Dr Gawande had another article in the New Yorker last month called "Overkill". This piece is ostensibly about the epidemic of unnecessary medical care that is carried out in this country. This ought to be a fairly uncontroversial proposition: we certainly do too many procedures, order too many expensive tests in the United States. The question is why. And Dr Gawande, in his latest high profile New Yorker piece, offers, um, a sorta rambling wreck of incoherence. We hear about a lady he saw in clinic with a thyroid nodule, unlikely to cause harm or shorten her life, that he tells her would be better off observed rather than sliced out. And he.....goes right ahead and books her for surgery. We read about a guy with back pain who, because of a corporate inside deal, gets to go see a neurosurgeon at a far away certified Center of Excellence for a 2nd opinion, and non operative therapy is recommended rather than surgery and he does well; the implication being that local physicians will always give bad, profit driven advice so you should unceasingly seek a specialist at major tertiary care centers (sorta like the one where Dr Gawande practices!) where all the doctors are magnanimous altruists who cry themselves to sleep every night with regret that they have to deposit a paycheck every 2 weeks for services rendered. We also read about his friend Bruce whose father fainted and, after an extensive workup was determined to need a triple vessel CABG. Unfortunately, he suffered a stroke during the surgery and was never the same. From this anecdote, he segues into a paragraph about a conversation he had with one of the hosts of the dorky public radio show "Car Talk" about how those Quik-E-Lube shops are always trying to "up-sell" the customer during an oil change on new air filters or windshield wipes or exhaust fans or serpentine belts. The analogy, I guess, is to nefarious doctors (like cardiac surgeons who consulted on Bruce's father) who... umm... do the same? Yeah, you have gallstones and RUQ pain. That's one thing. But you also have a right colon. Maybe that should be changed out too??
Gawande's article makes no mention of the deleterious effects of defensive medicine or the profit margins of so called "non profit" hospital conglomerates. It makes no mention of physician income decreases or the fact that most physicians these days are employees rather than entrepreneurial private practitioners. No mention about dwindling reimbursements for commonly performed procedures. No mention of medical device manufacturer profit margins. No mention of the fact that 30% of Medicare spending occurs in the last 6 months of a person's life (from a man who wrote "Being Mortal"!) Once again he treats health care spending in a vacuum, completely dependent on individual physician decision making. And once again, what drives that decision making is personal benefit and greed. It is unfair and incomplete. Now in real life I think Dr Gawande is actually a pretty cool, laid back guy. On Twitter he seems pretty chill. He likes decent bands. He seems to be intellectually curious, lacks the typical Ivory Tower mega-ego, is honest and open, etc etc. But in these pieces, he is doing a real disservice to his profession. With his cherry picked data and skewed anecdotal-based evidence, he makes it easy for the truly rapacious entities in American health care--- Big Pharma, Medical device makers, Hospital conglomerates, the Health Insurance Industry-- to unequivocally blame and demonize the very professionals who provide the bulk of actual value to our unwieldy system. I wish Dr Gawande would stop doing that.