Atul Gawande might be the best medical writer ever. He is the best medical writer at The New Yorker, at least, and the best one I’ve ever read. He consistently writes clearly, thoughtfully, and originally about the big issues in medicine. That is why his recent article about health care costs (my comment here) and his graduation speech at the Univesity of Chicago are so telling. And not in a good way, I’m afraid.
The graduation speech starts off with an excellent story:
The program, however, had itself become starvedâ€”of money. It couldnâ€™t afford the usual approach. The Sternins had to find different solutions with the resources at hand.
So this is what they decided to do. They went to villages in trouble and got the villagers to help them identify who among them had the best-nourished childrenâ€”who among them had demonstrated what Jerry Sternin termed a â€œpositive devianceâ€ from the norm. The villagers then visited those mothers at home to see exactly what they were doing.
Just that was revolutionary. The villagers discovered that there were well-nourished children among them, despite the poverty, and that those childrenâ€™s mothers were breaking with the locally accepted wisdom in all sorts of waysâ€”feeding their children even when they had diarrhea; giving them several small feedings each day rather than one or two big ones; adding sweet-potato greens to the childrenâ€™s rice despite its being considered a low-class food. The ideas spread and took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped sixty-five to eighty-five per cent in every village the Sternins had been to. Their program proved in fact more effective than outside experts were.
Bill Gates, Jeffrey Sachs, are you listening?Â Gawande goes on to say that to improve medicine, there needs to be the same sort of study of “positive deviants”. Here is his first example:
I recently heard from one such positive deviant. He is a physician here in Chicago. Heâ€™d invested in an imaging center with his colleagues. But they found they were losing money. They had a meeting about what to do just a few weeks ago. The answer, they realized, was to order more imaging for their patientsâ€”to push the indications where they could. When he realized what he was being drawn to do by the structure he was in, he pulled out. He lost money. He angered his partners. But it was the right thing to do.
No kidding. The contrast between mothers who figure out creative iconoclastic new ways to feed children on tiny amounts of money and a doctor who merely refuses to be a scumbag could hardly be greater. But Gawande uses the same term (“positive deviant”) for both! This is the depth to which a writer and thinker of Gawande’s stature has to descend, given the straitjacket of how he thinks about medicine. Gawande thinks that doctors will improve medicine. He’s wrong. Just as farmers didn’t invent tractors — nor any of the big improvements in farming — neither will doctors be responsible for any big improvements in American health. The big improvements will come from outside. I’m sure they will involve both (a) advances in prevention and (b) patients taking charge of their care.
When these innovations happen, where will doctors be? Helping spread them or defending the status quo? That’s what Gawande should be writing about. One big advance in patients taking charge was home blood glucose testing. It came from an engineer named Richard Bernstein. Best thing for diabetics since the discovery of insulin. Doctors opposed it. When I invented the Shangri-La Diet, and lost 30 pounds, my doctor didn’t ask how I lost all that weight. Not one question. Like all doctors, he had many fat patients; the notion that I, a mere patient, could know something that would help his other patients didn’t cross his mind. When I was a grad student I did acne experiments on myself that revealed that antibiotics (hugely prescribed for acne) didn’t work. My dermatologist appeared irritated that I had figured this out. That’s a little glimpse of how doctors may react to outside innovation involving patients taking charge. Of course doctors, like dentists, cannot do good prevention research.
If Gawande took the first story he told to heart, he might realize it is saying that the improvements to health care won’t come from doctors, just as the improvements to the health of those village children didn’t come from experts. As I said earlier, doing my best to channel Jane Jacobs, a reasonable health care policy would empower those who benefit from change. That’s what the village nutrition program did. It empowered mothers who were innovating.