & Expo to deliver a talk on the importance of thoughtful care, particularly at the end of life, and how it can be incorporated into a better healthcare system.

Currently, Gawande is a general and endocrine surgeon at Brigham and Women’s Hospital and professor of surgery at Harvard T.H. Chan School of Public Health and Harvard Medical School, as well as being a prolific author and speaker. He told the AHIP audience that across his whole career, and with the multiple hats he wears, he’s been driven by the mission of seeing a pathway to a better care system than the top-down approaches in place now.

To illustrate, he told a story about his mom fainting in the grocery store, then receiving a barrage of unnecessary testing that could have been avoided if any of the doctors had asked about her day: she had not been drinking enough water and had recently raised the dosage of her diuretic pills. This focus on diagnosing and performing procedures, instead of listening to patients, can have consequences far more serious than the wasteful use of low-value care. Gawande also conveyed the story of a friend’s father, who was in poor health and advised by his care team to undergo 2 operations in hopes of preventing a stroke or heart attack years down the road—even though the operations had upfront risks. However, he had a stroke after the cardiac surgery, leaving him unable to eat or walk and he died 6 months later.

According to an essay by 2 philosophers that had inspired Gawande early in his career, there are 2 causes of failure: ignorance and ineptitude. Although scientific breakthroughs and discoveries have helped overcome ignorance and increase life expectancy over the past century, we still often fail at execution. Gawande called the present day a “pivot point in history, in that ineptitude—lack of execution—has become as important in our lives as ignorance.” With the thousands of procedures and drugs currently available, the job of physicians has become to “deploy that capability town by town to everybody alive,” which he considers “the most ambitious thing human beings have ever attempted.”

How can health systems deliver the best possible outcomes and performance? Gawande posited that the answer lies beyond education, incentives, or mandates, but instead with systematizing best practices so they become the norm and “ultimately, making the right care the easy thing to do.” He and his colleagues have attempted that approach through the use of checklists in operating rooms, which has shown positive results, but they believe that those kinds of solutions are needed in every part of medicine.

The need for systematization is especially clear in cases of serious life-limiting illness, as Gawande has learned from interviewing multitudes of palliative care providers and the patients who are facing the end of life. He’s learned that people have priorities besides survival that make up their quality of life and reasons for living, but because physicians don’t ask these questions, the care they provide is not in alignment with patients’ priorities.

To elicit a better understanding of patients’ joys and fears, Gawande thinks that practitioners need to transform from being technicians, who present treatment options and risk-benefit profiles, to being counselors, who listen to each patient’s goals and make recommendations based on those priorities. Furthermore, asking those questions and tracking the answers is important not just at the end of life, but across the entire lifespan as people accumulate chronic disease.

“System science and innovation is the next massive major opportunity to advance human well-being and health,” Gawande concluded. “Our bottom line is going to be to imagine the lives that are worth living for us, follow how we’re doing against it, and then drive our medical capability to enable it.”

Perhaps, inevitably, after Gawande finished his talk, the conversation drifted to his new job, as moderator Susan Dentzer, president and CEO of the Network for Excellence in Health Innovation, asked him what he personally hopes to accomplish in that role. He replied that he feels “incredibly lucky” to get a million new patients of all ages whose jobs range from warehouse workers to bank tellers, and despite their differences, they each need solutions. He hopes he can be part of the process during which we, as a society, “generate scalable solutions that change the practice of medicine. It’s a long road, but clearly it’s possible; there’s that much gain available.”