The Courage to Improve


Inspired by Dr. Gawande’s thoughts on waste in the healthcare system and what we can do about it.

Did you catch Dr. Atul Gawande’s recent article in The New Yorker (May 11, 2015). It’s entitled, “Overkill. An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?” It’s a follow-up to an article he wrote six years ago called “The Cost Conundrum: What a Texas town can teach us about healthcare.” Both articles tackle the  issue of healthcare costs in the United States. As I read his latest article and went back to recall his earlier one, I found myself admiring the courage it took for Dr. Gawande to write them. As a healthcare provider himself, you might think he’d like to brush the topic under the rug and hope that people don’t give it much thought. But he does exactly the opposite.

In “The Cost Conundrum” (2009), Dr. Gawande had reminded us that “Our country’s health care is by far the most expensive in the world. In Washington, the aim of healthcare reform is not just to extend medical coverage to everybody but also to bring costs under control.” Likely to the dismay of many in McAllen, Texas, Dr. Gawande looked to that community for answers since McAllen was at the time one of the most expensive healthcare markets in the country. Dr. Gawande had written that “In 2006, Medicare spent fifteen thousand dollars per enrollee here (McAllen), almost twice the national average” and “three thousand dollars more per person here than the average person earns”. He compared McAllen to El Paso, another Texas community with essentially the same demographics and generally the same healthcare offerings and services (“neonatal intensive care units, advanced cardiac services, PET scans, and so on”) but with Medicare expenditures (which he cited as ‘our best approximation of overall spending patterns’) in 2006 at about half as much as in McAllen.

Dr. Gawande had worked with economist Jonathan Skinner of the Dartmouth Institute for Health Policy and Clinical Practice to determine whether overuse of medical care was the problem in McAllen. What he shared in “The Cost Conundrum” was that “Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.” Yet, he did not find that the quality of care was any better in McAllen than in El Paso, and in some cases performed worse (based on Medicare rankings of hospitals on metrics of care).  What he concluded at the time was there seemed to be an extensive level of inappropriate and unnecessary healthcare services in McAllen, Texas. “Americans like to believe that, with most things, more is better. But research suggests that where medicine is concerned it may actually be worse.” And “That’s because nothing in medicine is without risks. Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value, the harm can be greater than the benefits.”

As you might imagine, that earlier article by Dr. Gawande was not appreciated by everyone. As one doctor from a hospital within the McAllen community told him, “We hated you.” The story “put us in a spotlight, in a bad way.” But on reflection, the doctor added that it was “in a good way at the same time.” He went on to explain that “they knew there were problems, but they didn’t know the magnitude.”

So six years later, Dr. Gawande is taking a look back. In his recent article “Overkill,” he again calls attention to this sensitive topic of waste in the healthcare system. Dr. Gawande reminds us of the 2010 report in which the Institute of Medicine stated “that waste accounted for thirty percent of healthcare spending, or some seven hundred and fifty billion dollars a year, which was more than our nation’s entire budget for K-12 education.” Did you get that? Healthcare waste accounted for more than our nation’s entire budget for K-12 education! And the biggest culprit? “The amount spent on unnecessary healthcare services”.

Dr. Gawande doesn’t point fingers at others without holding a mirror to himself as well, sharing questions he now asks himself of his own decisions as he reflects back on years past. As he admits – and I think most would agree, it is much easier to err on the side of too much (service or treatment) than to err on the side of too little. But we must ask what is unnecessary and when is ‘more’ not ‘better’? It takes courage to ask “What can we do better?”

Dr. Gawande shares a number of people’s personal stories about unnecessary testing or treatment. As he began to ask around, he said “Almost everyone had a story to tell.”

As you read Dr. Gawande’s latest article, you might again feel a bit of pessimism about the waste, the costs, the inefficiency. But read on. There is hope and there is optimism. As difficult as change can be, we can change. As challenging as it is to have one’s actions and outcomes scrutinized, and to be rewarded or penalized by those actions and results, it does seem to be driving improvement. Progress is being made in that Texas community of McAllen, and nationwide.

Dr. Gawande shares that “The test of health-care reform was whether McAllen or El Paso would become the new norm. Would McAllen’s costs come down or El Paso’s go up? Now that it has been five years since the passage of the Affordable Care Act, I thought I’d find out.” Gawande again worked with the economist Jonathan Skinner “to get a sense of what recent data reveal. As it turns out, the cost of a Medicare patient has flattened across the country, El Paso included. U.S. health-care inflation is the lowest it has been in more than fifty years. Most startling of all, McAllen has been changing its ways. Between 2009 and 2012, its costs dropped almost three thousand dollars per Medicare recipient. Skinner projects the total savings to taxpayers to have reached almost half a billion dollars by the end of 2014. The hope of reform had been to simply ‘bend the curve.’ This was savings on an unprecedented scale.”

Let’s just pause there for a minute and take that in. We are heading in the right direction. Progress is being made. This is great and positive news, especially when we are used to hearing the negative. But we can’t pause too long; we’ve got a long way to go. We have to ask “What more can we do to eliminate the waste, make the system better, and provide better care at a lesser cost for more people?”

This transformation cannot be done by one person or one group, but must be addressed by all of us – healthcare providers, vendors, even patients. Providers must ask themselves the tough questions like, “will the treatment have value?” Patients must dig deeper to fully understand the value of a treatment vs. the possible harm. Vendors must ask what they can do as well. As an employee of a healthcare IT solutions provider, I know that we must continually ask ourselves and our customers how our tools can help drive the necessary change? What type of analytics and decision making support is needed? How can we support the efficient delivery of care, regardless of the caregiver’s location? How can we foster collaboration of the care team and sharing of information to help drive less redundant tests, shorter hospital stays, and the right care for the right patient at the right time?

So let’s celebrate the progress but commit to moving forward. Let’s all have the courage of Dr. Gawande to admit there is more we can do, and act on it.


“Overkill, An avalanche of unnecessary medical care is harming patients physically and financially. What can we do about it?”, Atul Gawande, May 11, 2015.

“The Cost Conundrum. What a Texas town can teach us about health care.”, Atul Gawande, June 1, 2009.

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