Because he thinks in stories, Atul Gawande – surgeon, author, professor – started a recent lecture about the costs and failures of the country's healthcare system with a story about a middle-aged car mechanic in Alabama.
The man had been suffering from severe abdominal pain every time he ate and had lost 25 pounds over a couple of months. He needed care for a swollen ankle, but didn't have the money or insurance. His condition worsened. Eventually his bowel ruptured.
"Would it matter to you that I saw him in a district hospital in India or in Amman, Jordan?" Gawande asked. "In fact, where I saw him was in Boston, where he had arrived as an insurance refugee," Gawande said.
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As Gawande tells it, because Massachusetts has universal healthcare, the car mechanic from Alabama eventually received care, but not when it should have been rendered and at a much higher cost than if he had been treated at the start of his illness.
"Every country is struggling with healthcare and how to afford it," Gawande said, speaking at the 96th Scientific Assembly and Annual Meeting of the Radiological Society of North America last month in Chicago.
"I'm honored and a little bit embarrassed to be here – a surgeon among radiologists," he told his audience.
Gawande is affiliated with Brigham and Women's Hospital and Dana-Farber Cancer Institute in Boston. He is a staff writer for The New Yorker and the best-selling author of three books on healthcare, including The Checklist Manifesto. He teaches at Harvard Medical School and the Harvard School of Public Health and serves as director of the World Health Organization's Global Challenge for Safer Surgical Care.
Gawande is used to asking questions, he said, but also has some answers. His checklist, for example, has proven to help provide better and safer patient care while saving money.
But he doesn't have the answer to fix what ails the U.S. healthcare system. He admits to "bafflement."
In the United States, he said, 40 percent of the population doesn't receive healthcare. It would be easy to blame government, the insurance companies or litigation. "But at the root of what makes it hard to do what we do day to day is complexity," he said.
"We have identified 13,600 ways to make people's lives better (he bases this on the number of ICD-9 codes), 6,000 drugs and 4,000 medical procedures. What we are attempting to do now is to deploy these capabilities town by town to every human being alive ... and it's turning out to be hard. We don't know how to do it. We're in need of a science to understand how to deal with our knowledge."
"We are closing in on 20 percent of our entire economy to pay for healthcare. We in medicine hear this. We hear it with some bafflement," Gawande said.
He said the bell curves for quality and cost don't match. Often, the hospitals and physicians who spend less prove to be more effective.
Training doctors longer or applying more technology don't seem to be the answer, he said. Antibiotics given on time, and making sure everyone in the room knows everybody's name, seemed to hold possibility.
And so was born the checklist – inspired by the airlines.
Focusing on small improvements can make a big difference, as Gawande's checklist has proven. It has been tested in eight hospitals in the world, from the richest to the poorest. "In every hospital, the complication rates fell," he said.
"If this were a drug, I'd be a multi-billionaire," he said.
In the past month, the Department of Veterans Affairs reported that using the checklist resulted in an 18 percent reduction in deaths.
Even as successes are achieved, "efforts to provide a basic human need are beginning to sap our energy," Gawande said.
"Systems innovation will save more lives," he said. The battle "is for the soul of medicine."