Medical Failures, and Successes Too: A Q&A With Atul Gawande

As I’ve written before, I am a big fan of the writing of Atul Gawande, a surgeon who also happens to be a wonderful writer. His current book is called Better: A Surgeon’s Notes on Performance. Between his operating and his writing, he also found time to answer this Q&A we sent him. After you read this, go read his book.

Q: What do you think are the most intractable problems in medicine today?

A: Intractable problems come in two flavors. There are failures due to scientific ignorance (lack of knowledge), and failures to use the knowledge we have (ineptitude). Two of the most intractable failures of ignorance are how to deal effectively with chronic pain — one of the most common complaints people come to doctors with — and how to treat diseases of the immune system (not just HIV but also conditions like multiple sclerosis, some types of diabetes, and rheumatoid arthritis). Still, to me the most depressing are the failures to consistently use discoveries we’ve already made — and leading my list are our failures to wash our hands consistently and prevent the rampant spread of hospital infections (which kill an estimated 90,000 Americans each year), to reliably getting patients hospitalized with pneumonia (the country’s No. 1 killer) the correct antibiotic and in a timely way. We’re only now beginning to realize that reliable performance doesn’t just happen in medicine. It is extremely difficult. And success requires work and innovation.

Q: One of the most compelling articles incorporated into Better deals with the evolution of obstetrics. In the piece, you discuss how forceps were invented but kept secret within a single family of obstetricians. How many lives do you think were lost because of that failure to share new technology? Are there any similar instances today of failure to share such technology?

A: It was more than a century that the Chamberlens kept forceps under wraps. And obstructed labor — a baby that won’t come out — was among the most common causes of newborn and maternal death. It had to have been millions of lives lost. Millions. But are there similar instances of technological advancements being kept secret? No. It’s almost impossible to keep a technology secret nowadays. The reason technological advancements nonetheless fail to get out today is much more complex. First, there’s our inability to move quickly to put proven advancements into daily practice here at home (because medicine still regards itself as mainly a craft rather than an industry). Second, for poor and middle income countries, costs and patents have kept them from receiving newly discovered, life saving technologies. (One example is the HPV vaccine — which would prevent 70% of cervical cancers, the No. 1 cancer killer of women globally, but is still without a global distribution plan.)

Q: What’s your longterm view on a cure for cancer?

A: Well, there won’t be one cure. Cancer is in fact many diseases: a breast cancer is not the same as a skin cancer is not the same as a cervical cancer. So there will be many cures and the breakthroughs will come incrementally. We now cure 70% of cancers. I suspect we will gradually push that number upward through a combination of better prevention (the HPV vaccine is just one example), better treatments for specific cancers, and better detection of cancers when they are small and most easily cured.

Q: How has the growth of online medical advice affected the economics of medicine?

A: I’d be curious to see if medical advice websites are indeed having an effect on the economics — because day-to-day in the clinic, I just don’t see it. People are more likely to come in better informed. They may have Googled me, too. But I don’t think there’s nearly enough information to help them make genuine economic choices. One possible exception is the category of drug company websites, which are part of the companies’ marketing effort to get patients to make specific brand requests of their doctors. Overall, that does appears to be working. [N.B.: read this earlier discussion of direct-to-consumer advertisements.]

Q: Presumably, an informed patient is better than an ignorant one; if so, do these sites truly help patients become better informed?

A: I absolutely believe an informed patient is better than an ignorant one. Is there a lot of misinformation on the web? Yes. Does it bother me? No. Most people, I find, are aware that they can’t believe everything they read on the Internet and nonetheless manage to turn up at least some information useful to them. And it’s generally not that hard to disabuse people of genuinely bad ideas they picked up surfing. The biggest complaint I hear is that available information is generally only an inch deep.


lermit

Good picture. Such style should work for your next joint book!

.lermit

frankenduf

nice posting- I wonder if the doc thinks that medicine will become more democratized (open access to info and collaborative judgements), as health care reform is headed towards financial socialization

kurtthorsten

We all ought to become e-patients and our own healthcare providers. Nice post.

Kurt
http://www.ideasforsurgery.com

Peeved Michelle

Thank you for linking to Dr. Gawande's obstetrics article in the past. I have about a month left in my pregnancy and reading that article early on really helped me to feel better about the use of medical intervention during labor and delivery, and to understand the all the different things that can happen during that time. It also provided me with a response to those who like to say things like, "Women have been having babies naturally for thousands of year. I don't see why it is so complicated now." I usually just tell them the horrifying fact that blue babies, who can now be resuscitated and go on to live normal, healthy lives, were left for dead before the institution of the Apgar score.

bryn

I've been having my own medical experience recently, and I've been thinking a lot about politics, economics, and medicine on a very personal level. Here's the whole story, but the short version is that I don't see how anyone can become a medical consumer on a financial basis, since there are no incentives that get back to the doctor from the patient along financial lines.
Doctors have financial incentives from their clinics and parent hospitals, from medical insurance companies, from medical malpractice suits and malpractice insurance companies, and least of all from their actual patients. The path of financial recompense from the patient to the doctor has got to be the most complicated path out there. You pay whether you get good service or not, and you can't get a refund for ineptitude unless you sue. You can't even get an apology (it's easier to get money than to get an apology or admission of wrongdoing).

Read more...

William Peters

Atul Gawande's writings are so fresh and crystal clear, so infused with morality. It seems that year by year space between what is wrong and right in medicine grows a darker shade of grey. Gawande is willing to place himself in that grey zone with an ethical mind and reexamine conventional practices. Most importantly, he has the courage to say when they need revising.

john ferguson, m.d.

he's not so brilliant....large scale handwashing increses in icu's in a recent study did not have any effect on transmission of nosocomial infection...huge study by authors that expected to find the dogmatic finding of the opposite....this week a diabetes study arm in a an nih study that was to have its blood sugar optimized to normal was stopped early because the patients made "normal" died sooner...huge study..authors expected to find opposite and so did the drug companies who its all about anyway.....lancet in 1999 showed that "optimizing" cholesterol in the elderly leads to increased death....so why do so many old people still take zocor?? $$$$$.....besides statins do in most studies lead to decresed death from cardiovascular disease, but its matched by an increased rate of death in many other causes including most notably cancer...so choose what you want to die of, but keep the $$$$ coming>>>>this is just to show you that no matter how brilliant a doctor you are, everything you are saying is going to be wrong including this guys pontificating about how hand washing will dramatically decrease deaths or injury in the hospital is wrong...dead wrong even though even you can't believe it either...but look it up study just came out......dr's are b.s. salesman for the pharmaceutical industry...how do i know...i am a doctor myself...US educated all the way and i have seen nothing but disappointment in knowledge, intellect, integrity from my fellow so called educated cohorts. my advice to you is don't put doctors on pedestals and beware of the therapies they try to sell you. within 10 years almost all current thought on chronic medical problems and therapies will be considered suboptimal at best and downright dangerous in many, remember prempro for postmenopausal women?? less than 10 years ago considered standard of care, now considered high risk.

Read more...

John Blanton

You have an error in SuperFreakonomics regarding obstetrical forceps. You describe forceps as a device to turn a breach presentation into a vertex presentation. Forceps are used to deliver the head of a baby -- either vertex or breach -- when labor is slowed or stopped because of the head. The head may be stuck, facing up instead of down. The pelvis may be small. The mother may be exhausted and labor not progressing. Or there may be signs of fetal distress, with forceps used to hasten delivery.
There are obstetrical manuevers to convert a breach to a vertex (or to convert one kind of breach to one more conducive to easier delivery. There is no role for forceps in conversion of a breach to a vertex presentation.
I agree with you about Semmelweiss. I have taught students (including my astrophysicist son as a child) his story as an example of the scientific method ignored by mainstream science for decades.
Lastly, love your books. Can't wait for "Supercalafragilistic Megafreakonomics".
--John E. Blanton, M. D., FAAFP

Read more...

lermit

Good picture. Such style should work for your next joint book!

.lermit

frankenduf

nice posting- I wonder if the doc thinks that medicine will become more democratized (open access to info and collaborative judgements), as health care reform is headed towards financial socialization

kurtthorsten

We all ought to become e-patients and our own healthcare providers. Nice post.

Kurt
http://www.ideasforsurgery.com

Peeved Michelle

Thank you for linking to Dr. Gawande's obstetrics article in the past. I have about a month left in my pregnancy and reading that article early on really helped me to feel better about the use of medical intervention during labor and delivery, and to understand the all the different things that can happen during that time. It also provided me with a response to those who like to say things like, "Women have been having babies naturally for thousands of year. I don't see why it is so complicated now." I usually just tell them the horrifying fact that blue babies, who can now be resuscitated and go on to live normal, healthy lives, were left for dead before the institution of the Apgar score.

bryn

I've been having my own medical experience recently, and I've been thinking a lot about politics, economics, and medicine on a very personal level. Here's the whole story, but the short version is that I don't see how anyone can become a medical consumer on a financial basis, since there are no incentives that get back to the doctor from the patient along financial lines.
Doctors have financial incentives from their clinics and parent hospitals, from medical insurance companies, from medical malpractice suits and malpractice insurance companies, and least of all from their actual patients. The path of financial recompense from the patient to the doctor has got to be the most complicated path out there. You pay whether you get good service or not, and you can't get a refund for ineptitude unless you sue. You can't even get an apology (it's easier to get money than to get an apology or admission of wrongdoing).

Read more...

William Peters

Atul Gawande's writings are so fresh and crystal clear, so infused with morality. It seems that year by year space between what is wrong and right in medicine grows a darker shade of grey. Gawande is willing to place himself in that grey zone with an ethical mind and reexamine conventional practices. Most importantly, he has the courage to say when they need revising.

john ferguson, m.d.

he's not so brilliant....large scale handwashing increses in icu's in a recent study did not have any effect on transmission of nosocomial infection...huge study by authors that expected to find the dogmatic finding of the opposite....this week a diabetes study arm in a an nih study that was to have its blood sugar optimized to normal was stopped early because the patients made "normal" died sooner...huge study..authors expected to find opposite and so did the drug companies who its all about anyway.....lancet in 1999 showed that "optimizing" cholesterol in the elderly leads to increased death....so why do so many old people still take zocor?? $$$$$.....besides statins do in most studies lead to decresed death from cardiovascular disease, but its matched by an increased rate of death in many other causes including most notably cancer...so choose what you want to die of, but keep the $$$$ coming>>>>this is just to show you that no matter how brilliant a doctor you are, everything you are saying is going to be wrong including this guys pontificating about how hand washing will dramatically decrease deaths or injury in the hospital is wrong...dead wrong even though even you can't believe it either...but look it up study just came out......dr's are b.s. salesman for the pharmaceutical industry...how do i know...i am a doctor myself...US educated all the way and i have seen nothing but disappointment in knowledge, intellect, integrity from my fellow so called educated cohorts. my advice to you is don't put doctors on pedestals and beware of the therapies they try to sell you. within 10 years almost all current thought on chronic medical problems and therapies will be considered suboptimal at best and downright dangerous in many, remember prempro for postmenopausal women?? less than 10 years ago considered standard of care, now considered high risk.

Read more...

John Blanton

You have an error in SuperFreakonomics regarding obstetrical forceps. You describe forceps as a device to turn a breach presentation into a vertex presentation. Forceps are used to deliver the head of a baby -- either vertex or breach -- when labor is slowed or stopped because of the head. The head may be stuck, facing up instead of down. The pelvis may be small. The mother may be exhausted and labor not progressing. Or there may be signs of fetal distress, with forceps used to hasten delivery.
There are obstetrical manuevers to convert a breach to a vertex (or to convert one kind of breach to one more conducive to easier delivery. There is no role for forceps in conversion of a breach to a vertex presentation.
I agree with you about Semmelweiss. I have taught students (including my astrophysicist son as a child) his story as an example of the scientific method ignored by mainstream science for decades.
Lastly, love your books. Can't wait for "Supercalafragilistic Megafreakonomics".
--John E. Blanton, M. D., FAAFP

Read more...