Cell 2 Soul: The Humane Health Care Blog

What Matters in the End

Krista Tippet’s conversation with Atul Gawande

You can listen to this extraordinary interview on the podcast On Being. It lasts about 50 minutes and addresses some of what Gawande addresses in his book “Being Mortal.“

Here are some highlights:

At medicine’s core is the directive that all people deserve the same type of attention by practitioners. Of course, this doesn’t happen. Our biases prevent this.

What does it mean to be a good doctor one for a given patient when you can’t help to fix them? How do you feel and what do you do when you actually have harmed a patient?

With regards to our patients, how can we give them agency to live a good life to the end? That may mean not promoting painful, expensive fruitless therapies.

Medicines goal is really to support a patient’s well-being. This can often mean that the patient will direct her own life.

One can actually ask a patient “What does a good day for you look like? What is the quality of life that you live for? Quality of life should not always be sacrificed for quantity of life.

A 2010 study* from MGH show that those stage four lung cancer patients who saw a palliative care specialist stopped chemotherapy sooner, entered hospice far earlier, experienced less suffering at the end of their lives – and they lived an average of 25% longer. In other words, our decision-making in medicine has failed so spectacularly that we have reached the point of actively inflicting harm on patients rather than confronting the subject of mortality.

So it’s important to find out what our patients goals are. Susan Block, a palliative care specialist, told him: "A family meeting is a procedure, and it requires no less skill and performing in operation."

A few years ago, I put some notes on Gawande’s book on Google Documents.

*Jennifer S Temel et. al. Early Palliative Care for Patients With Metastatic Non-Small-Cell Lung Cancer. NEJM , 363 (8), 733-42, 2010 Free Full Text

Is Healthcare a Right?

by Atul Gawande
New Yorker, October 2, 2017
Link

This is a timely and informative essay.

Gawande meets with some old friends in Athens, Ohio, where he grew up, to discuss their take on the question. It is kind of a trip down memory lane for him.

The meat of the essay comes about halfway through when he discusses the work of the Oxford political philosopher Henry Shue who postulates that basic rights include physical security, water, shelter, and health care. Meeting these basics is among governments highest purposes and priorities.

I think the goal should be security. No matter how bad things get this shouldn't be what you worry about, namely healthcare.
When people in a society get very different deals on things like healthcare, the pact with the government breaks down. That's what is happened with American healthcare.
The reasons go back to a seemingly innocuous decision made during the Second World War. In that time, the administration permitted increases in health insurance benefits and made them tax-deductible for employers. It didn't seem like a big thing at the time, but ever since we've been trying to figure out how to cover the vast portion of the country that doesn't have employer-based health insurance. Therefore, we had to stitch together different rules and systems for each of these categories and the result is an unholy expensive mess that leaves millions of people un- or under-protected. As a country, where pretty much everyone gets options like K – 12 schooling we've been reluctant to address the Second World War mistake and establish a basic system of healthcare coverage that's open for all. The prospects and costs of healthcare in America very wildly and incomprehensibly according to your job, your state, your age, your income, your marital status, your gender, and your medical history, not to mention your ability to read fine print.
Do we want?

• Medicare for all
• Each state to have its own plan for care
• A nationwide market place where we all choose among a selection of health plans
• Or personal accounts that we can use to pay directly for healthcare?

Any of these could work. Each has been made to work universally somewhere in the world.

As a country, we don't have any of these at this time. Gawande's article is a lucid introduction to this area, and worth reading and studying for healthcare providers, the public, and all students.

Overkill by Atul Gawande

The New Yorker, May 11, 2015  Free Full Text.

This is a long, but invaluable, introduction to the topics of over-diagnosis and over-treatment.  The Lown Institute has impressively addressed this topic for the past three years or so and a cadre of physician scientist and clinicians around the world have been interested in subject as well.  In his polished way, Gawande covers the issue for the lay and professional reader.  He asks:  What can we do about the avalanche of unnecessary medical care that is harming patients physically and financially.

Download Excerpts from Gawande's Overkill