BHN Reports: Gawande on reform — “All health care is local.”

The notion that “all health care is local” may sound odd coming from someone who has been deeply involved in health reform at the national level.

But Boston surgeon and New Yorker writer Atul Gawande made the case for locally driven reform this morning at a health care quality colloquium at Harvard.  Communities, he said, need to find ways to create working systems out of the complex, fragmented elements of medicine.

“Our deepest struggle in medicine in this wake of health reform –we can imagine that it is money or the rules and regulations that exist or yet to come down,” he said. “But if you watch the day to day experience of what it is to take care of people, you realize that the deepest root of our struggle is the complexity of what we are trying to pull off. “

Health care workers are surrounded by tests of their ability to handle the complexity that comes in the form of 13,600 diagnoses, 6,000 drugs and 4,000 procedures.  And, he said, they are trying to do it within a system that was built for a world that had fewer, simpler solutions.

The system evolved in another era when medicine was “small, fragmented and artisanal in nature,” he said. “But the volume and complexity of our discoveries has now reached  a point where it has exceeded our ability as individual artisans to deliver optimal care reliably, safely and without the waste of resources.”

He used the advent of penicillin to make his point. Penicillin seemed like a miracle, he said. It could cure diseases that seemed incurable.

“It was so simple,” he said. “It was just an injection. And it made us imagine that this would be the future of medicine. We were fooled. It made us think that discovery was the hard part and execution would be easy.”

He compared the current execution to a poorly built machine with great parts. The fee for service system has “made us almost giddy in our use of high tech services” at the expense of low profit services like geriatrics, mental health and preventive health.

But, Gawande said that he sees solutions in his reporting on cost and practice pattern variations. The highest costs systems don’t always provide the best care, he said.

“That means there is hope,” he said. “It means that there is something to be learned from what we are doing to make quality and safety better in ways that actually reduce costs.”

Gwande spoke at the National Quality Colloquium,  which is being sponsored by the Jefferson School of Population Health at  Thomas Jefferson University in Phildelphia.


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