Dr. Atul Gawande on the heroism of incremental care

Physicians are heroes. They touch people's lives in a uniquely tangible way, and represent the difference between life and death for people on a daily basis. But not all physicians are viewed in the same way, and that is a problem that has broad-reaching repercussions, according to an article by Atul Gawande, MD, in The New Yorker

When we think of a heroic action, one of the first examples that might come to mind could be firefighters extinguishing a blazing house fire. The fire is put out and the dangerous situation is over. Done. People gravitate toward these depictions of heroism because they are episodic — they have a beginning and end, and most importantly, the benefit is instant and measurable.

In his article, Dr. Gawande explains that he was "drawn to medicine by the aura of heroism — by the chance to charge in and solve a dangerous problem." He ultimately chose to be a surgeon because "surgery was a definitive intervention at a critical moment in a person's life, with a clear, calculable, frequently transformative outcome."

In comparison, the medical field of primary care gave Dr. Gawande a "squishy and uncertain" impression. These clinicians don't put out a fire in a single night — or surgical procedure. Instead, their care is incremental, spanning weeks, months, even years or a lifetime, with progress often slow and medical approaches commonly amended as time carries on and symptoms change. Primary care often doesn't allow for the instant gratification so many of us desire, especially when it comes to correcting health, but it is indispensable to the healthcare system nonetheless.

Dr. Gawande believed becoming a surgeon would give him the opportunity to have the greatest overall impact on his patients' lives, but he eventually learned from observing his generalist colleagues that primary care "is the medical profession that has the greatest overall impact, including lower mortality and better health, not to mention lower medical costs."

Numerous studies support this assertion, as does the entire nationwide push under healthcare reform to encourage all Americans to have a primary care physician. Still, Dr. Gawande wondered what particular skill enabled this to be true.

"After all, for any given situation specialists are likely to have more skill and experience, and more apt to follow the evidence of what works," he wrote. "Generalists have no advantage over specialists in any particular case. Yet, somehow, having a primary care clinician as your main source of care is better for you."

All of the generalists he observed cited the same reason for this: the relationships they have with patients. "Studies have established that having a regular source of medical care, from a doctor who knows you, has a powerful effect on your willingness to seek care for severe symptoms. This alone appears to be a significant contributor to lower death rates," he wrote. "Observing the care, I began to grasp how the commitment to seeing people over time leads primary care clinicians to take an approach to problem solving that is very different from that of doctors, like me, who provide mainly episodic care."

Success in medicine, he realized, is not measured exclusively in episodic victories, although they are still important. Instead, "It is about the longer view of incremental steps that produce sustained progress. That, such clinicians argue, is what making a difference really looks like," Dr. Gawande wrote.

Unfortunately, the U.S. healthcare system and the way it reimburses primary care physicians and other clinicians who treat patients on an incremental basis does not recognize this truth, according to Dr. Gawande. He acknowledges that as a surgeon, he has "a battalion of people and millions of dollars of equipment on hand when I arrive in my operating room. Incrementalists are lucky if they can hire a nurse."

Chronic diseases, which impose the greatest financial and resource burden on the U.S. healthcare system, are also the conditions that fall under the responsibility of incrementalists. Yet these clinicians are paid substantially less than many specialists and are given fewer resources to do their job. "The difference between what's made available to me as a surgeon and what's made available to our internists or pediatricians or H.I.V. specialists is not just shortsighted — it's immoral," he wrote.

It is time for the shapers of healthcare policy to recognize "the heroism of the incremental," according to Dr. Gawande.

"We can give up an antiquated set of priorities and shift our focus from rescue medicine to lifelong incremental care. Or we can leave millions of people to suffer and die from conditions that, increasingly, can be predicted and managed. This isn't a bloodless policy choice; it's a medical emergency," he wrote.

Read Dr. Gawande's article in The New Yorker in its entirety here.

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