Tickets to Atul Gawande’s talk, “Was Your Operation Necessary?”, were among the first to sell out at the New Yorker Festival, which took place last weekend. Gawande, who is a surgeon, Harvard professor and staff writer at the New Yorker, is medicine’s answer to Malcolm Gladwell. Indeed, Gladwell has enthusiastically endorsed Gawande’s book “Being Mortal”, which is currently a New York Times bestseller. In addition to television appearances and a TED Talk that has drawn 1.3m views, the good doctor has 143,000 followers on Twitter.
I expected a geriatric crowd given that “Being Mortal” focuses on the difficult realities of aging, end-of-life care, and death. While that demographic was well represented, I found a mix of ages packed into the 550-seat theatre. Next to me sat a millennial from Brooklyn, who could have been a cast member on “Girls”. She comes to hear Gawande each year, who, like Gladwell, is now a fixture on the festival circuit.
The doctor strolled onto the stage seeming more like a television presenter than university professor. Confident and relaxed in a natty patterned sports jacket and tie, he didn’t bother with the podium as he moved about onstage, except to sometimes lean an elbow on it jauntily. His subject was the systemic pattern of “overprovision” in healthcare in developed countries. Medical professionals—eager to utilise the latest medical technology—perform excessive scans, lab work and procedures. Really, the talk could have been called “Were All Those Diagnostic Tests Necessary?” In the United States alone, he said, about 30% of all healthcare costs were a waste.
Gawande began with a story about his mother. One day in rural Ohio she fainted, and was medevaced to a big city hospital where doctors ran a battery of tests, including an EKG that came back “not entirely normal”. The doctors pressed ahead with a carotid catheterisation—a risky procedure which involves running a catheter up through the arm, or leg, to the carotid artery in the neck. Dye is injected so an image of the artery walls can be mapped. Luckily, his mother suffered no complications and her arteries looked fine. Only after she had spent a night in hospital did a doctor ask her questions. It turned out that she’d started a diuretic medication but had not been drinking enough water. This was a simple case of dehydration and a textbook example of medical overprovision.
Gawande was careful not to lay blame upon his colleagues, arguing that more fundamental elements of care—like speaking with a patient or reviewing their history to resolve abnormalities in test results—were being crowded out. The “tremendous technology for diagnosis”—CAT scans, EKGs, lab work, genetic tests—now allows doctors to look in finer and finer detail at what is going on inside a patient. Every year in the United States, which has a population of 330m, there are 100m CAT scans and MRIs, 10 billion lab tests and tens of millions of EKGs. The net effect is that more and more tests come back with “results not quite normal”, making it harder for doctors to hold back.
More than $13 billion is spent annually on back operations in the United States. And yet, Gawande said, there has been no improvement in the amount of back pain suffered by patients, “just lots more complications”. He suggested that if he were to scan the spine of everyone in the audience, half the results would show what looked to be degenerative diseases—pinched nerves, cartilage loss, irregular vertebrae—but many people with these issues would never feel any adverse effects.
At the end, he reiterated that overprovision is more often driven by altruism than recklessness on the part of the doctors. It’s only human for doctors—and patients—to wonder: “If there’s a possible abnormality, shouldn’t I do something about it?” But it’s the psychological what-ifs that compound this Sisyphean cycle. Gawande admitted that in 20 years of practice, what haunts him most are the diagnoses he’s missed.