Graduation Speech

Here is a very meaty speech, given to the graduating class of Harvard Medical School by Atul Gawande who, like me, is a brilliant surgeon also known for his ability to write.... (yeah, yeah, yeah, I know. I know. Academic surgeons aren't all that brilliant in the OR.)

The article is worth reading in its entirety because it's a damn good distillation of the changes in medical care in the last couple of generations, of the difficulties in controlling costs, and of what Gawande thinks might help; and it echoes much of what I've been saying, too. Specifically, about effectiveness research. (Being much more politic than me, he doesn't raise the extent to which all things needed -- and not only in health care -- are despicably distorted and bastardly blocked by teabaggRs.)

...Medical performance tends to follow a bell curve, with a wide gap between the best and the worst results for a given condition, depending on where people go for care. The costs follow a bell curve, as well, varying for similar patients by thirty to fifty per cent. But the interesting thing is: the curves do not match. The places that get the best results are not the most expensive places. Indeed, many are among the least expensive. This means there is hope—for if the best results required the highest costs, then rationing care would be the only choice. Instead, however, we can look to the top performers—the positive deviants—to understand how to provide what society most needs: better care at lower cost. And the pattern seems to be that the places that function most like a system are most successful.

Sorry, Dr Gawande: there's actually no hope of getting there when an entire political party is dedicated to maintaining the status quo, and is doing so by crying "death panels!" and "killing grandma!" at the very mention of even considering what's so clearly needed.

Unstained by cynicism such as mine, he tells a story:

Not long ago, I had an experience at our local school that brought home the stakes. I’d gone for a meeting with my children’s teachers, and I ran into the superintendent of schools. I told him how worried I was to see my kids’ art classes cut and their class sizes rise to almost thirty children in some cases. What was he working on to improve matters? I asked.

“You know what I spend my time working on?” he said. “Health-care costs.” Teachers’ health-benefit expenses were up nine per cent, city tax revenues were flat, and school enrollment was up. A small percentage of teachers with serious illnesses accounted for the majority of the costs, and the only option he’d found was to cut their benefits.

... That’s when it struck me. I was part of the reason my children didn’t have enough teachers. We all are in medicine. Reports show that every dollar added to school budgets over the past decade for smaller class sizes and better teacher pay was diverted to covering rising health-care costs.

This is not inevitable. I do not believe society should be forced to choose between whether our children get a great education or their teachers get great medical care. But only we can create the local medical systems that make both possible. You who graduate today will join these systems as they are born, propel them, work on the policies that accelerate them, and create the innovations they need. Making systems work in health care—shifting from corralling cowboys to producing pit crews—is the great task of your and my generation of clinicians and scientists.

I'm glad there are guys like Gawande around, with the insights and the energy to pursue the near-impossible. Without such people, changing the system is unimaginable; during my time in practice, my personal solution was just to work as hard as I could to deliver the best care I could to the most people I could for as long as I could. I dropped off committees, resigned from boards, kept my head down and plodded through the oncoming tide until, certain there was no way to get anyone to listen, I couldn't do it any more.

So take my dim view as probably less important than that of Gawande, who's still in it, and seems to be influential. But unless the Republican party returns to its days of thoughtfulness and seriousness, which pretty much ended with the arrival on the scene of Ronald Reagan; until they put aside indulging their basest instincts and stoking ours, leaving Sarah Palin and Michelle Bachmann and Mitch McConnell and Glenn Beck and Fox "news" and the RWS™ and the rest of their shallow, hate-as-policy, recyclers of failed ideas in the ditch where they belong, he's just whistling in the dark.

The very, very dark.