Atul Gawande on Social Structures in Medicine

Atul Gawande has a terrific article in the New Yorker about how the way doctors organize themselves into social groups affects the effectiveness and cost of the medical care.  (I first got turned on to Gawande by my daughter Karen, who gave me two of his books to read.  He’s very thoughtful and very smart about the problems of medical care — and a terrific writer who does freelance editing jobs on the side as well.)

There are tons of interesting thoughts in the article, which is a great read, as well as insightful.  Here I’ll just piece together the high-level flow of the argument around the structure of doctor’s organizations within a locale.

1) The most expensive areas of the country for Medicare are 2-3 times the cost of the least expensive.  If these most expensive areas could be changed to cost the same as the average areas, most of the expense problems of Medicare could be solved.

2) The most expensive areas of the country do NOT get better health outcomes than the less expensive areas.  They do provide substantially more “services” — hospitalizations, tests, surgeries, etc. — but patients don’t have live longer, aren’t healthier, and aren’t happier with the results.

3) By comparing expensive locales with less expensive locales, we can rule out most of the obvious causes of the difference.  The expensive locales are very similar in types of patients, the problems those patients have, the training their doctors received, etc.

4) One key difference is that in the LESS expensive locales the doctors have organized themselves to create a medical system that changes substantially the motivations.  Doctors are evaluated on long-term patient outcomes, and cannot make themselves richer by performing additional procedures on patients.  The doctors work together collaboratively to learn how to better serve patients.

Fascinating article.  Check it out!  (Yes, it is a stretch for this blog.  Perhaps we could argue that the connection is in understanding how big a difference social structure makes in the performance of an organization.  In our work we’re building computer tools to support those social structures; in this article, the doctors are inventing the structures themselves.)

John