One of Us?

Anchorage to Denali - photo by JoAnn Sturman

by Scott Sturman

As the only conservative in America whose favorite magazine is the New Yorker, I long ago stopped reading the editorial page.  Unlike the op-ed page, which reminds me of a high school valedictorian’s commencement speech proclaiming how their generation will right every wrong in the world, the articles are informative, entertaining, and well written.

Like many in my medical group I share the view there is too much waste in medicine, which is often exacerbated by needless regulations which make our jobs more difficult.  As an example, we are forced to discard perfectly safe and effective drugs which are not only scarce but expensive.  The insanity reminds me of my experience in the Air Force in 1973 when the nation was in the throes of a fuel shortage.  With cars backed up for miles at service stations, we flew so many hours that our butts cried for relief.   Even without a valid mission, Lt. Colonel Michaels ordered his pilots to bore holes in the sky and waste tons of JP4 for fear if not used, the unit would be allocated less flying time the next quarter.

And then in 1998 some articles began appearing in the New Yorker Magazine written by Atul Gawande, a physician who was also a surgical resident.  How did he have time to churn out these in depth, poignant observations, when at the time most surgical residents considered a hundred hour work week to be short?  Essays followed which discussed clinical problems from a unique, but refreshing point of view and exposed inefficiencies within the health care system which were expensive and extraordinarily wasteful.  Here was an eloquent spokesman for the medical profession and one of us.

After the Presidential election of 2008 Dr. Gawande’s writings took on more of a political slant, and although medical problems and waste were frequent topics, his articles were suffused with comments supportive of national health care.  His solutions to the the health care crisis made no mention of market forces, competition, or health savings accounts, but relied on central control, as he extolled the merits of ObamaCare.  If this bright man, whose success as a journalist was based on exposing inadequacies in the system, why did he virtually ignore tort reform and fraud as contributing causes?  He was no longer a colleague but the voice of socialized medicine.

An author’s background offers clues about personal motivations, and a glimpse at Wikipedia was revealing.  Medical students and residents may have political views, but most are not political activists; there is simply not enough time or resources.  This is particularly the case of general surgery residents, who battle fatigue and sleep deprivation, and extra time is spent collapsed in bed.  Dr. Gawande’s history is unusual in this respect.  As a student he volunteered for the Gary Hart Presidential campaign and again for Al Gore in 1988.  He took a hiatus from medical school in 1992 to campaign for Bill Clinton and served as a senior advisor for the Department of Health and Human Service in the Clinton Administration before returning to medical training.  During this time he cultivated contacts within the Democratic Party and main stream media which catapulted his career and gave him access to resources far beyond those of the normal surgical resident or practicing physician.

Dr. Gawande is a gifted writer, and he has used his skills to popularize issues in clinical medicine and to propose sweeping changes to the health care system.  However, when it comes to choosing between national health care or private practice medicine, he is one of them and not one of us.   

Gem of Thailand

Towards Mt. Shishapangma - photo by JoAnn Sturman

Scott Sturman

fliesinyoureyes.com

Atul Gawande has worked for the Presidential campaigns of Gary Hart, Al Gore, and Bill Clinton and began writing articles for the New Yorker Magazine as a surgical resident.  He has a way of presenting clinical medical issues in a manner which is entertaining and easy to read.  Of late he has eschewed the medical side of medicine and devoted his skills to convincing the public about the benefits of national health care.  This month in the New Yorker Magazine he suggests the U.S. health care system should be run more like the Cheese Cake Factory.  The clever comparison made its way to NPR, which immediately aired an interview with the author, who is not known as a champion of private practice medicine.  For Dr. Gawande to recommend a casual dining company as a model for the slightly more complex health industry, he must perceive the restaurant’s standardization, copious menu, tasty beverages, and inviting atmosphere as the epitome of the culinary experience.  Although the utter sameness and predictability of the Cheese Cake Factory make it a suitable metaphor for national health care, it is known best for its dessert menu: the portion of the meal which Americans should be most wary and avoid most often. 

Standardization is key to the casual dinning industry and socialized medicine.  As an example, the author cites a protocol developed at Brigham and Women’s Hospital in Boston which has led to a reduction in hospitalization days for patients undergoing total joint operations at that institution.  The implication is the rest of the country should follow suit, and in a national health care system where funds and standard of care are tightly controlled, certain centers will be responsible for any and all innovations.  Less prestigious academic or private institutions which deviate from the proscribed mantra without prior authorization could be subjected to financial and punitive action.  Ironically and unbeknownst to the author, the Boston miracle he describes may fall short of the performance of the Fresno Surgical Hospital, where total joint patients normally remain in the hospital for only two days following surgery without the benefit of legions of house staff and ancillary personnel.   

Protocols have a place in medicine, but one day’s standard of care eventually becomes obsolete as advances lead to more efficacious care.  Dr. Gawande’s solution to the health care crisis rests heavily on unvarying routine administered by doctors who are employees of large corporations.  In the author’s ideal medical world the physician functions as a waiter serving the same meal over and over again.  The concept of a man or woman practicing medicine independently has no place in Cheese Cake Factory medicine; doctor employees do what they are told and personal initiative, running one’s own practice, and the sixty hour work week become a thing of the past.

I tend to eat at mom and pop restaurants, which offer good service and inexpensive but delicious food and where one knows the owner and staff.  There is a small Thai restaurant in a strip mall at Herndon and Blackstone in Fresno called Gem of Thailand owned by a gracious Thai lady named Gem.

Not long ago my wife and I ordered out on a busy Friday evening, and when we arrived to pick up the food, there was a large backlog.  Rather than ignore us or ask us to take a seat, Gem asked us, “Would you like a glass of water or cold beer while you wait?”  This offer was “on the house” and stemmed from an owner who knows and values her customers.  On more than one occasion I have picked up food after work, only to find when I returned home a couple Singhas stuffed into the carry out bag.

Restaurants like Gem of Thailand represent the opposite pole from Dr. Gawande’s fascination with the Cheese Cake Factory and corporate medicine.  When given the choice I prefer a restaurant which is unique and managed by owners who can put a name to a face rather the cookie cutter model.  I feel the same way about my doctor, as well.