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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.