Monday, 14 December 2009
A Health Care Reform Revelation
Through many years, I have maintained a minor fetish for physician/essayists. Since about 1970, the number of books on my shelves from these men (they happen to all be men) who maintain two demanding careers, has expanded to scores.
It began, I think, with Richard Selzer, a Yale surgeon, who has written with clarity, compassion and humor through a dozen books about the body, its parts and the destruction various forces inflict on it.
Lewis Thomas, who died in 1993, held so many important medical positions it is hard to imagine how he also had time to write. The Lives of a Cell: Notes of a Biology Watcher is imaginative, bursting with information and like Selzer, witty too. In Late Night Thoughts on Listening to Mahler's Ninth Symphony, Lewis, as usual, covered an eclectic range of topics – alchemy, speech, the Pentagon, the brain and more.
The most well known of medical/science essayists is, of course Stephen Jay Gould who was a biologist, geologist and historian, not a physician. He entertained and educated millions of us from The Panda's Thumb to The Flamingo's Smile and many others before he died in 2002.
[You don't really need to know all that, but I like thinking about these writers who have enlightened and entertained me for so many years in ways that would not have happened without them.]
A new generation of physician/essayists has emerged and my favorite is Atul Gawande, a general surgeon in Boston (which does not begin to explain his accomplishments and credentials) who began writing medical essays at the instigation of his friend and Slate editor, Jacob Weisberg.
So far, there are two collections, Complications: A Surgeon's Notes on an Imperfect Science and Better: A Surgeon's Notes on Performance. For the past decade, Gawande has also been a staff writer at The New Yorker where he often writes about our health care system and when I see his name in the table of contents, I usually drop whatever I'm doing to read him.
Last week, in a remarkable essay in that magazine, he took on the Senate health care reform bill, comparing it favorably to the solution to America's agricultural crisis at the beginning of the 20th century.
”Only by improving the productivity of farming could we raise our standard of living and emerge as an industrial power,” he writes...
“The agricultural system was fragmented and disorganized, and ignored evidence showing how things could be done better...laissez faire had not worked...
“Government was enlisted to help millions of farmers change the way they worked. The approach succeeded almost shockingly well. [emphasis added]
Gawande uses the example of Seaman Knapp, an extension agent for the United States Department of Agriculture (USDA) who began the government's experiment in modernizing farming with just one farmer. Knapp gave the farmer, Walter C. Porter, a list of changes and techniques to improve his crop: better soil preparation and plowing, better seed, fertilizer and cultivation which Porter had never done before.
“...at the end of the season, Porter reported a substantial increase in profit, clearing an extra seven hundred dollars.”
The next year, the USDA dispatched 33 more agents to set up similar pilot farms throughout the country. Word of the success of these experiments grew among farmers and by 1920, there were 7,000 federal extension agents throughout the then-48 states.
The USDA created other initiatives: comparative-effectiveness research, tracking the origin of various blights, created hybrid varieties, new kinds of fertilizers and mechanization, a weather forecasting system, a food-grading system to discourage substandard quality and more as, through the years, these innovations arrived. And, importantly, by way of radio stations and print reports, the agency created an effective method of providing all this information to farmers in a timely manner.
“What seemed like a hodgepodge (of programs) eventually cohered into a whole,” writes Gawande. “The government never took over agriculture, but the government didn't leave it alone either. It shaped a feedback loop of experiment and learning and encouragement for farmers across the country.
“The results were beyond what anyone could have imagined. Productivity went way up, outpacing that of other Western countries. Prices fell by half...
“This could not happen by fiat. There was no one-time fix. The same goes for reforming the health-care system so that it serves the country's needs.
Gawande then explains how health care in the U.S. is as inefficient, diffuse and disconnected as farming was a hundred years ago. In our current system, he says, the country's thousands of hospitals, clinics, pharmacies, drug companies, device manufacturers, home-health agencies and individual physicians each pursues its individual interests with, overall, terrible outcomes.
“...it rewards doing more over doing right, it increases paperwork and the duplication of efforts, and it discourages clinicians from working together for the best possible results. Knowledge diffuses too slowly. Our information systems are primitive. The malpractice system is wasteful and counterproductive. And the best way to fix all this is – well, plenty of people have plenty of ideas. It's just that nobody knows for sure.”
As with farming, trial and error are what will improve the system, says Gawande, and that is what the Senate reform bill provides - dozens of programs that “would test various ways to curb costs and increase quality.”
“...hundreds of pages of these programs, almost all of which appear in the House bill as well, but the Senate reform package goes a few USDA-like steps further. It creates a center to generate innovations in paying for and organizing care...in the end, it contains a test of almost every approach that leading health care experts have suggested.”
In addition to mounds of commentary, I have actually read – well, skimmed a good deal – the 2,000-plus pages of the Senate reform bill. (By the way, those 2,000 pages are not really all that much reading; there are only about 15 to 20 lines per page.) What I didn't appreciate, before reading this essay, is what a vast undertaking it is and how good the bill might actually be – if understood with Dr. Gawande's comparison.
I, like virtually everyone, including all the media and the 100 senators who are for and against the bill, have concentrated only on the most simplistic aspects - cost, competition, public option and the sideshows of abortion and socialism attacks – rather than the complex whole.
If Dr. Gawande is correct in his comparison to agriculture in the early 20th century, the members of the Senate Finance Committee, who wrote this extensive bill (and let's not forget the scores of anonymous Senate aides who do much of the research and work) are to be congratulated in giving us a comprehensive starting point of “pilot programs” as Gawande calls them.
How could I have thought, as expressed in all the previous stories on reform here, that we could get a bill that would need only a few tweaks down the line. The problem is so much bigger than that.
I urge you to read this essay. It transformed my thinking on health care reform and gives me the first real hope for success, as lengthy and, sometimes, unfair it will be until we get it right.
”...if we're willing to accept an arduous, messy, and continuous process we can come to grips with a problem even of this immensity,” writes Gawande at the end. “We've done it before.”
At The Elder Storytelling Place today, Jeanne Waite Follett: Breakfast at Tiff... I Mean, Pablo's