Asaf tried to explain. “It’s no one thing we do. It’s all of it,” he said. I found this unsatisfying. I pushed everyone I met at the clinic. How could seeing one of them for my—insert problem here—be better than going straight to a specialist? Invariably, the clinicians would circle around to the same conclusion.
“It’s the relationship,” they’d say. I began to understand only after I noticed that the doctors, the nurses, and the front-desk staff knew by name almost every patient who came through the door. Often, they had known the patient for years and would know him for years to come. In a single, isolated moment of care for, say, a man who came in with abdominal pain, Asaf looked like nothing special. But once I took in the fact that patient and doctor really knew each other—that the man had visited three months earlier, for back pain, and six months before that, for a flu—I started to realize the significance of their familiarity.
For one thing, it made the man willing to seek medical attention for potentially serious symptoms far sooner, instead of putting it off until it was too late. There is solid evidence behind this. 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.
[---]
Like the specialists at the Graham Center, the generalists at Jamaica Plain are incrementalists. They focus on the course of a person’s health over time—even through a life. All understanding is provisional and subject to continual adjustment. For Rose, taking the long view meant thinking not just about her patient’s bouts of facial swelling, or her headaches, or her depression, but about all of it—along with her living situation, her family history, her nutrition, her stress levels, and how they interrelated—and what that picture meant a doctor could do to improve her patient’s long-term health and well-being throughout her life.
Success, therefore, is not about the episodic, momentary victories, though they do play a role. 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. In fact, it is what making a difference looks like in a range of endeavors.
[---]
The federal government launched a standard inspection system and an inventory of public bridges—six hundred thousand in all. Almost half were found to be either structurally deficient or functionally obsolete, meaning that critical structural elements were either in “poor condition” or inadequate for current traffic loads. They were at a heightened risk of collapse. The good news was that investments in maintenance and improvement could extend the life of aging bridges by decades, and for a fraction of the cost of reconstruction.
Today, however, we still have almost a hundred and fifty thousand problem bridges. Sixty thousand have traffic restrictions because they aren’t safe for carrying full loads. Where have we gone wrong? The pattern is the same everywhere: despite knowing how much cheaper preservation is, we chronically raid funds intended for incremental maintenance and care, and use them to pay for new construction. It’s obvious why. Construction produces immediate and visible success; maintenance doesn’t. Does anyone reward politicians for a bridge that doesn’t crumble?
[---]
Recently, I called Bill Haynes’s internist, Dr. Mita Gupta, the one who recognized that the John Graham Headache Center might be able help him. She had never intended to pursue a career in primary care, she said. She’d planned to go into gastroenterology—one of the highly paid specialties. But, before embarking on specialty training, she took a temporary position at a general medical clinic in order to start a family. “What it turned into really surprised me,” she said. As she got to know and work with people over time, she saw the depth of the impact she could have on their lives. “Now it’s been ten years, and I see the kids of patients of mine, I see people through crises, and I see some of them through to the end of their lives.” Her main frustration: how little recognized her abilities are, whether by the insurers, who expect her to manage a patient with ten different health problems in a fifteen-minute visit, or by hospitals, which rarely call to notify her, let alone consult her, when a patient of hers is admitted. She could do so much more for her patients with a bit more time and better resources for tracking, planning, and communicating. Instead, she is constantly playing catch-up. “I don’t know a primary-care physician who eats lunch,” she said.
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. More than a quarter of Americans and Europeans who die before the age of seventy-five would not have died so soon if they’d received appropriate medical care for their conditions, most of which were chronic. We routinely countenance inadequate care among the most vulnerable people in our communities—including children, the elderly, and the chronically ill.
- Atul Gawande, The Heroism of Incremental Care
“It’s the relationship,” they’d say. I began to understand only after I noticed that the doctors, the nurses, and the front-desk staff knew by name almost every patient who came through the door. Often, they had known the patient for years and would know him for years to come. In a single, isolated moment of care for, say, a man who came in with abdominal pain, Asaf looked like nothing special. But once I took in the fact that patient and doctor really knew each other—that the man had visited three months earlier, for back pain, and six months before that, for a flu—I started to realize the significance of their familiarity.
For one thing, it made the man willing to seek medical attention for potentially serious symptoms far sooner, instead of putting it off until it was too late. There is solid evidence behind this. 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.
[---]
Like the specialists at the Graham Center, the generalists at Jamaica Plain are incrementalists. They focus on the course of a person’s health over time—even through a life. All understanding is provisional and subject to continual adjustment. For Rose, taking the long view meant thinking not just about her patient’s bouts of facial swelling, or her headaches, or her depression, but about all of it—along with her living situation, her family history, her nutrition, her stress levels, and how they interrelated—and what that picture meant a doctor could do to improve her patient’s long-term health and well-being throughout her life.
Success, therefore, is not about the episodic, momentary victories, though they do play a role. 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. In fact, it is what making a difference looks like in a range of endeavors.
[---]
The federal government launched a standard inspection system and an inventory of public bridges—six hundred thousand in all. Almost half were found to be either structurally deficient or functionally obsolete, meaning that critical structural elements were either in “poor condition” or inadequate for current traffic loads. They were at a heightened risk of collapse. The good news was that investments in maintenance and improvement could extend the life of aging bridges by decades, and for a fraction of the cost of reconstruction.
Today, however, we still have almost a hundred and fifty thousand problem bridges. Sixty thousand have traffic restrictions because they aren’t safe for carrying full loads. Where have we gone wrong? The pattern is the same everywhere: despite knowing how much cheaper preservation is, we chronically raid funds intended for incremental maintenance and care, and use them to pay for new construction. It’s obvious why. Construction produces immediate and visible success; maintenance doesn’t. Does anyone reward politicians for a bridge that doesn’t crumble?
[---]
Recently, I called Bill Haynes’s internist, Dr. Mita Gupta, the one who recognized that the John Graham Headache Center might be able help him. She had never intended to pursue a career in primary care, she said. She’d planned to go into gastroenterology—one of the highly paid specialties. But, before embarking on specialty training, she took a temporary position at a general medical clinic in order to start a family. “What it turned into really surprised me,” she said. As she got to know and work with people over time, she saw the depth of the impact she could have on their lives. “Now it’s been ten years, and I see the kids of patients of mine, I see people through crises, and I see some of them through to the end of their lives.” Her main frustration: how little recognized her abilities are, whether by the insurers, who expect her to manage a patient with ten different health problems in a fifteen-minute visit, or by hospitals, which rarely call to notify her, let alone consult her, when a patient of hers is admitted. She could do so much more for her patients with a bit more time and better resources for tracking, planning, and communicating. Instead, she is constantly playing catch-up. “I don’t know a primary-care physician who eats lunch,” she said.
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. More than a quarter of Americans and Europeans who die before the age of seventy-five would not have died so soon if they’d received appropriate medical care for their conditions, most of which were chronic. We routinely countenance inadequate care among the most vulnerable people in our communities—including children, the elderly, and the chronically ill.
- Atul Gawande, The Heroism of Incremental Care
No comments:
Post a Comment