5 ms·

That’s actually my point, I would argue Gawande doesn’t have expert knowledge. Being an expert surgeon is a very different skill set than an expert in healthcar

by entee 8y ago

That’s actually my point, I would argue Gawande doesn’t have expert knowledge. Being an expert surgeon is a very different skill set than an expert in healthcare delivery and management. Let’s take the checklist manifesto, a fantastic idea that unfortunately isn’t as widely applied as it should be. Why? Because if you ask most surgeons they’ll say, “yeah it’s a great idea, I do it already/I don’t need to do it though because I’m that good”. In practice it doesn’t get applied because humans have ego and incentives get misaligned. It’s not actually that beneficial to reduce complications in surgery for the hospital as long as the patient is insured. And it’s not that beneficial for the insurance company to reduce costs because fundamentally as long as the insurance company can accurately predict how much costs will rise next year, they still make money. They just need to know how much premiums will go up. Healthcare is full of great ideas and ways to make things better, but they often just don’t get implemented because the whole system is so poorly set up. I don’t see any evidence that Gawande for all his talents has a good approach or the expertise to break through all that.

deleted 8y ago
[deleted]
sjg007 8y ago
Surgeons don't get to play God as much anymore. Checklists dominate and are the hallmark of a good institution. One of the biggest risks in hospitals are central lines and infection. So cleaning protocols / enforcement and as much automation as possible are ways forward. The ACA imposes financial penalties on hospitals if they don't reduce infection rates and readmission rates. You can only do that if you improve quality. A hotshot with an ego is bad for business.
- verisimilitude 8y ago
  Also, I think Gawande _wrote_ "The Checklist Manifesto"!
  - spurcell93 8y ago
    Yes, that's correct - a very worthwhile read, regardless of your profession.
  - zrobotics 8y ago
    After having worked with some A&Ps (aircraft mechanics) I was shocked that surgeons didn't operate with checklists. Doesn't matter how skilled you are, mistakes happen, especially when you are in a hurry. Aircraft mechanics also typically 'shadow' their toolboxes, which is where every drawer has individual cutouts for each tool to make it easy to verify that all tools are back in their place. And apparently instruments being left in a patient isn't that uncommon: "According to the U.S. Department of Health and Human Services, it is anywhere between 1 in 100 to 1 in 5000.[1] However a study done in 2008 reported to the Annals of Surgery that mistakes in tool and sponge counts happened in 12.5% of surgeries.[8]" Why are aircraft mechanics taking better precautions against this type of low hanging fruit than surgeons, aside from ego? Ref:https://en.wikipedia.org/wiki/Retained_surgical_instruments https://en.wikipedia.org/wiki/Retained_surgical_instruments
    - kilotaras 8y ago
      > Why are aircraft mechanics taking better precautions against this type of low hanging fruit than surgeons, aside from ego? Nothing new under the sun. A guy who found that doctors should wash hands between autopsies and deliveries was ostracized by colleagues and died in asylum. [1] [1] https://www.npr.org/sections/health-shots/2015/01/12/375663920/the-doctor-who-championed-hand-washing-and-saved-women-s-lives https://www.npr.org/sections/health-shots/2015/01/12/3756639...
booleandilemma 8y ago
I think Gawande is a good choice. He’s obviously a smart, visionary-type who lacked the power to implement his vision. Now he will have that power. And he’s neither a fraud (e.g. Scott Thompson) nor a finger-on-the-trigger egoist (e.g. Elon Musk)
aaavl2821 8y ago
Your point seems true regarding that particular article, though I dont think that is sufficient to demonstrate that he doesnt understand the system. As a surgeon, I'm sure he knows the barriers to adoption of such a tool, and being the head of a large buying consortium for health insurance (Amazon / berk / jpm) could give him the market power to "wag the dog" and push payers to implement such policies. But i agree that the checklist manifesto is prob not the best / most practical way to reduce spend I'd point to another article, his "cost conundrum" article actually was a pretty insightful piece that I think gets at the core of one of the main drivers of high HC spend: local monopolies [1] Another article of his, the "hot spotters" [2], was very influential among providers, administrators and even VCs as well. However, I dont think he's right that addressing frequent fliers is the solution -- you see the same cost concentration among a few patients in all countries, and even across time, so it doesnt appear that that phenomenon is the cause of the US' unique expensiveness i dont know of many other people who have ideas that demonstrate the same combination of independent thinking, reach / visibility and understanding of the system as atul gawande (i actually dont think there are many great ideas to improve healthcare, most dont even diagnose the problems accurately). some of his ideas will be wrong, but he has new and solid hypotheses, and being able to test those and learn is a great way to make progress [1] https://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum https://www.newyorker.com/magazine/2009/06/01/the-cost-conun... [2] https://www.newyorker.com/magazine/2011/01/24/the-hot-spotters https://www.newyorker.com/magazine/2011/01/24/the-hot-spotte...
- entee 8y ago
  Your point is an excellent positive case for his appointment :). I fully agree with you on monopolies and hot spotters. The monopolies are a pernicious issue that's incredibly hard to solve, and targeting hot spotters is not likely to be the silver bullet people hope it will be. I hope he succeeds given his perspective, I'm just skeptical that he can given the scale and structure of the problem. In particular the monopolies issue seems utterly intractable. Maybe some combination of remote care and creating vertically integrated treatment centers can help? I don't know, healthcare is really hard. I just hope this isn't a flash/vision over nitty gritty execution appointment.
tim333 8y ago
>doesn’t have expert knowledge ... very different skill set than an expert in healthcare delivery and management. He's kind of celebrated for an article he wrote in the New Yorker on healthcare delivery and management. (see 'This magazine article saved $500M in unnecessary Rx spending' https://www.cnbc.com/2015/05/08/this-magazine-article-saved-500m-in-unnecessary-rx-spending.html https://www.cnbc.com/2015/05/08/this-magazine-article-saved-...) It impressed Munger, Buffett's partner sufficiently that he sent a cheque for $20,000 to Gawande at the time as a gift without knowing the guy. https://www.cnbc.com/2018/06/20/charlie-munger-once-wrote-atul-gawande-a-check-for-20000.html https://www.cnbc.com/2018/06/20/charlie-munger-once-wrote-at...

by entee 8y ago

deleted 8y ago

[deleted]

sjg007 8y ago

Surgeons don't get to play God as much anymore. Checklists dominate and are the hallmark of a good institution. One of the biggest risks in hospitals are central lines and infection. So cleaning protocols / enforcement and as much automation as possible are ways forward. The ACA imposes financial penalties on hospitals if they don't reduce infection rates and readmission rates. You can only do that if you improve quality. A hotshot with an ego is bad for business.

verisimilitude 8y ago
Also, I think Gawande _wrote_ "The Checklist Manifesto"!
- spurcell93 8y ago
  Yes, that's correct - a very worthwhile read, regardless of your profession.
- zrobotics 8y ago
  After having worked with some A&Ps (aircraft mechanics) I was shocked that surgeons didn't operate with checklists. Doesn't matter how skilled you are, mistakes happen, especially when you are in a hurry. Aircraft mechanics also typically 'shadow' their toolboxes, which is where every drawer has individual cutouts for each tool to make it easy to verify that all tools are back in their place. And apparently instruments being left in a patient isn't that uncommon: "According to the U.S. Department of Health and Human Services, it is anywhere between 1 in 100 to 1 in 5000.[1] However a study done in 2008 reported to the Annals of Surgery that mistakes in tool and sponge counts happened in 12.5% of surgeries.[8]" Why are aircraft mechanics taking better precautions against this type of low hanging fruit than surgeons, aside from ego? Ref:https://en.wikipedia.org/wiki/Retained_surgical_instruments https://en.wikipedia.org/wiki/Retained_surgical_instruments
  - kilotaras 8y ago
    > Why are aircraft mechanics taking better precautions against this type of low hanging fruit than surgeons, aside from ego? Nothing new under the sun. A guy who found that doctors should wash hands between autopsies and deliveries was ostracized by colleagues and died in asylum. [1] [1] https://www.npr.org/sections/health-shots/2015/01/12/375663920/the-doctor-who-championed-hand-washing-and-saved-women-s-lives https://www.npr.org/sections/health-shots/2015/01/12/3756639...

booleandilemma 8y ago

I think Gawande is a good choice. He’s obviously a smart, visionary-type who lacked the power to implement his vision. Now he will have that power. And he’s neither a fraud (e.g. Scott Thompson) nor a finger-on-the-trigger egoist (e.g. Elon Musk)

aaavl2821 8y ago

Your point seems true regarding that particular article, though I dont think that is sufficient to demonstrate that he doesnt understand the system. As a surgeon, I'm sure he knows the barriers to adoption of such a tool, and being the head of a large buying consortium for health insurance (Amazon / berk / jpm) could give him the market power to "wag the dog" and push payers to implement such policies. But i agree that the checklist manifesto is prob not the best / most practical way to reduce spend I'd point to another article, his "cost conundrum" article actually was a pretty insightful piece that I think gets at the core of one of the main drivers of high HC spend: local monopolies [1] Another article of his, the "hot spotters" [2], was very influential among providers, administrators and even VCs as well. However, I dont think he's right that addressing frequent fliers is the solution -- you see the same cost concentration among a few patients in all countries, and even across time, so it doesnt appear that that phenomenon is the cause of the US' unique expensiveness i dont know of many other people who have ideas that demonstrate the same combination of independent thinking, reach / visibility and understanding of the system as atul gawande (i actually dont think there are many great ideas to improve healthcare, most dont even diagnose the problems accurately). some of his ideas will be wrong, but he has new and solid hypotheses, and being able to test those and learn is a great way to make progress [1] https://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum https://www.newyorker.com/magazine/2009/06/01/the-cost-conun... [2] https://www.newyorker.com/magazine/2011/01/24/the-hot-spotters https://www.newyorker.com/magazine/2011/01/24/the-hot-spotte...

entee 8y ago
Your point is an excellent positive case for his appointment :). I fully agree with you on monopolies and hot spotters. The monopolies are a pernicious issue that's incredibly hard to solve, and targeting hot spotters is not likely to be the silver bullet people hope it will be. I hope he succeeds given his perspective, I'm just skeptical that he can given the scale and structure of the problem. In particular the monopolies issue seems utterly intractable. Maybe some combination of remote care and creating vertically integrated treatment centers can help? I don't know, healthcare is really hard. I just hope this isn't a flash/vision over nitty gritty execution appointment.

tim333 8y ago

>doesn’t have expert knowledge ... very different skill set than an expert in healthcare delivery and management. He's kind of celebrated for an article he wrote in the New Yorker on healthcare delivery and management. (see 'This magazine article saved $500M in unnecessary Rx spending' https://www.cnbc.com/2015/05/08/this-magazine-article-saved-500m-in-unnecessary-rx-spending.html https://www.cnbc.com/2015/05/08/this-magazine-article-saved-...) It impressed Munger, Buffett's partner sufficiently that he sent a cheque for $20,000 to Gawande at the time as a gift without knowing the guy. https://www.cnbc.com/2018/06/20/charlie-munger-once-wrote-atul-gawande-a-check-for-20000.html https://www.cnbc.com/2018/06/20/charlie-munger-once-wrote-at...