Surgeons Nuland And Gawande Look To The Future Of Medicine
Surgeons Nuland And Gawande Look To The Future Of Medicine
As the Affordable Care Act rolls out and technology changes certain procedures, the role of doctors continues to shift. As part of TOTN's "Looking Ahead" series, Dr. Sherwin Nuland and Dr. Atul Gawande discuss the future of the practice and profession of medicine.
NEAL CONAN, HOST:
This is TALK OF THE NATION. I'm Neal Conan in Washington. Of the many programs we've aired over the years on medicine, none has been more interesting than the series of conversations with Sherwin Nuland and Atul Gawande, both surgeons and teachers. Both have also gone public as writers on their profession both to inform the public about what they do and why and how it's changing and to speak with their colleagues about what works and what doesn't.
We're taking advantage of our series Looking Ahead to ask them back. We'd also like to hear from doctors in our audience today. What is changing? What works, and what doesn't? 800-989-825(ph). Email firstname.lastname@example.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION.
Later in the program, Jason Osder on his documentary on a standoff that ended after the Philadelphia Police Department dropped a bomb that would eventually kill 11 men, women and children, "Let the Fire Burn." But first we're joined by Dr. Sherwin Nuland, professor of medicine at Yale School of Medicine, author most recently of "The Soul of Medicine: Tales from the Bedside." He joins us from studios at Yale. Welcome back.
SHERWIN NULAND: Well, it's a pleasure, Neal, thanks.
CONAN: And Dr. Atul Gawande, surgeon at Brigham and Women's Hospital, author of "A Surgeon's Notes on Performance," who is with us from studios at the hospital there in Boston. Good to have you back, as well.
ATUL GAWANDE: Thank you, Neal, thanks for having me on.
CONAN: And Dr. Nuland, let's start with you. I wonder, as you sit - at this - from this vantage point, what interests you the most about the profession?
NULAND: Oh my. It's fun. Can you imagine anything more rewarding than the opportunity to help people who are desperately in need because of sickness, to help their families for example, to see that something has changed because of a set of maneuvers or thoughts or whatever it may be that you yourself have carried out?
We're all looking for self-esteem, and perhaps I shouldn't admit this, but I don't know a group of people in general, men or women, who have more reason for self-esteem than those who have had the privilege of being able to help others, whether individually or in large groups.
CONAN: Dr. Gawande, let me ask you the same question.
GAWANDE: Well, it's interesting. You know I'm at that mid-stage in my career, and I feel like the work is the most meaningful that people can do. And we're also struggling, though, with what it means to be really good at this work in our profession. So our struggle is now over the fact that the complexity of the volume of knowledge we're dealing with, the skills we have to have, the number of specialists that we interact with have made it so we're transitioning from understanding how we have always thrived as cowboys, but now we're trying to become teams. We're trying to become parts of pit crews, and it chafes sometimes. That part of it is a struggle.
CONAN: I've learned that cowboys work together very well as a team. So it's a slander, sir.
CONAN: But anyway, the issue, as you look forward, though, to working in teams, Dr. Nuland, it was much easier when you started out to have command over large swaths of specialty.
NULAND: Well, that's true. For example my own training in surgery involved learning how to treat the heart, how to treat the lungs surgically, how to treat the contents of the abdomen and the contents of abdominal and chest wall. Well, we've become so super-specialized that we now have the intestinal tract divided into about three or four parts that different people - different people treat.
This is fascinating because at the same time as this is happening, and Atul was implying this, too, and you were, we are trying to learn how to work in teams in the sense that all members of the team may not carry that MD after their names because there are many diagnostic and therapeutic maneuvers that can be carried out just as well by people with perhaps a less rigorous kind of training.
And I'm thinking about physicians' assistants. I'm thinking about nurses who have had a special type of training so that we call them nurse practitioners. We are beginning to learn that the right way to give medical care is a team, but it's not a bunch of cowboys going out together all on the same kind of pinto pony. It's a team where the responsibilities are divided based largely on what each person can contribute with the leader, of course, of the team being the one most educated in physiology and pathology, and that will always be the doctor.
CONAN: And do you wonder if cowboys use surgical metaphors? I don't know. Anyway...
CONAN: Dr. Gawande, as you look at this, it is not only that these teams are expanding. The costs of using different kinds of people as costs become such a big focus of how we think about medicine now.
GAWANDE: Yeah, you know, the interesting thing is we're discovering in the last couple decades that there's a bell curve. There is a wide difference in the results that different places provide for the same operation or the same kind of diagnoses depending on where you go. There's also a big difference in the costs. And the curves don't match. The most expensive places are not the places that get the best results. Often they're among the least expensive.
And when we look at what the positive deviants do, they are often places that look more like systems of care, like teams that work together. Just a little story, my mother had knee surgery last year. It went beautifully well. She spent three days in the hospital. I sat with her. I'm kind of bored sitting around, so I just start counting the number of nametags that come in the room and make a decision for her care or touch her and are crucial to the success of her care.
And I counted 63 people. Those people can't be cowboys. If they don't work together, it's incredibly expensive, things go wrong. But when they work together, it's pretty amazing. And, you know, I'll take exception a little bit with what Dr. Nuland had to say. There were times when it was clear the best person wasn't necessarily the orthopedist in charge in order to get her the best care, make sure she was rehabilitating well, make sure she was getting out and strengthening. It is a passing range of responsibility and leadership, and I think that's where some of our pain at the change comes in.
NULAND: I think we're saying very much the same thing. This is in fact what we've come to, the realization that these kinds of teams do not require the head man to carry out every one of the therapeutic maneuvers that are involved in recovery that these can be very well done by other people. And its manpower, its cost, all sorts of considerations make this easily the better way to go.
CONAN: If that's one thing that is working, what isn't? What worries you, Dr. Nuland?
NULAND: Oh, what worries me, of course you can imagine what I'm going to say. It has to do with the increased technological emphasis in medicine with the increasing gap between the emotional and spiritual needs of the patient and what the world of medicine is able to provide. The more technological we are, and in fact the more scientific we are, the more we look for objective criteria.
Medicine, I believe, by its very nature is not objective, and it is not a science. It is an art that requires science in order to carry out its work most efficiently. One obviously has to know all the cutting-edge science. But at the same time, this seems to come - and it comes in education, too, of doctors - seems to come at the sacrifice of something that perhaps patients may need as much as they do the technology, namely that human touch that serves in many ways for a lot of people as a placebo, in fact, that helps them recover.
CONAN: Dr. Gawande, is that what concerns you the most?
GAWANDE: Yeah, it's interesting, you know, the question is why is it still so hard to provide humanity along the way. You know, conversation and in the course of how decisions are made, what people really are needing and wanting is - there's the combination of the decisions being made in a way that take into account what people's real priorities are and especially when they near the end of life.
There's also the conversations just to recognize that this person is suffering. And people often feel that their suffering is not even acknowledged. The most common complaint that I hear is that people just...
CONAN: I don't mean to interrupt - yes, I do - but the complaint we hear is doctors do not have the time as they're seeing one patient after another in rapid succession, to have those kinds of conversations to even use that healing touch.
GAWANDE: Yeah, so I think it's partly that each doctor or any clinician - nurses and everybody else - feel we just have a piece of care. We just do our little part, and that's all we do. There's no one who sees the whole. The most common complaint I hear from patients is that there doesn't seem to be anybody in charge.
And that problem is not one of time, it's one of someone feeling that that whole view is simply not part of their job. You can it's because they don't feel they're paid for it, but at a deeper level I don't think that all of us clinicians feel that we are responsible for being in charge and providing that need.
CONAN: Dr. Nuland, is that a responsibility someone should be assigned, or is that a responsibility someone should assume?
NULAND: Well, first let me say, Neal, that I'm not quite sure you're right about the question of how much time is available. I think most doctors who have practiced for a period of even several years know that there is five minutes that one spends with a patient and five minutes that one spends with a patient. Some patients just exude a kind of personal shepherding, I think, that makes those five minutes very valuable to the patient emotionally.
Some doctors come sliding in like, oh, Kramer on "Seinfeld," just (makes noise) right through the door, and they're working on their handheld computers, and they're getting lab tests and shouting orders to someone and they're out in the same five minutes. So I think a lot of this - although you're of course obviously partially correct, a lot of this has to do with the way physicians are trained with the kinds of role models that young people are seeing today that didn't exist in the careful clinical post-operative, let's say, visits of many years ago when there was less technology to use and much more hands-on and minds-on care.
CONAN: We need to hear from doctors. What's happening in your field? What's changing, what works, what doesn't? 800-989-8255. Email us, email@example.com. We'll return with more with Dr. Sherwin Nuland and Dr. Atul Gawande in just a moment. Stay with us. I'm Neal Conan. You're listening to TALK OF THE NATION from NPR News.
(SOUNDBITE OF MUSIC)
CONAN: This is TALK OF THE NATION from NPR News. I'm Neal Conan Dr. Sherwin Nuland and Dr. Atul Gawande are our guests today in our latest conversation Looking Ahead, this time at surgery in particular, medicine in general. They're both very well-known in their field, surgeons with decades of experience who also teach new classes of doctors how to practice medicine, how to care for patients.
They're also accomplished authors. Dr. Nuland has written a shelf's worth of books. His most recent, "The Soul of Medicine." He won the National Book Award for his best-seller "How We Die." Dr. Atul Gawande's most recent book is "The Checklist Manifesto: How to Get Things Right." He's also the author of "Better: A Surgeon's Notes on Performance," also a national best-seller.
So doctors, we want to hear from you today. What's changing in medicine? What works? What doesn't? 800-989-8255. Email us, firstname.lastname@example.org. You can also join the conversation on our website. That's at npr.org. Click on TALK OF THE NATION. And we'll get to calls in just a minute, but I wanted to ask you both, why did you decide to devote such an important component of your time, a very precious commodity, to be a writer? Dr. Gawande?
GAWANDE: Boy, that's a hard one. I didn't expect to be in writing. I ended up writing midway through my surgical residency. And I found it was just because it was my way of thinking out loud about these puzzles, about how we get good at what we're doing, when I felt how I get good at what I'm doing, when I felt like the field was changing. I'm sort of obsessed with failure, and it was a great way to work through why failures happen even for myself.
CONAN: Dr. Nuland?
NULAND: Well, I think the chief appeal of writing to me is it's a way of trying to find out what I really think about things. I use my unconscious mind when I'm writing. I just let it flow. And astonishing things happen to my ability to understand thought processes and to synthesize all kinds of facts that don't seem to come together until I try to explain them to somebody else, on the end of my pencil.
And that's been the most gratifying part of it all, to do that and to realize that in a specialty like surgery, where you are taking care of one person at a time, and you've really, in your early origins, wanted to be a family physician, you have become family physician to the world now because you're able to explain to large numbers of people in a rather relaxed way what it is that sickness consists of, how the human body works, these kinds of things that are so difficult for us to bring to a large audience if we don't have the opportunity and the privilege to write.
CONAN: Well, let's get some of those callers in as I promised. Mike is on the line with us from San Francisco.
MIKE: Hi, good morning, I really enjoy your show.
CONAN: Thank you.
MIKE: I have a comment about the challenge of health care. I believe that the challenge, the biggest challenge is cost. And I think obviously it's multi-factorial. I'm a cardiologist, and my field is really driven by advances in the technology over the last few decades. And as a result, the cost has gone up, and I think as a response, the payers, namely the insurance companies and the government, have tried to contain costs by decreasing their reimbursement.
And subsequent to that, the physicians' response in trying to maintain their practice is to do more and more, and that has driven up the cost. And this has led to a vicious cycle so that the care actually may not be dramatically improved, although the cost has gone up, and the number of tests and treatments have gone up, as well.
CONAN: And I just wanted to follow up with you, Mike. There is an increased emphasis in the new legislation, the Affordable Care Act, on outcomes rather than on payment for procedures. And do you think that's the right way to go?
MIKE: I think that's a great step in the - in our models. But I think the biggest challenge still is because the majority of our country practices in a fee-for-service kind of model, that just really - the reality of it is that people have to make a living in a way to maintain the practices. But I think that's definitely a right model for the pay for performance.
CONAN: And Dr. Gawande, we've heard this not just from cardiologists but from psychologists and just about everybody else.
GAWANDE: Yeah, yeah, when we pay for widgets, we get widgets and not always a lot of sense of whether we're getting results. The last five years have been extraordinary. We have recognized that paying fee for service, fee for procedure, just leads to more procedures. And we are grappling for how to move to what some call fee for value or for paying for results. But we don't - we haven't known how.
We don't have the measures, we don't have the experience, and we are in the midst of this transition where many, many places are trying ways of doing it. Some of them are already producing some extraordinary improvements in results, which include higher quality and loser costs. But we're in this fertile phase of experimentation, and when there's a lot of change going on, it can lead to great distress but also great opportunity.
NULAND: Mike brings up a fascinating dilemma that medicine, the government, the public and insurance agencies face every day. Here we are in cardiology, and have the costs really gone up? If you take someone who has a coronary and can now within an hour, an hour and a half, have an arteriogram, coronary arteriogram, have a stent put in and doesn't need a very expensive coronary bypass, is that a savings?
Now, the other part of this issue is that cardiology - and infectious disease - are the only specialties in which real therapeutic advances and statistical advances in life-saving measures have occurred in the 20th century. So let's say the cost has gone up. In this particular situation, does that not become justified by the increased longevity that cardiac patients have?
The James Gandolfini situation, for example, was so common when I was an intern and a house officer. Middle-aged men who were obese, perhaps hypertensive, would have a sudden coronary, and there wasn't much we could do about it, and the death rate was enormous.
Well, right now with proper facilities, which we have in most American hospitals, people like that survive and survive for long periods of time. So what about the cost? In general, Mike, I agree completely with you. Cardiology is a mixed bag, and we've got to remember that this is one of the difficulties of solving the problem. What are we sacrificing when we cut costs?
CONAN: Did you want to follow up?
MIKE: Yeah, no, I think one of the thoughts I had was, you know, obviously politically, it's very difficult, but I believe that the only way to really contain costs and maintain quality is to try to have some kind of pre-payment model, nationalized health care. But obviously this is debated hotly, and it's very difficult. But I really think that is the way to go. You know, but it may not happen in this century.
CONAN: It may not happen in this century. You may be right about that.
CONAN: Mike, thanks very much for this call, appreciate it. Let's see if we can go next to - this is a call from Austin, Texas. It's Will.
WILL: Hi, thanks for having me on.
CONAN: Go ahead, please.
WILL: I'm a pre-medical student at the University of Texas and hoping - I'm applying to medical school this application cycle. It's an honor to talk to both of you guys. I've read all of Dr. Gawande's books. They've had a huge influence on me.
And I had a question, just what advice would you give to the sort of doctors of the future about what to expect and how to prepare for not only practicing the act of medicine but how to be involved in how medicine is practiced and the more overarching themes like you talk a lot about? So I just had a question for both physicians. Thanks.
CONAN: Go ahead, well Dr. Gawande, you got the royalty check already, so you start.
GAWANDE: Well, that was great. So besides making my day, let me try to answer the question. The - you know, maybe we can use Mike's example of coronary artery disease. Here we are in a country where 50 percent of coronary artery disease patients receive incomplete or inappropriate care. They don't get preventive remedies, they don't get the proper steps for blood pressure control, for dietary advice and many steps along the way, and that's just talking about the medical side.
Add in smoking and prevention, we have tremendous opportunity on that side. And there's a tremendous amount of inventiveness on the specialist side. How do we make it so that if you do have a coronary attack, we are more likely to be providing the right care in the right away and doing it in ways that don't bankrupt society.
We have only had a few years of innovators who are discovering how to produce far better results in our system for both prevention and treatment. When they're attacking the system in that way, it's mostly been leaders who know how to put the dots together, and they're getting some extraordinary results. I think that's the future for many young people in medicine; is understanding that innovation isn't just about producing a drug or a device or the - or another specialty. It's understand the innovations required to knit everybody together and make them successful. And I think that'll be the future.
WILL: Thank you, I appreciate it.
CONAN: Dr. Nuland, did you want to weigh in?
NULAND: Well, yes, I think so. I think if I were to advise Will, I would point out that most of the increase in life expectancy - which doctors love to take credit for in the 20th century, from age 49 to about age 77 - has not come from physicians. It has come from people in public health, of course aided and spurred on by physicians. The - as I say, infectious disease, yes, cardiology, yes. But we've made very small gains in cancer. We've made very small gains in the dementias and most of the other major disease.
Remember that public health has been the major issue throughout the 20th century. Immunizations, water purifications, good prenatal care, better housing, better diet. This is the primary reason why we have gone long as well as we have. So I think we've got to take some of the hubris out of ourselves as physicians, as organizations of physicians and remember that public health measures, preventive medicine will always be the key to better health.
This is seem - this seems to be much more well known in European countries than it is in our own, but we're beginning to go over the hedge, as it were, and see what's on the other side. I always think of good old Mayor Bloomberg who gets hit so hard, but his attacks on the probability of obesity in the population of New York City I think are very commendable.
CONAN: Well, Will, thanks very much for the phone call, and good luck with your studies.
WILL: Yeah. Thanks for having me on. I appreciate it.
CONAN: Here's an email we have from Donna in Tucson: What's changing in medicine is the rare female physician. I am a woman M.D. practicing 30-plus years in internal medicine who takes issue with his idea that he as the head of the team is always a doctor or that it is a man. Dr. Gawande's point was glossed over. It is not always the doctor who leads the care. And with greater than 50 percent of medical students now being women, it is not always a man.
And, Dr. Gawande, as I'm sure you look out over your classes, this is going to change more and more.
GAWANDE: Yeah. It's interesting. Surgery, which was sort of the last redoubt of not admitting females or attracting females to join our profession, has also crossed over to the point we now have - in my residency program, four to five out of our seven each year now are women.
And, you know, you see a dramatic change in two ways. One, is that as the restrictions on work hours have come in so that you can make it possible for people to have family life in their 30s as they're going through training, that's opened the door for more women who also want to start families.
And the second way is it's forced us, even in surgery, to become more family-friendly, and that's paid off for faculty like me who still has a young family and wants to make that part of what we do while still getting the work in very intense professions. And I think that's changing us for the better, not just because we have women coming on board but because we're forcing ourselves to be more family-friendly.
CONAN: Surgeons, professors of medicine and authors: Dr. Atul Gawande and Dr. Sherwin Nuland are with us. You're listening to TALK OF THE NATION from NPR News.
And let's see if we can go to Mark(ph), and Mark's with us from Knoxville.
MARK: Hello. How are you all doing?
CONAN: Good. Thanks.
MARK: Well, I was catching you driving back to town, and I just - I may have missed this earlier, but I was wondering if we can maybe open a little bit of discussion towards cost containment through decreased liability. I'm a physician, and I find myself as I'm getting more into evidence-based medicine - and that's what's being taught now - that maybe as a group, we can come together and, through legislation or whatever, we can have basic practice principles that if we do certain things that are accepted as evidence-based medicine, then we should be released from some of the liability if we miss something that's extremely rare or very unusual.
And I think your physicians on the panel are familiar with what I'm talking about, maybe over-testing or doing things that aren't necessarily evidence-based, more for liability reasons.
CONAN: Yeah. See why...
MARK: I was just curious what their comments were on that.
CONAN: (Unintelligible) reasons that, Dr. Gawande, you were talking about, your obsession with failure, and you've written about this.
GAWANDE: I have. I've become a supporter of no-fault liability. You know, the vaccine industry nearly got bankrupted by malpractice - well, product liability costs, and now 75 cents on every vaccine goes into a fund that then gets paid out to people when they're injured by vaccines, and it's allowed that world to thrive. And I think we could carry over some of those fundamental ideas.
What he's getting at is the notion that, you know, as we arrive at certain kinds of standards, people who follow them should be able to adhere to - be able to not be sued. But the core of failure of the malpractice system is only 1 percent of those who are actually harmed and injured by errors end up being able to be compensated in the system. Two-thirds of the money they get goes to lawyers in the court system, and it takes seven years or longer to see that.
I've paid well over a million, million-and-a-half dollars in premiums, and I know it could have gone to have helped patients who had serious complications with my care rather than where it's gone now. I think a no-fault system could have gotten there, but, you know, we're a long way. You said earlier a national system of health care is a century away. Well, this is even further away.
Neither the Democrats are interested in moving in this direction, and the conservatives have been interested mainly - the Republicans have mostly been interested in the - in capping the system rather than creating a no-fault system in itself, at least so far from the legislation we've seen.
CONAN: Dr. Nuland - and thanks very much for the call, Mark - this whole relationship with the legal system, with - and with the political system, that seems to me as a profound difference since you started.
NULAND: Oh. I have to point out to your listeners that I'm 82 years old and I've been at this for a very, very long time. And a generation of beyond, or I should say before Dr. Gawande, and he has had the good fortune to see attention, the searchlight of attention, turned on these dreadful problems of, for example, people not adhering to appropriate standards of care. Yes, we should base our decisions largely on evidence-based medicine. But all of us know that the evidence of today turns out to be totally erroneous tomorrow, and that medicine is essentially an uncertain profession.
CONAN: Thank you, both, as always, for your time today. We really appreciate it.
GAWANDE: We'll miss this show.
CONAN: I'll miss talking to you. Dr. Atul Gawande joined us from Boston and Sherwin Nuland joined us from New Haven; one teaches at Harvard, one teaches at Yale, you guess. Thank you very much for your time. When we come back...
NULAND: Thanks so much.
CONAN: ...let the fire burn. Filmmaker Jason Osder joins us to talk about his documentary. It's the TALK OF THE NATION from NPR News.
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