Tag Archives: Atul Gawande

  

Innovations in India’s Health Care

After reading this Bloomberg article, Heart Surgery in India for $1,583 Costs $106,385 in U.S., I couldn’t resist thinking about the end of Atul Gawande’s book, “Better: A Surgeon’s Notes on Performance“…cost comparisons to India inevitably bring up discussions along the lines of, “Well, just how good can their health care be?” Certainly, it’s hard to think of apples to apples metrics that would allow us to compare quality of care between the U.S. and India due to selection bias: patients in India who are able to go through heart surgery (and pay for it) may have a different health profile than the average American who undergoes that treatment.

Still, Gawande’s closing chapter in “Better” argues that even in relatively poor conditions, real, industry-changing innovation can occur due to necessity. In this final chapter, Gawande describes spending time in India as a visiting surgeon to see how innovative medical care was possible in comparatively squalid circumstances. The Nanded hospital he describes below serves 1,400 villages, about 2.3 million people, with just 9 surgeons (Gawande says that’d be comparable to the state of Kansas having 9 surgeons):

Among the many distressing things I saw in Nanded, one was the incredible numbers of patients with perforated ulcers. In my eight years of surgical training, I had seen only one patient with an ulcer so severe that the stomach’s acid had eroded a hole in the intestine. But Nanded is in a part of the country where people eat intensely hot chili peppers, and patients arrived almost nightly with the condition, usually in severe pain and going into shock after the hours of delay involved in traveling from their villages.

The only treatment at that point is surgical. A surgeon must take the patient to the operating room urgently, make a slash down the middle of the abdomen, wash out all the bilious and infected fluid, find the hole in the duodenum, and repair it. This is a big and traumatic operation, and often these patients were in no condition to survive it. So Motewar did a remarkable thing. He invented a new operation: a laparoscopic repair of the ulcerous perforation, using quarter-inch incisions and taking an average of forty-five minutes.

When I later told colleagues at home about the operation, they were incredulous. It did not seem possible. Motewar, however, had mulled over the ulcer problem off and on for years and became convinced he could devise a better treatment. His department was able to obtain some older laparoscopic equipment inexpensively. An assistant was made personally responsible for keeping it clean and in working order. And over time, Motewar carefully worked out his technique.

I saw him do the operation, and it was elegant and swift. He even did a randomized trial, which he presented at a conference and which revealed the operation to have fewer complications and a far more rapid recovery than the standard procedure. In that remote, dust-covered town in Maharashtra, Motewar and his colleagues had become among the most proficient ulcer surgeons in the world.

BTW, I whole-heartedly recommend Gawande’s “Better”, written in 2008. It extends upon his previous work, Checklist Manifesto, which was best known in its New Yorker incarnation.

  

Is Solitary Confinement Torture? From Atul Gawande and the New Yorker

Punishment Cells

Punishment Cells. From: Page 257 of part II of Vlas Mikhailovich Doroshevich «Sakhalin (Katorga)», Moscow. Sytin publisher, 1905.

Thanks to longform.org for spotlighting another thought-provoking piece by Dr. Atul Gawande in the New Yorker. The tag line is: Hellhole: The United States holds tens of thousands of inmates in long-term solitary confinement. Is this torture?

Dr. Gawande’s reporting builds a strong case for “Yes.” Some interesting bullet points:

  • America holds at least 25,000 inmates in solitary confinement in Supermax prisons
  • More than a century ago, the U.S. Supreme Court considered banning solitary confinement
  • A 2003 analysis of Arizona, Illinois, and Minnesota found that levels of inmate-on-inmate violence were unchanged after their supermax prisons opened
  • The state of Maine has more inmates in long-term solitary than does all of England

Supermax prisons and the long-term isolation of large numbers of inmates, Dr. Gawande notes, is only a decades-old concept in the American prison system. However, in the 1890 SCOTUS case, Medley vs. U.S., the court takes note of a solitary confinement system in Philadelphia back in 1787. The conditions and consequences, noted more than two centuries ago, aren’t much different than what Dr. Gawande describes today:

The peculiarities of this system were the complete isolation of the prisoner from all human society, and his confinement in a cell of considerable size, so arranged that he had no direct intercourse with or sight of any human being and no employment or instruction….

A considerable number of the prisoners fell, after even a short confinement, into a semi-fatuous condition, from which it was next to impossible to arouse them, and others became violently insane; others still committed suicide, while those who stood the ordeal better were not generally reformed, and in most cases did not recover sufficient mental activity to be of any subsequent service to the community.

It became evident that some changes must be made in the system, and the separate system was originated by the Philadelphia Society for Ameliorating the Miseries of Public Prisons, founded in 1787.

Following the standard journalistic narrative, Dr. Gawande leads with his best anecdote and ends with his second-best. The entire piece is a must read, but the last anecdote is particularly astonishing. Gawande describes the case of Robert Felton, who spent 14 years of his 36 years on earth in solitary confinement. The isolation drove him crazy, Gawande writes, and Felton tried so many times to set his cell on fire with a lightbulb that “the walls of his cell were black with soot.”

Gawande writes about one of his last meetings with Felton. Felton had just found out the prison director who kept him in solitary confinement had just been convicted of bribery (from lobbyists, a sidestory that would probably illuminate why America holds on to certain prison strategies regardless of effect) and sentenced to two years in prison:

“Two years in prison,” Felton marvelled. “He could end up right where I used to be.”

I asked him, “If he wrote to you, asking if you would release him from solitary, what would you do?”

Felton didn’t hesitate for a second. “If he wrote to me to let him out, I’d let him out,” he said.

This surprised me. I expected anger, vindictiveness, a desire for retribution. “You’d let him out?” I said.

“I’d let him out,” he said, and he put his fork down to make the point. “I wouldn’t wish solitary confinement on anybody. Not even him.”

Read Dr. Gawande’s story in the New Yorker.

  

“Letting Go” – The New Yorker’s Atul Gawande, on giving up life to live

Trinity Church Cemetery

Trinity Church Cemetery

Dr. Atul Gawande’s latest New Yorker piece is described as another examination on on what’s behind the cost of health care, but it serves more as a lesson on how to both cope with the finality of death and to appreciate life.

It took me several times to get through it, and luckily I wore my sunglasses in the subway so I wouldn’t look like some snob getting teary-eyed over his iPad.

The opening (and ultimately, closing anecdote) is about an ill-fated patient of Dr. Gawande’s, a Sara Thomas Monopoli, who discovers she has incurable cancer 39 weeks into her first pregnancy. Dr. Gawande describes Monopoli’s long struggle to stay alive, with taking a series of experimental drugs with harsh side effects; at one point, she hides the fact that she’s lost feeling in her hands and had double vision for two months, for fear her treatment would be stopped.

Gawande’s sprawling piece ends up being kind of a travelogue of his journey of accepting death for his patients. He believes, as do most people, that hospice care is meant to hasten death, even though at least one survey of terminal cancer patients found that those who elected for intensive care had similar survived no longer than those who entered hospice care.

As Gawande puts it:

Curiously, hospice care seemed to extend survival for some patients; those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months. The lesson seems almost Zen: you live longer only when you stop trying to live longer.

Gawande relates this to the current health care crisis by pointing out a 2004 Aetna study in which policyholders expected to die within a year could choose hospice services and have all the other treatments. The hospice care was so appealing, apparently, that these patients spent far less time in hospitals and ICUs, even though they didn’t have to give up any options. Costs fell by nearly 25%

The benefits of accepting fate are not just monetary. Gawande writes that by many objective metrics, patients who seriously discussed end-of-life care ended up suffering less:

Two-thirds of the terminal-cancer patients in the Coping with Cancer study reported having had no discussion with their doctors about their goals for end-of-life care, despite being, on average, just four months from death. But the third who did were far less likely to undergo cardiopulmonary resuscitation or be put on a ventilator or end up in an intensive-care unit. Two-thirds enrolled in hospice. These patients suffered less, were physically more capable, and were better able, for a longer period, to interact with others. Moreover, six months after the patients died their family members were much less likely to experience persistent major depression.

In other words, people who had substantive discussions with their doctor about their end-of-life preferences were far more likely to die at peace and in control of their situation, and to spare their family anguish.

I can’t think of many other journalists who I respect more than Dr. Gawande. Besides having incredible eloquence as a writer, he’s a respected professional in the field he covers. His book “Complications,” nearly made me quit journalism to try med school – it was that fascinating of a look into how terrifying, yet intellectually challenging, it would be to be an ER surgeon – until I realized it would be a long, uphill slog for someone who never took a college level biology class.

Atul Gawande

Atul Gawande

Gawande has had at least two other notable pieces. One, related to the subject of “Complications,” was how a checklist consisting of steps as simple as reminding doctors to wash their hands was saving a staggering number of patients from post-surgical infections. And the second, about how one town in Texas managed to have the highest, by far, health care costs per capita. The article reportedly caught President Obama’s eye during the health care overhaul.

Both are instructive essays on the complexity of health care. “Letting Go” is less so, perhaps because there are no cost-benefit studies that would convince either death-panel-fearing-Tea-partiers or an insurance-company-demonizers that the health care system would ever be right to compel a patient to give up treatment.

But as a collection of tragic anecdotes, “Letting Go” really shook me and at least made me remember to appreciate what’s good in life. Maybe that’s Gawande’s ulterior strategy all along, to convince the reader to place enjoying life over prolonging it, and by doing so, maybe, get both.

—

Another New Yorker piece (h/t/ longform.org), written in 2001 by Gary Greenberg, also examines the moving line between life and death, and in particular, how where the line is drawn has been influenced by the demand for organs. With the concept of “brain death”, organs can be retrieved in a more viable state, as opposed to waiting until the heart stops beating. But doctors and ethicists (I assume today, as well as in 2001) are still arguing about the different kinds of brain death, and even those who accept it, they still have to train themselves to think of a warm, breathing body as “dead”:

“It took us years to get the public to understand what brain death was,” [Howard M. Nathan, who heads an organ-procurement group] said. “We had to train people in how to talk about it. Not that they’re brain dead, but they’re dead: ‘What you see is the machine artificially keeping the body alive . . .’ “ He stopped and pointed to my notebook. “No, don’t even use that. Say ‘keeping the organs functioning.’ “

And if you’ve got even more time to spend reading life-or-death longform pieces, I’ll pitch this 13,000-word Pulitzer-winning piece by my ProPublica colleague, Sheri Fink. The subject is how doctors at a New Orleans hospital may have been to quick to euthanize a group of patients while desperately waiting for rescue after Katrina.

The overarching theme, as it is in the New Yorker articles mentioned here, is what makes a life worth living/saving, and can doctors make that decision when patients can’t?

Gawande:

“Is she dying?” one of the sisters asked me. I didn’t know how to answer the question. I wasn’t even sure what the word “dying” meant anymore. In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die.

Greenberg:

He wanted to show that the higher-brain rationale, which holds that living without consciousness is not really living—and which the President’s commission rejected because it raised questions about quality of life which science can never settle—was the sub-rosa justification for deciding to call a brain-dead person dead. He wanted to make it clear that these doctors were not making a straightforward medical judgment but, rather, a moral judgment that people like Matthew were so devastated that they had lost their claim on existence.

Fink:

According to Memorial workers on the second floor, about a dozen patients who were designated as “3’s” [a triage category for patients thought to be close to death] remained in the lobby by the A.T.M. Other Memorial patients were being evacuated with help from volunteers and medical staff, including Bryant King. Around noon, King told me, he saw Anna Pou holding a handful of syringes and telling a patient near the A.T.M., “I’m going to give you something to make you feel better.” King remembered an earlier conversation with a colleague who, after speaking with Mulderick and Pou, asked him what he thought of hastening patients’ deaths. That was not a doctor’s job, he replied. Patients were hot and uncomfortable, and a few might be terminally ill, but he didn’t think they were in the kind of pain that calls for sedation, let alone mercy killing. When he saw Pou with the syringes, he assumed she was doing just that and said to anyone within earshot: “I’m getting out of here. This is crazy!” King grabbed his bag and stormed downstairs to get on a boat.