Can This Patient Be Saved?By ATUL GAWANDE
Guest Columnist, New York Times
As a surgeon, I’ve seen some pretty large tumors. I’ve excised fist-size thyroid cancers from people’s necks and abdominal masses bigger than your head. When I do, this is what almost invariably happens: the anesthesiologist puts the patient to sleep, the nurse unsnaps the gown, everyone takes a sharp breath, and someone blurts out, “How could someone let that thing get so huge?”
I try to describe how slowly and imperceptibly it grew. But staring at the beast it has become, no one buys the explanation. Even the patients are mystified. One day they looked in the mirror, they’ll say, and the mass seemed to have ballooned overnight. It hadn’t, of course. Usually, it’s been growing — and, worse, sometimes spreading — for years.
Too often, by the time a patient finally seeks help, I can’t help much.
We are adaptable creatures, and while that is generally good, sometimes it’s a problem. We have no difficulty taking prompt action when faced with a sudden calamity, like a bleeding head wound, say, or a terrorist attack. But we are not good at moving against the creeping, more insidious threats — whether a slow-growing tumor, waistline or debt.
It’s as true of societies as of individuals. We did not muster the will to reform our long-broken banking system, for example, until it actually collapsed in the Great Depression.
This is, in a nutshell, the trouble with our health care crisis. Our health care system has eroded badly, but it has not collapsed. So we do nothing.
For at least two decades, polls have shown that most consider our health system seriously flawed. With family insurance premiums now averaging $12,000 a year, the insured fear it will become unaffordable, and businesses regard health benefit costs as their single greatest obstacle to competing globally.
People without insurance are proven to be more likely to die, and 28 percent of working-age Americans are now uninsured for at least part of a year. Emergency rooms, required to care for the uninsured, have become so full they turned away 500,000 ambulances last year. As a result, large majorities support the idea of fundamental change.
Surveys also show, however, that 89 percent of Americans remain satisfied with their own health care and that 88 percent of the insured are satisfied with the coverage they have. So time and again, when confronted with the details and costs of any thoroughgoing reform, our enthusiasm evaporates.
I learned this lesson the hard way. I was in the Clinton administration when we lost health reform, partly because of special interests’ attacks, but mostly because the insured feared change more than the status quo. When voters in Oregon, one of our most liberal states, voted down a single-payer plan in a referendum in 2002, it was just the most recent sign of the pattern.
The only time the country has enacted a large-scale health system change was after a collapse. In 1965, when Medicare was created for the elderly and disabled, some 70 percent had no coverage for hospital costs. We’re not that badly off yet. Our health care system is like one of those tumors growing in my patients. The only questions are: When will it become bad enough to make us act? And will that be too late?
Reformers think we’re on the verge of waking up some morning, looking in the mirror and noticing the size of this tumor with enough alarm to do something radical about it. But isn’t it more likely we won’t?
Malcolm Gladwell has argued that when health care costs drive General Motors into bankruptcy, and 300,000 workers lose coverage overnight, that will be the next big crisis to prompt wholesale change. I thought so, too. But it now looks as if G.M. will instead wither slowly, shedding a plant here, a division there. And faced with a slow withering, we all just muddle on.
The case for sweeping reform — for severing health insurance from the workplace and creating a new system — is undeniable. But it’s going to be a long time before the large majority of Americans with decent coverage are persuaded to risk changing what they have. How then to cure a malignant health care system? Can we act before the patient collapses?
The answer is yes, but only if we make changes that alter most people’s coverage gradually, while still providing a path out of this mess. My next column will describe just that.
Atul Gawande, a general surgeon at Brigham and Women’s Hospital and a New Yorker staff writer, is the author of the new book “Better” and a guest columnist this month.
1 comment:
After I read this article .I agree we have a the trouble with our healthcare system.
hospital dir
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