Dr. Robert Pearl wrote an original article in Forbes (June 25, 2018) titled, “Why Atul Gawande Will Soon Be the Most Feared CEO in Healthcare.” Dr. Gawande was named CEO of the new Amazon-Berkshire-JPMorgan Chase healthcare partnership. Dr. Gawande is a Professor of Surgery at Harvard/ Brigham and Women’s Hospital, and is the bestselling author of multiple nonfiction books directed at healthcare topics. Gawande also has a Masters Degree in Public Health, and with his background as a clinician, he is well poised to interpret the problems of our current healthcare system. Per Dr. Pearl, Gawande was hired by the new Amazon-Berkshire-JPMorgan Chase healthcare partnership to “disrupt the industry, to make traditional health plans obsolete, and to create a bold new future for American healthcare.”
I’ve read Dr. Gawande’s books and I’ve heard him speak at Stanford. I have the highest respect for his intellect, clinical acumen, and insight. I’m intrigued and excited by what changes he might envision and enact for American healthcare. Surgical care comprises $500 billion, or 40% of healthcare dollars spent spent in America, so we can expect changes in our surgical world to be a likely source of healthcare savings.
Author Dr. Robert Pearl is the former CEO of Kaiser’s Permanente Medical Group, and brother to my Stanford University Department of Anesthesiology Chairman Ronald Pearl MD PhD. In his Forbes article, Robert Pearl lists three major reforms he anticipates Gawande will advocate for. Each reform is aimed to radically improve how care is paid for and provided—and each reform is aimed to radically alter how healthcare providers must function to survive in the future. Let’s look at these three proposed Gawande changes, and how they affect the future for anesthesiologists:
- Taking out the trash. Pearl writes, “It’s estimated that 25 percent of all U.S. healthcare spending (about $765 billion each year) is wasted. From arthroscopic knee surgeries for chronic cartilaginous injuries to chemotherapy administered in the last month of life, insurers have long reimbursed unnecessary claims and perpetuated a fee-for-service model that rewards doctors for providing more (not better) care. Dr. Gawande has witnessed the excesses of modern medical treatment first-hand, cataloging in his essays the toll wasteful care takes on patients, including his own friends and family. I believe one of his first operational goals will be to root out wasteful spending and services, not as way to ration care, but as a tool to improve clinical outcomes.”
EFFECT ON ANESTHESIOLOGY AND PERIOPERATIVE MEDICINE: Each “unnecessary claim” that needed an anesthesiologist and every “fee-for-service” procedure that involved anesthesia care would disappear, decreasing the need for anesthesiologists and anesthesia services. This proposed elimination of wasteful spending would decrease the demand for anesthesia professionals.
- Creating a checklist. Pearl writes, “Gawande earned national acclaim with his 2009 bestseller, The Checklist Manifesto, inspiring an entire industry to double down on evidence-based medicine. From the exam room to the operating room, doctors today follow a clear set of protocols that Dr. Gawande helped establish. He’s currently focused on extending these successes to other areas, including maternity care and the treatment of patients with complex and chronic diseases. For example, the doctor has observed how the best healthcare providers can help 90 percent or more of their patients control high blood pressure. And yet the national control rate is just 55 percent. Left to their own devices, physicians prefer to follow their guts when diagnosing and treating patients. Dr. Gawande knows that, most of the time, science (not intuition) saves more lives, raises the quality of care and lowers costs.”
EFFECT ON ANESTHESIOLOGY AND PERIOPERATIVE MEDICINE: In the future, specific evidence-based protocols and algorithms could dictate anesthesia “recipes.” In the past, every anesthesia provider has had the freedom to design and carry out the pharmacology, monitoring, and perioperative care for each patient as he or she saw fit. These individual decisions were based on each physician’s training and experience. But in recent years, for example, protocols have been introduced to standardize perioperative care for total knee replacement, so that anesthetics include a spinal anesthetic, an adductor canal nerve block, and sedation or a light general anesthetic as well as multimodal analgesia with oral analgesic supplements. These total knee protocols have become standardized and accepted. What about future protocols? Can an insurer dictate what they will or will not pay for, based on their assessment of scientific evidence? This could occur if the insurer has data that the non-protocol care does nothing to improve quality, and it costs more. Let’s look at an example: There are a variety of pharmaceutical choices for the anesthesia care of a shoulder arthroscopy. An ultrasound-directed nerve block is optional. Is there evidence that the block provides safer or cheaper outcomes? If an evidence-based analysis is conducted and it shows that complications, costs, room time, and ancillary staff support are most economical with general anesthesia sans a nerve block, then that interscalene nerve block could be deemed an extraneous charge—an extraneous procedure that will not be paid for. If an anesthesiologist wanted to use the nerve block, the insurer would not reimburse those costs. Only the drug costs, procedures, and protocols approved by the insurance company would be approved. In the current fee-for-service practice, the anesthesiologist may be reimbursed $1000 for an ultrasound-directed nerve block that takes 5 minutes to perform. In the future the anesthesiologist may be doing that block without any reimbursement, yet still be responsible for any costs of that block and any risks or complications of that block. Having Amazon/Gawande dictate evidence-based protocols for postoperative care may produce cost-cutting economics, and anesthesiologists might find their hands tied to a recipe dictated from on high.
- Being human. Pearl writes, “In Being Mortal, Dr. Gawande shines an unflattering light on end-of-life care in America, revealing that treatment for our nation’s elderly is often expensive, ineffective and inhumane. He has long been an advocate for the model of clinician as counselor, not as technician, and for the power of palliative care to make end-of-life treatment more compassionate and personal. His stories about his own father and mother are moving, and underscore the emotions driving his desire to improve care for our nation’s sickest patients.”
EFFECT ON ANESTHESIOLOGY AND PERIOPERATIVE MEDICINE: All physicians have witnessed expensive and often futile end-of-life intensive care management for elderly patients. If physicians and hospitals are offered an open checkbook, they may choose to administer expensive high-tech interventions to elderly patients during their last weeks of life, including ventilator care, pressors, multiple antibiotics, blood product transfusions, and surgeries. In America we value every life as a precious resource. We value saving every life. It’s probable true that we can no longer afford to spend millions of dollars on the last weeks of each sick elderly patient’s life. It’s probably true that we need some conscience, some compassion, some judgment, and some empathy to choose who to attempt to save. Currently physicians cannot police these decisions themselves, and the government cannot set any rationing policies regarding end-of-life care. It may very well be insurance companies like Amazon/Gawande who set the incentives and disincentives directing payment or non-payment for such care. If surgeons and medical centers lose incentives to perform end-of-life surgical procedures, there will be decreased caseloads for anesthesiologists.
The expense of the current American healthcare system is unsustainable. Healthcare costs are 17% of the Gross National Product, and this percentage is growing every year. The cost of insuring employees is a large share of the wage and benefit expenses of every American CEO. The cost of insuring loved ones with current high-deductible insurance plans is a large share of the expense budget for every American family.
Something has to change. The driver of change may very well be the combined economic clout and intellect of: Amazon, the company that delivers UPS packages to our door 36 hours after placing an order; Warren Buffett, the world’s third richest man; J P Morgan Chase, a multi-national investment bank; and d) a talented physician/author/visionary named Atul Gawande.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
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