What's Wrong With American Medicine?

The New Yorker ignores the elephant in the room: money.

By Tony Dajer|Friday, May 18, 2007
RELATED TAGS: HEALTH POLICY

Jerome Groopman and Atul Gawande, two Harvard University ­researchers, clinicians, and best-selling authors, are for my money the best medical writers around. The New Yorker’s one-two punch for a decade now, the two have set a new standard with their precise prose, command of facts, and investigative brilliance. On topics ranging from the proper care of terminal cancer patients to how the best cystic fibrosis doctors push their patients’ life spans far beyond the mean, they have certainly educated this colleague. Now, from different angles, they each go after the same crucial question: Why isn’t medical care better? And each, in turn, misses the mark.

Medical errors made headlines in 1999 when an Institute of Medicine report revealed that these mistakes cause 98,000 deaths a year. Since then, a bevy of cognitive-science studies have demonstrated how doctors jump to conclusions, overrely on quick pattern recognition, let prejudices sway them, and of course, don’t listen enough.

In his new book, How Doctors Think (Houghton Mifflin, $26), Groopman goes at the problem from the inside out, examining “what goes on in a doctor’s mind as he or she treats a patient.” His concern stems from recent studies confirming that “the majority of errors are due to flaws in physician thinking, not technical mistakes.” By acquainting laymen with the most common mental errors, he aims to give patients and their families the tools to help their doctors think and thereby prevent misdiagnoses.

Groopman sifts through representative cases for the mental blinkers, blind spots, and prejudices that lead to error. There’s the saga of a woman repeatedly misdiagnosed over 15 years with irritable bowel syndrome and psychiatric problems until a gastroenterologist detects celiac sprue—an immune assault triggered by gluten in her diet. Next is the adopted Vietnamese baby girl with severe infections: She almost gets a bone marrow transplant until her Web-scouring adoptive mother persuades doctors to repeat her immune-function tests, which all turn out to be normal.

In Better (Metropolitan Books, $24), Gawande, for his part, gives us case studies of high-performing medical innovators—from military surgeons in Iraq who have devised ways to improve the survival of the severely injured to the designers of hand-washing campaigns to reduce hospital-borne infections in the United States—and roots through the methods of these “positive deviants” to reveal how they do things, well, better than the rest of us. The elements of their success, he tells us, boil down to key personal strengths: diligence, moral integrity, willingness to acknowledge failure, and ingenuity in seeking solutions. This includes carefully tracking the details of their own performance, since only by measuring outcomes can they later analyze which approaches work and which do not.

A subtle provincialism pervades both of these heartfelt, well-­reasoned accounts. Both authors describe the tribulations of American medicine as if they were universal. Worse, by concentrating on individual minds or hospitals and ignoring larger-scale malfunctions, they unwittingly illustrate exactly what’s wrong with how American doctors think. Like most in our profession, Groopman and Gawande fail to adequately acknowledge—much less take on—the larger institutional forces that landed us in our current health care mess.

Consider: We spend 50 percent more per capita on health care than any other country, for a total of $2 trillion a year, yet our health system, according to the World Health Organization, ranks 37th worldwide (France is number one). By any measure—longevity, infant mortality, burden of disease—we sit in the basement of the industrialized world. Yet we American doctors still fancy ourselves the best-trained ­anywhere, our care second to none. Why the disconnect? And why, if physicians’ cognitive pitfalls are so predictable and the benefit of measuring outcomes so compelling, can’t our vaunted medical schools (including Harvard) simply teach success?

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