By Evan Falchuk

Ezra Klein recently wrote that doctors were at the root of our health care problems, citing Atul Gawande’s discussion of McAllen as his inspiration, as well as Steve Pearlstein’s work.  I’ve already noted how both Klein and Pearlstein misunderstand Gawande’s work.

Now, Klein has scored an interview with Gawande.

Gawande thinks we don’t have nearly enough data to make the kinds of important changes to our system we are talking about.  It’s clear that his central question – what will be the anchor model of health care – is being lost in questions of public plans and payment schemes, and in the rush to pass legislation.

All medicine is local, says Gawande, and we need to find out how and why and how to spread what works:

But getting there requires a change in local medical cultures and rebuilding local medical systems. All medicine is local just as all politics is local. But let’s create a cadre of researchers who go into these communities and figure out what’s going on and spread the word.

The Washington debate — there are smart reasons to think about including a public option in the mix, but we have not been thinking hard enough about how we control costs and make a better system. I think it’s achievable in about 10 to15 years, and maybe even faster.

Financial incentives are real, but we need to understand the real reasons for cultural differences, because you can’t explain them by just looking at the money:

It’s not just about incentives. The interesting thing to me is not that McAllen is different from elsewhere. it’s that El Paso is different than McAllen. They have the incentives to go in that direction! My hypothesis is that communities have local anchor institutions that foster values and norms that make the medical system successful. My sense is that in McAllen it was about a few institutions striking out in different ways that set the norm for what others did. . . .

What I’ve observed — and we really need some real data behind in it — but in those places with organized systems of care, with lower cost and higher quality, they’ve had to find some way to blunt the incentives of quantity over quality, or, more bluntly, revenues over patients’ needs. Some of them have done it by moving doctors to salaries, like Mayo or Kaiser. But others, like Grand Junction, don’t salary. They have fee-for-service. But they have medical groups that make sure that people who see more Medicaid or uninsured patients aren’t penalized, and they remove a physician’s privilege to practice at the hospital if they don’t participate in a strong peer review system. And there are, to be sure, salary hospitals where you see very poor quality of care and people leave at three.

On how the progress of science, as much as the system, is making the lives of doctors more difficult:

On the medical side, there is a much greater sense of dissatisfaction in our work lives. We’re working incredibly hard to make the system work for our patients. But it doesn’t work very well for them or us. Some of that is the march of science. The increase in coordination and complexity makes it impossible to do this stuff out of your office. We’re not in a system that’s well equipped to make this a satisfying way to spend your time. . . .

The underlying force here is not the politics but the science. We have 13,000 diagnoses for people. 13,000 ways the human body can fail. We can treat a lot of it. But it’s not like penicillin. It’s complex stuff. . . .Our health system was built for a 20th century science.

Gawande is saying we need to learn more.  We need to understand how by oversimplifying these problems we may only make them worse.

But more than this, he is saying on the path we are following, we can’t possibly win.  Health care is more complicated than we could possibly understand.

Obi-wan Gawande