Being Mortal

Over and over, we in medicine inflict deep gouges at the end of people’s lives and then stand oblivious to the harm done. Atul Gawande

We may fear it, deny it, or avoid thinking about it, but in time it will come to all of us. No matter how alive we feel now, eventually we will come to the end of the line. What kind of ending do we hope for?

Unless you carefully express yourself on the matter, it is likely you will end up in a hospital hooked up to a collection of tubes and monitoring machines. Is that what you want? Medicine’s focus is on prolonging your life, repairing the breakdown of your bodies, using its technical arsenal to extend your life.

In Being Mortal: Medicine and What Matters in the End, Atul Gawande, says this approach has failed. It has failed because it neglects the quality of life at its endpoint.

We are living longer, healthier lives but our body eventually breaks down. Medicine’s model is to fix the broken parts, usually by hospitalizing you, where you are stripped of control of your life and subject to treatments that more often than not only increase your pain.

The story begins with the breakdown of teeth, bone density declines, lung capacity decreases, the brain shrinks, working memory and judgment are impaired. Old age is a continuous series of losses. Eventually these losses accumulate to the point where daily life becomes more than we can physically or mentally manage on our own.

This was not a problem when individuals lived in a multigenerational home where one or more of their children could assist them. In contemporary society this type of household is rare. Very few of individuals in their 70s or 80s live with their children, in fact, most live completely alone.

“There remains one problem with this way of living. Our reverence for independence takes no account of the reality of what happens in life: sooner or later, independence will become impossible. Serious illness or infirmity will strike. It is as inevitable as sunset.”

The consequence is that doctors try to extend life for as long as possible, dosing people with mind-numbing drugs, shocking their hearts back in action, delivering painful chemotherapy with unknown effects. He cites data that 25 percent of all Medicare spending is for the five percent of patients who are in their last year of life and that most of that money goes for care in the last couple of months that is of little apparent benefit.

Gawande reports that medical interventions for people in this stage of life cause more harm and suffering that doing nothing. “…terminally ill cancer patients who were put on a mechanical ventilator, given electrical defibrillation or chest compressions or admitted near death to intensive care had substantially worse quality of life in their last week that those who received no such interventions.”

Being Mortal describes several alternatives to medical treatment at the end of life. Gawande considers nursing homes, most of which have a checkered history and explores the benefits and drawbacks of assisted living centers, hospice and palliative care. There are enormous variations in the quality of care in each of these settings.

He asks readers to discuss the type of life they want at its end with their doctor. Is there anything that makes this stage of life worthwhile? Each of us probably has our own answer. Many want to be at home, others with their family. He describes one program that brought children, plants, and various animals into a senior housing setting. Compared to the period before this intervention, the director reported that drug costs fell by 38 percent and deaths declined by 15 percent.

Most people fail to discuss their end of life care with their physician, leaving them at the mercy of hospital treatment. In the event that happens, it is important to make clear your answers to four crucial questions:

1. Do you want to be resuscitated if your heart stops?
2. Do you want aggressive treatments such as intubation and mechanical ventilation?
3. Do you want antibiotics?
4. Do you want tube or intravenous feeding if you can’t eat on your own?

Ideally you should also give you doctor a notarized Advance Directive Form that is legally binding in your state.

Toward the end of Being Mortal, Gawande briefly discusses euthanasia. He critiques the end-of-life policy in the Netherlands in the belief that as a doctor “our ultimate goal is not a good death but a good life to the very end.”

The book is liberally sprinkled with case histories that document Gawande’s central themes.

“I never expected that among the most meaningful experiences I’d have as a doctor—and, really, as a human being-would come from helping others deal with what medicine cannot do as well as what it can…When to shift from pushing against limits to making the best of them is not often readily apparent. But it is clear there are times when the cost of pushing exceeds it value.”

Being Mortal is a difficult book to read, some will find it irrelevant to their life, others will find it quite timely. Most likely it depends on your age. But its difficulty is more than outweighed by the quality of Gawande’s writing and his honesty in discussing mortality.

"Stupid Little Checklists"

Did you ever go to the market only to find you left your shopping list at home? Who hasn’t? Who hasn’t made far more serious mistakes? Doctors make them all the time, airline pilots do on occasion, construction engineers are known to make them too.

Dr. Atul Gawande’s latest book, The Checklist Manifesto: How to Get Things Right, is a study of mistakes, about making and preventing them and how to do so quickly and effectively, at least how to make a start in that direction. Gawande is a surgeon, a staff writer for the New Yorker, a professor at Harvard, and a MacArthur fellow. It is a mistake not to listen to him.

Early in the book he writes, “…the volume and complexity of what we know has exceeded our individual ability deliver its benefits correctly, safely, or reliably. Knowledge has both saved us and burdened us.”

Consider the enormously complex situation an airline pilot faces as he sits in the cockpit getting reading to fly a massive 358,000 lb (that’s empty) Boeing 747 crammed with 545 passengers several thousand miles across the sea. At least a thousand things could go wrong causing the death of the passengers to say nothing of himself and his 33-member crew. How does he avoid making a potentially horrible mistake—a single one could be fatal--in a situation where countless things that could go wrong?

What he does is to start going over, one by one, a set of really simple checklists. There are the checklists he goes over as he inspects the outside of the plane, and those that he reviews before turning on the engines, and another set before pulling away from the gate, plus those before taxiing out to the runway, etc.

He also has a sizable notebook consisting of the “non-normal” checklists “covering every conceivable emergency situation a pilot might run into: smoke in the cockpit, different warning lights turning on, a dead radio, a copilot becoming disabled, and engine failure, to name just a few.” Gawande dramatically describes instances when a careful review of one of these checklists avoided a crash and a few when they weren’t looked at carefully that ended in a tragedy.

Gawande admits doctors don’t much like those “stupid little checklists,” that they aren’t much fun, and that physicians are often reluctant to employ them, largely because they raise doubts about their competence. Against this reluctance, he marshals one study after another to demonstrate how effective checklists are in reducing the alarming number of medical errors.

In one study the introduction of a checklist reduced infections when an intravenous line is inserted into patents in intensive care units (I.C.U.) to zero from its normal rate of 11 percent. Two years after the checklist was introduced it was estimated that it had prevented 43 infections, avoid 8 I.C.U deaths, and saved the hospital in which it was studied approximately $2 million.

Another study for the World Health Organization examined the effects of introducing checklists in surgical care at eight hospitals in both developed and undeveloped countries. “The rate of major complications for surgical patients in all eight hospitals fell by 36 percent after the introduction of the checklist. Deaths fell 47 percent. …Overall in this group of nearly 4,000 patients, 435 would have been expected to develop serious complications based on our earlier observation data. But instead just 277 did. Using the checklist had spared more than 150 people from harm—and 27 of them from death.”

The checklist may seem like a minor, relatively innocuous tool to employ in order to avoid making mistakes. The evidence that Gawande assembles from medical, construction, and aviation situations suggests otherwise. It is another mistake not to take these findings seriously.

Errors will continue to be made, accidents will occur, mental lapses are inevitable, but the use of a checklist will help overcome some of them. They are a start and only a start in confronting the fallibility of the human judgment in the face of the increasing complexity of modern life.

The Cost Conundrum

As the debate about health care reform moves into its decisive and most contentious phase, Atul Gawande has once again joined the fray in the June 1st issue of The New Yorker. In this article he reports on the costs of medical care in McAllen, Texas, an obscure town on the south-west border of the state that claims to be the Square Dance Capital of the World. Why McAllen?

According to Gawande, McAllen is one of the most expensive health-care markets in the country. He says in 2006 Medicare spent fifteen thousand dollars per enrollee there, almost twice the national average. Gawande wants to know why. Step by step he considers each of the likely reasons.

He notes that the people who live in McAllen are not healthy and with its high poverty rate “has an incidence of heavy drinking, sixty percent higher than the national average. And the Tex-Mex diet has contributed to a thirty-eight percent obesity rate.”

Still he says that the incidence of cardiovascular disease there is actually lower than the national average and that the health statistics in nearby El Paso County are “just as bad as in McAllen, yet Medicare expenditures were half as much as in McAllen, so an unhealthy population couldn’t be the reason that McAllen’s health care costs are so high.”

Further, after visiting most of the hospitals in the area, Gawande concludes there’s no evidence the treatments and technology in McAllen are superior (and therefore more costly) than those found at some of the best medical centers in the country, e.g., Harvard, Stanford and the Mayo Clinic.

So the service is no better, physician malpractice insurance isn’t any higher, and McAllen is no more litigious than anywhere else in the country. A surgeon finally confessed, “We all know…There is overutilization here, pure and simple. Doctors, he said, were racking up charges with extra tests, services and procedures.”

Gawande writes, “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…critically ill Medicare patients received almost fifty percent more specialist visits in McAllen than in El Paso…twenty percent more abdominal ultrasounds, thirty percent more bone density studies, sixty per cent more stress tests with echocardiography…The primary cause of McAllen’s extreme was, very simply, the across-the-board overuse of medicine.”

In spite of this, the patients in such high spending areas do “no better than other patients, whether this is measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything they seemed to do worse.” They simply do not get what they need, such as low cost preventive services, flu and pneumonia vaccines, etc.

In addition to over utilization of costly medical technology, the physicians in this area of the country have come to view their practice as primarily a business, as a revenue stream. Gawande writes, “They instruct their secretary to have patients who call with follow-up questions to schedule an appointment, because insurers don’t pay for phone calls, only office visits. They consider providing Botox injections for cash. They take a Doppler ultrasound course, buy a machine, and start doing their patient’s scans themselves, so that the insurance payments go to them rather than to the hospital. They figure out ways to increase their high-margin work and decrease their low-margin work.”

Taken together with the over-utilization of medical services, the medicine-as-business mindset has led to the extraordinary per person cost of medical care in this community, while at the same time, doing little if anything to improve patient health.

To get a handle on these costs, Gawande urges the expansion of “accountable care organizations in which doctors collaborate to increase prevention and the quality of care while discouraging overtreatment, undertreatment, and sheer profiteering.”

The President has said that the biggest threat to our nation’s economic future is the “skyrocketing” cost of medical services. Gawande makes it abundantly clear that we can avoid this threat by delivering better health care, avoiding unnecessary medical tests, and taking measures to blunt excessive financial incentives. Doing all this is likely to reduce significantly the “skyrocketing” costs of medical services in this country without negatively affecting the quality of patient care.

On Torture

In the March 30th issue of the New Yorker Atul Gawande has written a disturbing article about the effects of extreme sensory deprivation or what is more commonly known as solitary confinement. The issue looms large in current discussions of torture, as well as reform of the prison system in this country.

When I was doing undergraduate work in psychology, the research on sensory deprivation was already well known. The work of Harry Harlow on isolating infant monkeys (Gawande notes they “usually go into a state of emotional shock, characterized by…autistic self clutching and rocking.”) had been published, as had the earlier work of John Lily on isolating individuals in salt-water tanks without light or sound. It was clear from the research that the effects of prolonged periods of isolation caused extreme anxiety, hallucinations, anti-social behavior, and depression.

Gawande asks: “If prolonged isolation is—as research and experience have confirmed for decades—so objectively horrifying, so intrinsically cruel, how did we end up with a prison system that may subject more of our own citizens to it than any other country in history?”

He describes the cases of prisoners who have spent several years in isolation, as well as the experiences of hostages, such as the journalist Terry Anderson and the war prisoner John McCain, all of whom described their experience of total isolation as nothing less than extreme torture.

My main interest in this article is not so much the profound effects of such an experience, but rather the efforts to provide an alternative form of treatment for potentially dangerous prisoners. Gawande describes an approach adopted in Great Britain designed to prevent “prison violence rather than on delivering an ever more brutal series of punishments for it.” The program assumes that violence within a prison setting is largely a function of the conditions of incarceration.

Some of the conditions introduced in this program include: (1) work opportunities, educational programs and training in social skills, (2) mental-health treatment programs, (3) more social contacts—visits, phone calls, joint meals, (4) a procedure for airing grievances, etc.

According to Gawande: “The use of long-term isolation in England is now negligible. In all of England, there are now fewer prisoners in extreme custody than there are in the state of Maine.” However, he says nothing about the other effects of the program—the frequency of prison violence, the overall behavior of the inmates, the likelihood of early parole or anything else about the effects of the work or educational programs, or the recidivism rate, if any, of the prisoners released from the prison.

We do know, however, from other studies that prisoners who have been subject to solitary confinement without other support programs have an extremely high rate of recidivism. Other studies have indicated that the introduction of so-called “supermax” prisons (there are now well over sixty in this country) where solitary confinement is widely practiced does not reduce the levels of inmate violence.

According to Gawande efforts in the United States to adopt a similar program in place of long-term isolation and other punitive approaches “went nowhere, of course. Whatever the evidence in its favor, people simply did not believe in the treatment.” He says any elected official or prison commissioner in this country who advocates the abolition of solitary confinement would be committing political suicide.

Has the public mood change of late? We do know that there has been a reversal in the stated government policy concerning torturing captured “terrorists.” Perhaps that will eventually generalize to the prison system itself.

Near the end of his analysis, Gawande concludes: “The United States now has five per cent of the world’s population, twenty-five per cent of its prisoners, and probably the vast majority of prisoners who are in long-term solitary confinement.” It is safe to say that this type of punishment is doing nothing to reduce the overall level of violence within or outside of the prison system.

Health System

The January 26th issue of The New Yorker published a provocative essay on the US health care system by Atul Gawande. He begins by noting: “In every industrialized nation, the movement to reform health care has begun with stories about cruelty.” Those currently abound in our own country.

He argues that it is essential to respond to the US health care crisis by building on the current system and attempts to support this view with examples (selectively) from other countries that have a universal health care system.

For example he reports that in Great Britain: “The N.H.S. was a pragmatic outgrowth of circumstances peculiar to Britain immediately after the Second World War….As a matter of wartime necessity, the government began a national Emergency Medical Service to supplement the local services. By 1945, when the National Health Service was proposed, it had become evident that a national system of health coverage was not only necessary but also largely already in place—with nationally run hospitals, salaried doctors, and free care for everyone.”

And in France: “With an almost impossible range of crises on its hands—food shortages, destroyed power plants, a quarter of the population living as refugees—the de Gaulle government had neither the time nor the capacity create an entirely new health-care system. So it built on what it had, expanding the existing payroll-tax-funded, private insurance system to cover all wage earners, their families, and retirees. The self-employed were added in the nineteen sixties. And the remainder of uninsured residents were finally included in 2000.”

Gawande claims that in each case the response to the crisis that existed in these countries gave rise to a health care system based upon the existing one, a process he calls “path dependence” following social scientists who have used that term to describe similarly designed system-wide social changes. The new system was not created de novo or based on a totally new design that replaced the existing system, but rather each countries “own history, however, imperfect, unusual, and untidy.”

In the United States it is estimated that the cost of health care is twice as much as other “developed” nations that have a universal health care system. The US also ranks well below these countries on various measures that assess the overall health of its citizens. More than 40 million American are said to have no health insurance, including a sizable number who are denied insurance by for-profit private insurance providers.

These conditions are crises enough to mandate change. But unlike Great Britain, we do not face a wartime emergency or like France, a post-war breakdown of society. While we face major economic problems, we do have adequate time to consider a fundamental change in the US health care system, one that would take the best of our current system and combine it with features that make it universal and more cost effective. We do not have to ignore what is currently in place, but we do not have to retain all of it either.

On my view that would involve a universal health care system based on Medicare, our current hospital and physician services, research facilities and pharmacies. It would also eliminate for-profit insurance providers that are no longer necessary under this type of universal health care program. In short, such a program would build upon our current system while, at the same time, centralizing its administration, expanding its coverage, and reducing its costs.

While this is far from the major topic of Marks in the Margin, it is one that interests me enormously. I can’t help but think it is one that most everyone is confronted with today and the fact that it is the subject of a thoughtful analysis in The New Yorker led me to write a few words about it. Some additional passages from Gawande’s essay are posted below.


Today, Securite Sociale provides payroll-tax financed insurance to all French residents, primarily through a hundred and forty-four independent, not-for-profit, local insurance funds. The French health-care system has among the highest public-satisfaction levels of any major Western country, and compared with Americans, the French have a higher life expectancy, lower infant mortality, more physicians and lower costs.

…at some alchemical point, they [the stories] combine with opportunity and leadership to produce change.

On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And on the right, the free marketers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.

The country has this one chance, the idealist maintains, to sweep away our inhumane, wasteful patchwork system and replace it with something new and more rational. So we should prepare for a bold overhaul, just as every other Western democracy has. True reform requires transformation at a stroke. But is this really the way it has occurred in other countries? The answer is no.

…other countries came to universalize health care under entirely different circumstances.

Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens.

Employers who wanted to compete for workers [during World War II] could, however, offer commercial health insurance. That spurred our distinctive reliance on private insurance obtained through one’s place of employment…that we’ve struggled with for six decades.

Some people regard the path-dependence of our policies as evidence of weak leadership; we have, they charge allowed our choices to be constrained by history and by vested interests.

So accepting the path-dependence of our health-care system—recognizing that we had better build on what we’ve got—doesn’t mean that we have to curtail our ambitions.

It should leave no one uncovered…It should no longer be an economic catastrophe for employers. And it should hold doctors, nurses, hospitals, drug and device companies, and insurers collectively responsible for make care better, safer, and less costly.