September 2, 2012 - 7:37am
What We're Reading: A discussion on Atul Gawande's 'Big Med'
BY JENNIFER XU AND ZACH BERGSON AND YOSSI LICHTERMAN
“What We’re Reading” is a feature published every week in The Tangent, where Magazine Editor Jennifer Xu, Deputy Magazine Editor Zach Bergson and Editor in Chief Yossi Lichterman gather together to discuss a recent longform article and offer various perspectives on its issues. The Daily doesn’t just operate on a campus level, but also on a state and national level, so our hope is to stimulate some conversation on matters that concern the world outside of the University of Michigan.
This week we’re talking about Atul Gawande’s “Big Med,” which was published in the August 13 issue of The New Yorker. Gawande starts off the piece marveling at the efficiency of the vertically integrated Cheesecake Factory, and wonders whether such a system could be implemented within the health care arena. If a surgeon at Mayo Medical Center had perfected a particular method to operate on thyroid glands, then the new system would allow surgeons from all across the nation to learn his particular technique and spread it across a wide population of people, in addition to providing quality control, cost control and low variability in procedures.
Zach: I had ambivalent feelings towards this story. Initially I was really into it. Millions of people across the U.S. don't have access to affordable healthcare. In places like Mississippi and Alabama, the current healthcare system is a complete mess. If it was possible to standardize practices throughout the country, then maybe we could help those people in rural America who don't have the medical privileges that Northeasterners have.
But yesterday I went to Mount Sinai hospital in New York City to visit my Bubbie. My Zeyde (who's a professor at the medical school) and I started talking about the story and he brought up a couple of points that I didn't think about. Essentially, what he said was implementing a 'Cheesecake Factory’ system would turn many aspiring doctors away from the profession. Aspiring doctors want to be in the profession because there is a lot of freedom and room for innovation in the profession.
Jennifer: That’s the biggest thing I'm worried about, too – the innovation. The U.S. has distinguished itself as the leader of coming up with new therapies in regards to drugs and surgeries, and a lot of that has to do with doctors acting autonomously. So if that gets taken away, what are we really left with? Just a stagnant health care system that operates really well but never progresses.
Yossi: It seems to me that the progress and innovation he described though, for instance the virtual ICUs, came through this big medicine system.
Jennifer: Yossi, I think that's a good point. But the virtual ICU is an innovation that improves within the bounds of the current knowledge we're given. It was more to lessen mistakes. But, let's say I really wanted to discover a cure for cystic fibrosis. Currently, the average lifespan of a CF patient is something like 12 years. Even if we were more vigilant about standardizing the therapies, we'd maybe increase it by 1 year using ICU-like virtual technologies. In order to double the lifespan, you have to be really, truly innovative in order to get that dramatic of a change.
And that takes super smart doctors who can afford to think out of the box, independently, non Cheesecake Factorily.
Zach: If you implemented a system like Atul's, doctors would essentially be a glorified service professional. Which, by the way, goes against every American construction of a doctor.
Yossi: Jennifer, that's what I'm interested to hear from you. You're someone who wants to go into medicine, how would this approach impact your desire to go into the field?
Jennifer: Well, for me, the thing that scared me the most was that there's a learning curve with changing the way you do things. In order to change from one surgical technique to the other, lives are being lost in the process. You're killing a few patients in the meantime while you're trying to learn this new, possibly standardized method.
Zach: I also think there would be a lot of push back. And probably a lot of flight from the profession. Biology majors might steer clear of medical school and go into biotech.
Yossi: I still think there are a lot of appealing aspects to the system he describes ... lower costs, more efficient care. As a patient, that's what you want, right?
Zach: Can't we still have these great research hospitals, but also have hospitals that have standardization? The latter could serve most of the population.
Jennifer: OK, well, let's say we could implement this middle ground method. But with government being more involved in healthcare, I feel like the opposite will happen. The government is so slow and bureaucratic with implementing things. It seems like a standardized system will maybe lose the efficiency it means to implement.
Yossi: And don't forget all the political aspects as well. Implementing the Affordable Care Act was such a challenge, that any larger changes will be impossible in this environment.
Zach: There's also another thing to consider here that we haven't touched on yet. Malpractice suits. This topic was brought up in one of the letters to the editor this week. Basically, if we were to implement this system we would have to change how people sue for medical malpractice. Instead of suing an individual doctor, wouldn't they have to sue the medical provider? If the doctor is just a part of a homogenous system, the fault would have to lie on the system as a whole. This could actually help a lot of doctors out, who are currently paying thousands of dollars a year to cover malpractice insurance.
Yossi: And, if the reporter's system works, care will be better, so there will be fewer malpractice cases presumably.
Jennifer: Along with the fewer malpractice cases, I think the amount rewarded in courts for poor care will be higher. In the current environment, malpractice suits aren't typically won by patients because it's really difficult to suss out who was at fault and whether that was human error or just an inevitable outcome. However, if a patient under a standardized care system that sold itself as being literally infallible legitimately got sick or died, he'd have a real reason to sue. He’d get more money from a legal system and wouldn't be limited by the fact that doctors don't have billions and billions of dollars.
Zach: I see a barrage of class action suits in the near future haha.
Jennifer: It would all be very Erin Brockovich.
Yossi: Moving away from the legal aspects, I think it was pretty cool that UMHS got a shout out.
Jennifer: I liked that, the concept of a wider phenomenon of doctors working collaboratively with each other rather than autonomously. Doctors say they can do nothing in regards to lowering health care costs, but they can by ordering less overlapping tests. If a patient is sick and he sees two separate specialists, an internist and a cardiologist, and they're not talking to each other, it takes a lot longer for them to individually figure out what's wrong with you.
Yossi: That's what I liked about the UMHS system too.
Jennifer: I guess the question would be, ought this system be implemented for the "greater good?" It appears to be more of a patient benefit than a health care provider benefit.
Yossi: Isn't the point of healthcare to provide more of a benefit to patients though?
Zach: Actually, I think the only losers in this situation are the doctors. The patients get more affordable care. The healthcare providers become more efficient and cost-effective. But the doctors get stuck in this potentially innovation-stifling system.
Jennifer: Zach, was your grandpa totally against this sort of system?
Zach: Yeah, my Zeyde thought the story was ridiculous. Which I thought was kind of ironic considering his socialist tendencies.
Jennifer: The entire time I was reading it, I was like, dude, Atul Gawande is essentially eliminating the joys of his own job. He's a surgeon! Does he seriously want his "art" of medicine to become as automatic as grilling a steak at the Cheesecake Factory?
Zach The analogy is kind of nauseating. Do we want our doctors to feel like McDonalds employees?
Yossi: Frankly, the whole analogy made me hungry.
Jennifer: Yeah, more than anything it made me want to go the Cheesecake Factory.
Yossi: and there aren't any in Michigan!
DISCUSSION HAS BEEN CONDENSED AND EDITED.
