Atul Gawande

Bill Haynes is a chronic migraine sufferer. After years of treatments, he landed at a headache specialty clinic where a physician “started by lowering expectations…Success meant that the headaches became less frequent and less intense, and that the patients grew more confident in handling them.”

SYSTEMATIC INCREMENTALISM

We have a certain heroic expectation of how medicine works. Following WWII, penicillin and then a raft of other antibiotics cured the scourge of bacterial diseases that it had been thought only God could touch. New vaccines routed polio, diphtheria, rubella, and measles. Surgeons opened the heard, transplanted organs, and removed inoperable tumors. Heart attacks could be stopped; cancers could be cured. A single generation experienced a transformation in the treatment of human illness as no generation had before. IT was like discovering that water could put out fire. We built our healthcare system, accordingly, to deploy firefighters. Doctors became saviors.

But the model wasn’t quite right. If an illness is a fire, many of them require moths or years to extinguish, or can be reduced only to a low-level smolder. Chronic illness has become commonplace, and we have been poorly prepared to deal with it. Much of what ails us requires a more patient kind of skill.

Primary care is the medical profession that has the greatest overall impact, including lower mortality and better health, not to mention lower medical costs…reforms in California that provided all Medicaid recipients with primary care physicians resulted in lower hospitalization rates. By contrast, private Medicare plans that increased co-payments for primary-care visits–and thereby reduced such visits–saw increased hospitalizations rates. 

Incrementalists…focus on the course of a person’s health over time–even through a life. All understanding is provisional and subject to continual adjustment…Success, therefore, is not about the episodic, momentary victories, though they do play a role. It is about the longer view of incremental steps that produce sustained progress. That, such clinicians argue, is what making a difference really looks like. 

Gawande tells the story of the Silver Bridge which collapsed in 1967. It was the first catastrophe reviewed by the National Transportation Sfety Board. Until this point in history, bridges, roads, dams, etc were not reviewed at all. In fact, they were usually only replaced after a catastrophic event. He draws the parallel to healthcare and how we need to move from only treating problems once they require heroic efforts, to annual physicals, to real-time tracking. 

Today, however, we still have almost a hundred and fifty thousand problem bridges. Sixty thousand have traffic restrictions because they aren’t safe for carrying full loads. Where have we gone wrong? The pattern is the same everywhere; despite knowing how much cheaper preservation is, we chronically raid funds intended for incremental maintenance and care, and use them to pay for new construction. It’s obvious why. Construction produces immediate and visible success; maintenance doesn’t. Does anyone reward politicians for a bridge that doesn’t crumble?

We don’t like to addresss problems until they are well upon us and unavoidable, and we don’t trust solutions that promise benefits only down the road. Incrementalists nonetheless want us to take a longer view. They want us to believe that they can recognize problems before they happen, and that, with steady, iterative efforts over years, they can reduce, delay, or eliminate them. 

Instead of once-a-year checkups, in which people are like bridges undergoing annual inspection, we will increasingly be able to use smartphones and wearables to continuously monitor our heart, breathing, sleep, and activity, registering signs of illness as well as effectivenesss and the size effects of treatments. 

Our healthcare system is not designed for this future–or, indeed, for this present. We built it at a time when such capabilities were virtually nonexistent.When illness was experienced as a random catastrophe, and medical discoveries focused on rescue, insurance for unanticipated, episodic needs was what we needed. Hospitals and heroic interventions got the large investments; incrementalists were scanted. 

The evidence of the here vs. incrementalists societal value is evidenced by physician salaries where intervential specialists make twice that of family medicine, infectious disease, psychiatry, reheumatoloty, etc…

In this era of advancing information, it will become evident that, for everyone, life is a preexisting condition waiting to happen. We will all turn out to have–like the Silver Bridge and the growing crack in its criticism steel link–a lurking heart condition or a tumor or a depression or some rare disease that needs to be managed. This is a problem for our healthcare system. It doesn’t put great value on care that takes time to pay off. But this is also an opportunity. We have the chance to transform the course of our lives.

Doing so will mean discovering the heroism of the incremental. That means not only continuing our work to make sure everyone has health insurance but also accelerating efforts begun under health reform to restructure the way we deliver and pay for healthcare.