The future of patient priorities with Atul Gawande

未来耐心优先权与Atul Gawande

Sean Ruck, Contributing Editor | November 26, 2014
Atul Gawande
From the November 2014 issue of HealthCare Business News magazine

Accomplished surgeon and New York Times bestselling author Dr. Atul Gawande spoke with HealthCare Business News about a key topic presented in his latest book, Being Mortal, which hit stores in October.

HCBN: Your books call into question the way health care professionals do things they’ve been doing for decades. Do you ever get backlash from peers?
Not nearly as much as I expected. I think it’s because I’m voicing struggles and confusions I’m having in my own practices – how do we cope with our own imperfections? How do we measure ourselves? How do we deal with complexities in medicine which is highly specialized and also fragmented? And in my latest book, how do we deal with problems we can’t fix?

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HCBN: Would you consider yourself a health care revolutionary?
No. I think in a funny way, I’m an incrementalist, I’m interested in difficult problems, but not interested in blowing up what works. We’ve made enormous progress in medicine. We have incredible talent. But we have genuine difficulties dealing with certain problems. So what’s the path forward? Sometimes there are pretty interesting paradigm shifts, like how we could better manage mortality.

HCBN: In Being Mortal, you provide numerous examples of how the system is failing the elderly and terminally ill. You also suggest ways to give them the best lives possible for the time they have left. If money and politics weren’t obstacles, is there any solution that sticks out as the most worthy of pursuit?
First, there needs to be recognition that a very fundamental mistake we’re making is not realizing people have priorities other than just living longer. Second, the most reliable way to find out what those priorities are is just to ask. But we most often do not ask even when people are just weeks or months away from the possibility of the end of their lives. When we have those conversations, the results are often transformative. It’s a little complicated, because to be effective, these conversations have to be repeated over time because values change. Health systems should support their palliative care departments to not just support patients, but also staff. They should be monitoring what is our quality of conversations with patients and help coach and improve these skills. We need patients to be able to sign things in the ER to determine their priorities – not just their insurance. We also need to track the humanities – how many doctors actually know and respect the priorities of patient lives and their care.

HCBN: Do you believe that health care professionals will take action on issues like caring for the elderly in time to prevent major failures to the system, or has that time already passed?
We’re training fewer geriatricians than a decade ago at a time when the number of elderly is increasing dramatically. What are the solutions? We need to make these professions more rewarding and encourage the growth.

We also have to redefine what a “win” is in medicine. Our medical values are that health and safety come first but in people’s lives, they live for more than just health and survival. I think also sometimes people in the movement around assisted suicide think the win is a good death, but that’s wrong too – the goal is as good of life as possible all the way to the very end. You can’t enable that as a clinician unless you know what a patient feels is a good life.

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