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A Health Care Reform Revelation

UPDATE: Ashleigh Burroughs, who blogs at The Burrow, has added her photo to the Where Elders Blog feature. You can see it here, and you can add yours too. Instructions are here.

category_bug_politics.gif 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


If I can get myself together, I will read the essay. I need to be bouyed at the prospect that the health care reform bill is not as bad as I think it is. Though I wonder how many of our esteemed Congressional representatives will read or even understand the essay and the continued need for health care reform.

I am glad to read your thoughts on this and a positive light ahead possibly. I won't have time to read the bill until I get back from Arizona... actually not until January; but am glad someone is doing it and analyzing it :)

Thank you for showing us this essay Ronni!

I printed out the essay and plan to read it later today. Your mentioning Stephen Jay Gould has prompted me to look for a program(s) I taped quite some time ago when he was part of a discussion group and the main reason for the taping.

What is striking about Gawande's perspective -- and what I think is true -- is that he assumes "they want to provide good care ..." At least most primary care physicians and nurses do. They want to get paid, but they also want to do well by patients.

We lose track of that at our peril. There are pure sharks in all this -- I think that applies to the whole private profit insurance industry.

But professionalism and a desire to give good service are also real forces that our economic understanding doesn't capture, yet which can serve as forces within a social context. If all this experimentation brings them more to the fore in a group of people who already have a high quotient of them, it will help a lot.

Just some thoughts.

I read Dr. Gawanda's essay on my Kindle last week (I'm a subscriber and incidentally, I think that the New Yorker is one of the best things left in print}
Gawanda's essay was thoughtful and the most optimistic treatment of HCR (Health Care Reform) I've come across to date.
It does not get our President off the hook for his "dithering, shillyshalling" and the total lack of passion and commitment he has exhibited relating to this issue so far. Perhaps, sometime in the future, we will realize that we finally got Health Care Reform - in spite of the efforts of Barack Obama.
So it could be a long time before our broken system is fixed but maybe (just maybe) my grandchildren (the younger ones anyway) will have a decent system for the delivery of health care services by the time their children are born.
Light at the end of the tunnel?
Maybe. We shall see.

It's a great essay and it gives you plenty to think about...unfortunately, I thought about the HUGE farm support bills that are routinely passed and signed every five years without a thought to their content. And of course I was frustrated by the fact that the medical community finds it so hard to move into the 21st century with electronic data. I came from the construction industry and we started this fifteen years ago when we saw the inevitable. When I retired, a copy of every single piece of paper we generated or received was accessible instantly on our PC's. Today, I have to beg the doctor for my records and then he gives them to me on a CD! What? Oh, and he charges me $20.
Okay, I'm cynical and I find that helps these days, but I still found that the essay gave me some hope. As did your post!

Hi Ronnie,

I read this essay in the New Yorker a few months ago and I was non-nonplussed by a system designed to test more, profit more and the taxpayers be damned.

If you would like to expand your range of physician/writers (and if you don't already know him) try Abraham Verghese's, "Another Country," a superb account of his experiences dealing with the newly discovered AIDS crisis in Appalachia during the 1980's. He is a superb writer and storyteller. His last book, a novel, "Cutting for Stone," is a huge sprawling work set in Ethiopia and the U.S., focusing on twin doctors who were the illegitimate sons of an Indian nun and British physician. Verghese's use of language and his story telling abilities are pure joy--as are his characters.

Both Gawanda and Verghese manage skillfully to put a human face on medicine, its practice, practitioners and patients. They should be required reading for all our legislators who hold the key to our future health.



Ronni--Like you, I was somewhat taken aback by what I (as a subscriber to the on-paper version of The New Yorker) read when Dr Gawanda's piece was published. It made me less pessimistic about the process we see being followed in The Congress. Thanks for your thoughtful attention to the piece.

Thank you for the link. Thank you for the hope.

I've been reading Gawande's writings for several years, intending to review some additional books of his I've read not mentioned here, but just haven't gotten to it.

I did write a piece about one of his articles within the past year but disappointingly hadn't noted any other references in other blogs I read giving him much, if any, attention. Am glad to see more attention being focused on his writings and knowing about the piece you mentioned here as I've gotten behind on my reading, so will be sure to take time for this one. Thanks!

To clarify a couple of points in the comments, the essay from which I've quoted is not from months ago - it was published last week.

And aside from a new book from Dr. Gawande which will be published next week, he has written no others but the two I mention above.

No harm - I'm sure it's just too much information in our lives to track correctly.

These are the books to which I refer as mentioned in his bio:

"In 2006, he received the MacArthur Award for his research and writing. His book COMPLICATIONS: A SURGEON'S NOTES ON AN IMPERFECT SCIENCE was a finalist for the National Book Award in 2002 and is published in more than a hundred countries. He was editor of THE BEST AMERICAN SCIENCE WRITING 2006. His most recent book, BETTER: A SURGEON'S NOTES ON PERFORMANCE is a New York Times bestseller and one of Amazon.com's ten best books of 2007."

Many thanks. Your post and the comments mention three mainstays of my bookshelf: Gould, Thomas and Verghese, but more importantly steered me to a new name (Gawande), who I heard for the first time on NPR in the last few days.

(OK, Ronni. Ease my pain here. Should I have said "whom I heard...?")

Thanks for the shout out, Ronni. I do love TGB!

The 30 minutes the geriatrician spent with my 86 year old mother and me, holding her hand and looking into our eyes as we discussed her end of life desires and clarified her decisions was the most impressive doctor/patient interaction I've ever had. Listening to our elected representatives diminish this experience by calling it a "death panel" made my blood boil. To think that this kind and generous man received no reimbursement for his time because there is no Medicare Code...... it's just wrong.

Thanks for the reading list; I'm off to the library in the morning.

Must of read the post naming the books much too fast when I wrote my comment above. They're really very good.

Hope they do something about healthcare soon.

good posts. Healthcare reform has it's goods and bads.

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