For Many People, Medical Care Works Best When It's Incremental

Jan 17, 2017
Originally published on January 23, 2017 3:40 pm

There's the heroic, lightning-quick medical care that saves us from crises. And then there's the slow-but-steady incremental medical attention that doctors provide for weeks, months, years, even decades in the attempt to heal complex conditions.

As a surgeon, The New Yorker's Atul Gawande practices the heroic type of medicine. In his new article, "Tell Me Where It Hurts," Gawande examines the quieter side of health care. Chronic diseases including heart disease, cancer, Type 2 diabetes and arthritis have become the leading causes of death and disability in the U.S. Gawande argues that it's time for the health care system to discover the heroism of "the incremental."

Gawande discusses his article with NPR's Robert Siegel, touching on the status of incremental medicine and what a shift in healthcare might mean for primary care in upcoming years. The interview has been edited for length and clarity.


Interview Highlights

On a case that shows the importance of incremental medicine

"I start out the story with a man who has the worst chronic migraine headaches imaginable. He has suffered for decades with headaches on almost a daily basis: More days of the month with a terrible headache than not, to the point of throwing up. It's hard to keep your job, hard to make things work. He'd seen all kinds of doctors who offered all kind of fixes, and nothing ever worked. But then he found a physician who saw him regularly over three years. Dr. Elizabeth Loder, whose career has been built on paying enormous attention to 'Let's try a little something now, see what happens, tweak it again, tweak it again.'

The problem in our existing health care system is that it's not made to put great value in opportunities that take time to pay off. What [the migraine patient] would have received in an emergency room would be a shot of morphine, a CT scan...and be sent on his way. Cured for an hour or two only to have it come back again later. But after three years [of working with Dr. Loder,] at the age of 62, his headaches were cured. And that's the opportunity we're missing."

On who decided emergency care should be most valuable

"We all decided it. If you go back to the 1940s or 1950s, medicine was really only able to rescue. It was an amazing thing that we could bring on antibiotics like penicillin to cure bacterial diseases, or do operations to take care of problems like heart conditions. Primary care physicians couldn't do much. We didn't know high blood pressure was one of the biggest problems we have, much less how to address it. Fast forward to where we are now. Only half of people [with high blood pressure] have their blood pressure controlled and are receiving adequate treatment for it. And what it takes to control blood pressure is step-by-step incremental investment. And we don't make it. We wait for the heart attack or kidney failure caused by the high blood pressure. It's too little too late, and at great expense. We raid our commitment to maintenance and prevention to put money into that expensive back end rescue. And that's what has to shift."

On what a rollback of Obamacare might mean for primary care

"Obamacare put incentives in [health care] that strengthen and give resources to primary care clinicians to have more team oriented care, and even for people to reach outside the clinic and serve you virtually. Some areas of the country are already doing the majority of their visits by virtual means. [Clinicians] are in touch with you in many different ways. But that's what we miss, that's what's at stake if we repeal legislation without replacement that keeps this kind of direction moving."

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ROBERT SIEGEL, HOST:

Here are two kinds of medical treatment - the heroic intervention that rescues us from catastrophe and the incremental attention of a doctor who knows and treats our pains and discomforts year in, year out. The New Yorker's Atul Gawande, as a surgeon, practices the heroic kind of medicine. And in his article, "Tell Me Where It Hurts," he reports with great admiration on the other side of the health care fence. He comes away convinced that our health care system had better discover the heroism of the incremental, those his words.

And he joins us now from the World Economic Forum in Davos, Switzerland. Welcome to the program once again.

ATUL GAWANDE: Thank you for having me, Robert.

SIEGEL: An example of effective incremental care that you write about is treating headaches. Describe a case of incremental care that really struck you as important and effective.

GAWANDE: Yeah, I start out the story with a man who has the worst chronic migraine headaches imaginable. He is someone who has suffered for decades with headaches on almost a daily basis, seen all kinds of doctors who offered all kinds of fixes, and nothing ever worked. But then he found a physician, Dr. Elizabeth Loder, whose career has been built around taking care of folks like him by paying enormous attention to let's try a little something now, let's pay attention to what happens and then tweak it again and tweak it again.

What I'm pointing to is that the problem in our existing health care system is it's not made to put great value on opportunities that take time to pay off. But after three years, at the age of 62, his headache was cured. And he'd missed 40 years of life with this terrible thing. And that's the opportunity we're missing.

SIEGEL: Talk about the value that's placed on different kinds of doctors. You cite a survey from last year which found that the five highest-paid specialties in American medicine - I'm quoting now - are "orthopedics, cardiology, dermatology, gastroenterology and radiology. Practitioners in those fields average $400,000 a year." And lowest-paid specialties, who average about half that much, are pediatrics, endocrinology, family medicine, HIV/infectious disease, allergy/immunology, internal medicine, psychiatry and rheumatology. Why do those doctors make so much less? Is it my power as a consumer? Is it policy makers, insurance companies? Who decided that?

GAWANDE: Well, we all decided it. And it came from a history that, you know, if you go back to the 1940s, 1950s, medicine was really only able to rescue at that point. It was an amazing thing that we could bring on antibiotics like penicillin to cure bacterial diseases or to do operations to take care of problems even like heart conditions or bring on dialysis machines. Primary care physicians couldn't do much. We didn't even know high blood pressure was one of the biggest problems we have, let alone how to address it.

Fast-forward to where we are now. We now know our biggest killer in the country now that smoking is declining is high blood pressure. And what it takes to control blood pressure is that kind of step-by-step incremental investment. And we don't make it. We wait until the heart attack.

SIEGEL: I'm just trying to imagine the surgery department at a major hospital and you coming along and saying, here's the good news. We're going to have much better health care in the country. The bad news is our pay gets cut in half. You can sell that to your fellow surgeons?

GAWANDE: It's not really about how much we're individually paid. When I go to work as a surgeon, I have at my fingertips millions of dollars' worth of equipment and an entire team to provide a rescue for people. But if I want to prevent that problem from happening, if I'm an incrementalist in a field where I can prevent someone from coming to the operating room, we barely are willing to provide resources to offer them a nurse or an innovation like encourage them to buy applications that let you track on people's phones what their blood pressures are and give them feedback that way.

SIEGEL: Is our health care system at a point where somebody could pull some levers and enact some new laws, whatever it might be, that would shift the emphasis toward more incremental primary care? Or would it take decades for us to alter the system that we have?

GAWANDE: I think we're already on our way there. Obamacare put incentives in that are strengthening and giving resources to primary care clinicians to have more team-oriented care for people, even reach outside of the clinic and serve you virtually. But that is what, I think, we miss is at stake if we have repeal of legislation without replacement that keeps this kind of direction moving.

SIEGEL: Atul Gawande's article in The New Yorker magazine is called "Tell Me Where It Hurts." Thanks for joining us.

GAWANDE: Thank you.

(SOUNDBITE OF ELLIOTT SMITH SONG, "NEEDLE IN THE HAY") Transcript provided by NPR, Copyright NPR.