Atul Gawande might be the best medical writer ever. He is the best medical writer at The New Yorker, at least, and the best one I’ve ever read. He consistently writes clearly, thoughtfully, and originally about the big issues in medicine. That is why his recent article about health care costs (my comment here) and his graduation speech at the Univesity of Chicago are so telling. And not in a good way, I’m afraid.
The graduation speech starts off with an excellent story:
The program, however, had itself become starved—of money. It couldn’t afford the usual approach. The Sternins had to find different solutions with the resources at hand.
So this is what they decided to do. They went to villages in trouble and got the villagers to help them identify who among them had the best-nourished children—who among them had demonstrated what Jerry Sternin termed a “positive deviance” from the norm. The villagers then visited those mothers at home to see exactly what they were doing.
Just that was revolutionary. The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children’s mothers were breaking with the locally accepted wisdom in all sorts of ways—feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet-potato greens to the children’s rice despite its being considered a low-class food. The ideas spread and took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped sixty-five to eighty-five per cent in every village the Sternins had been to. Their program proved in fact more effective than outside experts were.
Bill Gates, Jeffrey Sachs, are you listening? Gawande goes on to say that to improve medicine, there needs to be the same sort of study of “positive deviants”. Here is his first example:
I recently heard from one such positive deviant. He is a physician here in Chicago. He’d invested in an imaging center with his colleagues. But they found they were losing money. They had a meeting about what to do just a few weeks ago. The answer, they realized, was to order more imaging for their patients—to push the indications where they could. When he realized what he was being drawn to do by the structure he was in, he pulled out. He lost money. He angered his partners. But it was the right thing to do.
No kidding. The contrast between mothers who figure out creative iconoclastic new ways to feed children on tiny amounts of money and a doctor who merely refuses to be a scumbag could hardly be greater. But Gawande uses the same term (“positive deviant”) for both! This is the depth to which a writer and thinker of Gawande’s stature has to descend, given the straitjacket of how he thinks about medicine. Gawande thinks that doctors will improve medicine. He’s wrong. Just as farmers didn’t invent tractors — nor any of the big improvements in farming — neither will doctors be responsible for any big improvements in American health. The big improvements will come from outside. I’m sure they will involve both (a) advances in prevention and (b) patients taking charge of their care.
When these innovations happen, where will doctors be? Helping spread them or defending the status quo? That’s what Gawande should be writing about. One big advance in patients taking charge was home blood glucose testing. It came from an engineer named Richard Bernstein. Best thing for diabetics since the discovery of insulin. Doctors opposed it. When I invented the Shangri-La Diet, and lost 30 pounds, my doctor didn’t ask how I lost all that weight. Not one question. Like all doctors, he had many fat patients; the notion that I, a mere patient, could know something that would help his other patients didn’t cross his mind. When I was a grad student I did acne experiments on myself that revealed that antibiotics (hugely prescribed for acne) didn’t work. My dermatologist appeared irritated that I had figured this out. That’s a little glimpse of how doctors may react to outside innovation involving patients taking charge. Of course doctors, like dentists, cannot do good prevention research.
If Gawande took the first story he told to heart, he might realize it is saying that the improvements to health care won’t come from doctors, just as the improvements to the health of those village children didn’t come from experts. As I said earlier, doing my best to channel Jane Jacobs, a reasonable health care policy would empower those who benefit from change. That’s what the village nutrition program did. It empowered mothers who were innovating.
Well said, Seth. Most doctors simply do not care and take any questions or suggestions made by the patient as an affront. It’s happened to me and family members many times – it’s happened to me on my blog in a discussion about statins: https://mangans.blogspot.com/2009/03/dont-take-statins-if-you-need.html
I do think that perhaps you overestimate the degree to which patients will take charge of their health. Many people simply don’t care, and others aren’t smart enough, the two categories overlapping of course.
Thanks, Dennis. I think you make a good point about patient inaction. My guess is that there is vast epidemic of subclinical depression and what to do about it is a different topic.
As an exercise, is there a way to test your three assertions historically? The three assertions are:
1) Doctors will not be the ones responsible for big improvements in American health, outsiders (non-doctors) will.
2) Big improvements in American health will involve advances in prevention.
3) Big improvements in American health will involve patients taking charge of their care.
By “test historically,” I mean: Can we look at the great health innovations of the past to see if they fit Seth’s three assertions? Here is one list of the greatest medical innovations in history:
https://www.infoplease.com/ipa/A0932661.html
I don’t know if it’s the best list but it’s probably pretty good. Just looking through it as a non-expert, I can see several examples of Seth’s premises in action, but also several counterexamples: of advances coming from within the medical establishment, of advances via treatment rather than prevention, and of advances that happened without patients taking charge of their care.
Seth, is there anything “special” about the specific diseases of American modernity (obesity and diabetes, asthma, allergies, depression, etc.) that leads you to believe that advances in them will come via your three assertions?
Being a doctor is a job like sniffing armpits (deodorant testing). The purpose is to sniff armpits but they do not care how the armpits smell. They do the job just to get paid. As soon as you give them $10 million, they will quit.
So why should the doctor care about your ideas. He just wants to do his job and get paid. Your ideas do not make that any easier for him. Give him $100 million and he will quit his job and do something that he wants to do like play golf.
Then approach him with a tip on how to play golf better and he will listen to you. “Money makes the world go round.” Many people do not believe in God, but they believe in money. Money did not exist for 3 million years and then they locked up the food and created the need for money.
Nadav, that’s an interesting question — the empirical support for my predictions. One is the vast improvement in health over the last 100-odd years. As many have concluded, it is unlikely to be due to advances in medicine. Another is the home testing example, an improvement in diabetes care much greater than anything doctors have come up with. Third is that those diseases you list are all much rarer in at least some poor countries — so they are “diseases of civilization” caused by lifestyle. Figuring out how lifestyle causes them — which doctors will never do — will pay enormous benefits. It’s true that doctors have pioneered a few important things, such as vaccinations. But that was long ago. See the movie First Do No Harm for an example of how doctors actively impede progress.
Thanks for your reply Seth.
I think you’re generally right: if civilization were to hold a “contest” to eliminate the chronic diseases of civilization, with one contestant the medical/pharmaceutical establishment and the other the Seth Roberts’ and Richard Bernsteins of the world, I would bet on the latter to produce better solutions at lower cost with fewer side effects. I think the internet will greatly help the latter also relative to the former.
But does that imply that the medical establishment should not be allowed to be a contestant at all? I don’t think so, for three reasons:
First, the medical establishment is a collective, made up of individuals. The word “maverick” describes an individual member of the establishment who comes to hold a view outside the establishment (which often results in excommunication), and many medical advances have been the results of mavericks: William Harvey was a maverick, as was Ignaz Semmelweiss.
Second, the medical establishment should be allowed to compete because sometimes it comes up with the best solution. I had my thyroid gland removed, and need synthetic thyroid, an invention of the medical establishment, in order to live. You and I, and perhaps the majority of college-educated Americans, suffer from an incurable disorder of unknown cause, that tends to get worse over time, and that untreated is crippling to one’s quality of life. It’s called nearsightedness, and the medical establishment has figured out a way to treat it in such a way that no one really thinks about it as a disease at all. I’m happy about that. Maybe one day a pharmaceutical company will discover a treatment for obesity that renders it as inconsequential as nearsightedness is today.
Third, the competition itself between the two contestants is healthy for society. Each side pushes (or should) the other, or at least embarrass the other, to improve solutions to problems.
Gawande is awesome. Great post
Seth, the doctors you encounter are, in every essential detail, not any different from your auto mechanic or the plumber who comes to your house. They learned a trade, and they’re executing what they learned. If they learn a few new tricks, they might be able to apply them, but they won’t mention them to others. Doctors, in particular, risk losing lawsuits if they depart in any substantive detail from what their competitors would have done. Of course they’re irritated to learn things they can’t use.
Improvements in automotive design and plumbing practice occur, when they do occur, outside your immediate circle, and they are overwhelmingly the work of engineers. Scientists — particularly social scientists — are taught to hate and fear engineers, but it is with engineers that practically all the improvements to details of modern life, where it does improve, originate. It is the same in medicine. In fact, it is often experienced engineers pursuing a second career in medicine who pioneer new procedures and practices. (E.g., read Gawande about changes to anesthesiology; or look up the leading hip replacement surgeon, working in Sacramento.)
Medical scientists work to understand biological processes, but there’s remarkably little prestige in applying such understanding to better patient care. That medicine does not recognize the role of the engineer is a crippling impediment to progress.