I will be doing a Conversations with Tyler with him, though podcast only, not a public event. What should I ask him?
I thank you in advance for your suggestions.
What should I ask Atul Gawande?
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Ask him what he thinks about the Assisted Death law in Canada.
1. American vs. Cuban healthcare outcomes.
2. Who should make “macro triage” (e.g. we need to focus resources on disease X, we need to build a specialized hospital at location Y) decisions? Markets? Elected representatives? Doctors?
3. Obesity: over-rated or under-rated?
Vaping. Escape route from cigarettes or Trojan horse
Medical error / culture – is progress being made? Has he followed the debate in the U.K. with the establishment of a Health Safety Investigation Branch? Does he buy the links others have made between safety culture and Dweck’s research on ‘growth mindset’?
1. India — what are its biggest issues in public health? How can it progress?
2. Obamacare — the future?
3. How does he do it all? Surgeon. Professor. Best-selling writer. Journalist. Public health expert. WTF?
Hi Sid,
Those are great questions. For the last two you may find the answers in his conversation with Ezra Klein on his podcast (The ezra klein show)
You could ask him about the Hippocratic Oath:
And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets.
Still relevant today?
More relevant, it is clear that the Republicans are not willing to Repeal and Replace because the Democrats would flood the media with pictures of dying little moppets the mean Republicans had snuck out and personally murdered. Does he think that there is any chance of restricting the amount of money spent on pointless medical interventions?
My answer to pointless medical interventions would be to allow Medicare to deny coverage for things that yield poor outcomes or are not cost effective, with exceptions on a case by case basis.
Agreed, but quite hard to do in practice.
Poor or not cost-effective determined by whom? Case by case exceptions determined by whom? The problem is not just that it is difficult to put into practice – in fact, it is easy to put into practice. But the problem is who gets the care and who does not and who pays for it? Your answer is not an answer at all. And, nobody really wants to answer those questions.
Determined by the scientific literature, when it exists. Yes, humans would have to be involved, which quickly gets into “death panel” hysteria, which docs, drug companies are very adept at stoking.
Every country in the world does it better than us. It is practically simple to do but does not happen because of politics and cowardice. The default in Medicare is to cover everything. So we will pay and pay and pay (yes, we are all paying, this is Medicare).
Your response ignores a world of rich countries’ experience.
I don’t usually agree with you, but I think you are spot on in this case.
Philosophical differences about what government should be doing aside, the fact is that government is paying for a lot of health care, and therefore they should have a sane method of assessing cost-effectiveness and only paying for care that meets a threshold.
It also should be political low-hanging fruit (in theory). It’s not an ideological issue; everyone should be able to agree “given that this program exists, it ought to work better”.
But in practice, it’s the opposite: politically untouchable, because no one wants to be the politician who denied treatment to Grandma. If one party tries to do anything about it, the other party will quickly move to make political hay from it.
No exceptions from the public payers. Period. Then I’m on board.
People want to augment care through private pay, they may do so.
We can ignore “how much money should we spend on the very sick?” for a long time, but eventually we will be forced to answer the question, after going through a lot of pain. It would be better if we figured out the answer before going through all that pain.
Farm it out to NICE to decide. https://www.nice.org.uk/
Yes, the “death panels” thing set us back, but it must be addressed.
Republicans are hell-bent on replacing Obamacare. If Dr. Gawande were to put aside his political affiliation (for argument’s sake), and advice the Republicans on a replacement bill – what would be his 3 (or 4 or 5) major suggestions? How could Obamacare be improved upon?
Great angle on the Obamacare question. +1
Should médecine be treated more like a commodity including less regulation of providers for many aspects (pharmacy, routine treatments, etc)?
If so where does he see the biggest (non-political) obstacles and the biggest risks?
If not why not?
No
How do we convince the religion charged politicians to enable voluntary euthanasia?
How do we help make faster other technological healthcare innovations? Especially ones that are currently blocked by regulations.
Consider the fda slowing drugs getting to market. With more deaths caused by the delays than would be saved by strict regulations, how do we go about reforming the fda?
“How do we convince the religion charged politicians to enable voluntary euthanasia? ”
Make them pay all the bills/support for the persons denied voluntary euthanasia.
Ever heard of a thing called “medicare?”
What are the prospects for a long-term care financing reform at the federal level? (Medicaid is by far the largest payer for long-term care services, as Medicare does not cover it, and it is likely to crowd out other Medicaid costs for younger people as the Boomers age.)
His opinion of how the medical establishment is dealing with the obesity epidemic or patients w/ obesity in general? My opninion is outcomes are very bad and I’m curious why.
Is he for single payer? Does he fear its dangers of being corrupted through lobbying are greater than in Europe?
How do conversations with patients and their familys about cost of care change as their life expectancy dwindles from years to months to days?
Ask him how he feels about how the most influential work he ever did, on medical costs based on McAllen and the Rio Grande Valley, was based on what turned out to be a signifigant statistical outlier.
http://www.texasmonthly.com/politics/mismanaged-care/
http://thehealthcareblog.com/blog/2010/02/19/mcallen-tx-as-outlier-why-not-houston/
I suggest this because from what I have read by and about him since is that he has clearly not been particularly troubled.
https://www.brookings.edu/blog/health360/2015/05/08/5-things-atul-gawande-learned-on-his-return-to-mcallen-tx/
This is an interesting story, but I think Gawande is basically right. There are some major outliers in Medicare utilization and spending. Those can be driven by a large number of factors beyond just how sick the population is. (Yes, Gawande does not seem to have understood all the drivers in McAllen, but each community will have at least slightly different factors.) And there are often opportunities for the care in those outlier locales to come more in line with the care in cheaper and high-quality communities. McAllen seems to have improved–great news.
Without wading too deeply into the literature, it does seem that whether “Gawande is basically right” on this issue is a matter of significant debate.
It would be nice to see this addressed some way in the conversation.
Ask him if he has read my book, Priceless.
Why, in the United States, is there always money to pay death merchants for devices to kill innocents, but never money to heal sick people? How many sick children is the F-35 worth?
Note that in the U.S. there is (a lot) more money going to healing sick people than anywhere else in the world. This includes the poor.
Total medicaid spending in the U.S. in 2015 was 532 billion, to cover 55 million beneficiaries. This is 3.5 times as high as total health spending in England, for example (for about the same number of people).
Unwillingness to spend money is not the problem.
If one does not know why the system is so little efficient, spending less won’t help, it will only remove Chesterton’s fence. Denying poor people treatment will not make the system better, it will only make it crueler.
I wasn’t advocating any particular changes, just pointing out that you are wrong (which you are).
While people at Congress haggle seeking an opportunity to cut healthcare budgets, each F-35 is expected to cost over 3000 times the mean yearly household income.
You are aware that the U.S. already spends far more on health care (both on absolute and relative terms) than any other country, right?
Private expenditure is four times bigger than in more normal countries http://data.worldbank.org/indicator/SH.XPD.PRIV.ZS
But what happens to poor people and the uninsured? Healthcare can be really expensive: http://www.nbcnews.com/politics/congress/personal-tragedy-drives-deal-making-gop-congressman-health-care-n752721
(1) Dr. Gawande has cited America’s “epidemic of unnecessary care”. Is that the fault of the way health care is funded or is it the fault of providers? (2) Medicaid for all (augmented with private insurance similar to Medicare supplemental insurance coverage) has been suggested as a better approach to funding health care, if for no other reason than it would (partially) end the current division of Americans into groups. Doesn’t Medicaid for all run the risk over time of the minnow (supplemental insurance) swallowing the whale (Medicaid), putting us right back to where we started?
1. His thoughts on pros/cons of employer sponsored healthcare?
2. What role will artificial intelligence play in the delivery of healthcare?
I would just like to say: way to go commenters, these are some great questions.
Usually the “What should I ask X?” posts generate a lot of garbage: snark, attacks disguised as questions, political claptrap, etc. But these are really good. I had to read quite far down to even see a non-good question.
yeah, a genuinely positive experience from this thread.
Overrated or underrated:
– e-cigarettes
– behavioural economics applied to public health
– wearables
Please ask him about the potential impacts on physician employment of artificial intelligence.
I would like to ask him his thoughts about how technology might interact with checklists to change the practice of medicine. I would ask him as a follow up to ask him what checklists and technology might mean for other professions. Will these things lead to more or less skilled and knowledgeable professionals? Will white collar work become more like factory work insofar as companies will start measuring output by the completion of checklists and other forms, instead of trying to asses outcomes? Could checklists in Medicine become a check the box procedure that functions more as a way to decrease legal risks and increase charges and net revenue instead of doing much for improving health outcomes?
Are restraints on trade – unions, cartels, monopolies, regulations passed by corrupt politicians – the principal explanation for the woes of American health care?
Does he think that doctors failed to understand the benefits and risks of opioid treatment? If so, why?
Yes, this is a good question. I’d like to hear his thoughts about the tradeoffs there, because they’re *ugly*–you can make it harder to get opiods and you’ll probably decrease the number of addicts, but increase the number of people in unbearable chronic pain.
Actually overuse of opiates for extended times in conditions not shown to benefit from extended use of opiates is probably increasing pain.
https://en.wikipedia.org/wiki/Opioid-induced_hyperalgesia
What is your view on existential biomedical risks like pandemics, immunity to antibiotics or bioterrorism?
What is the appropriate response to these high risk low probability (or really discounted)?
For all of these guests, I would start asking, “Which of your big ideas do people get wrong?” So for Gawande, it would be “What do people get wrong about check lists?”
You might want to ask him if Western Health care puts TOO HIGH a value on human life and as a result has worse outcomes than if the same level of resources were deployed more strategically. Thanks.
Nice. Yes. Optimize what? How is for clerks, what is the question.
1. How do conversations between patients and doctors go wrong?
2. How will the rise of “awake procedures” change the culture of the operating room?
3. Does he feel like he’s under-achieved in life?
Tyler, you said during a debate at the Singularity Summit in 2011 that you didn’t expect to see any breakthroughs in medicine and health care by 2030 although said it was always possible but that we should be worried about an aging society.
Since that debate, IBM announced Watson technology would be used in medicine, CRISPR technology looks promising and stem cell trials like the one completed at Stanford last year showed notable improvements in heart disease patients and stroke victims. In addition, anti-aging pills have been in the news over the last five years, which are intended to improve and significantly reduce the risk of diabetes, cancer and heart disease/stroke.
Maybe you could as if he expects these breakthroughs to significantly reduce costs over the next decade.
Most of the medical costs in the US have skyrocketed, leading to people having higher healthcare bills and thus requiring insurances as opposed to the early 20th century. This has played to the advantage of the insurance companies and has led them to manipulate the premiums they charge. Wouldn’t it make more sense to invest in products that are used, cheaper (maintaining the same quality standards) driving down the cost of healthcare, rather than focusing on insurance policies like obamacare and trumpcare?
By and large health insurance companies are not that profitable. I would ask something like this:
If the profit motive is the reason for our overspending and inefficiency, why haven’t nonprofits outcompeted? Why is their track record so poor (see the nonprofit coops that failed in Obamacare)?
Is there a market for nonprofit HMO type insurance that restricts payouts based on effectiveness? If this is the efficient model and would drive down costs (as Jan etc would argue) and thus drive down premiums why hasn’t this taken over?
Not being snarky, I think Jan has a good point I just don’t understand the market failure here. Unless it’s illegal due to regulation, why can’t a nonprofit contract include limiting malpractice suits and agree to only “proven effective” treatment? I would sign up for that deal.
Overrated or underrated: compensation for kidney donors
This is a good example of what I hope Tyler asks but with a twist.
With the anti-aging/health pills coming to market by 2019-2022, the need for kidney transplants would be significantly reduced and kidney dialysis no longer needed. Wouldn’t that drive down costs?
Sorry, but these health pills ain’t happening. I wish you were correct.
Tyler, is that you commenting under dan111’s name?
Effective stem cell treatments also not gonna happen? CRIPR a bust? Watson really only good at Jeapordy, which is after all a very simple game?
The health pills will improve over the next few years but for now it looks like NR will show efficacy when the first broader trial results on 140 people are announced in June or July. Just a hunch.
By the way, in 1996, only four research centers were researching slowing down ageing and by 2016 there were over 400 around the world including Calico.
There is the prospect of significant breakthroughs in health. However, you keep making a specific claim that “health pills” are going to radically transform healthcare and extend lifespan in the very near term. Here, for example, you are confidently claiming that these new treatments will eliminate the need for dialysis within five years.
I think this is bunk. I think you are reading way too much into research evidence that is still very early and limited.
Just one reason I think this: why is there a near-universal consensus among experts that costs are going to continue to rise, major chronic diseases will be an increasing burden, and there will be increasing pressure on health systems around the world? These experts have access to the same data that you are seeing, and probably more expertise than you or me (definitely than me; I don’t know your credentials). But none of them are saying what you are saying.
Thank you dan1111, this guy’s hobbyhorse needed some relief.
“Just one reason I think this: why is there a near-universal consensus among experts that costs are going to continue to rise, major chronic diseases will be an increasing burden, and there will be increasing pressure on health systems around the world? These experts have access to the same data that you are seeing, and probably more expertise than you or me (definitely than me; I don’t know your credentials). But none of them are saying what you are saying.”
I just did a three minute search of “kidney failure breakthroughs” and found this from this February:
” An estimated one in three diabetics go on to develop kidney disease. But the new study by King’s College London found diabetics suffering from the early stages of kidney disease have a deficiency of the protective “anti-ageing” hormone. The findings suggested Klotho may play a significant role in the development of kidney disease and testing levels could provide an early warning for those at risk. It could also lead to new treatments to prevent kidney disease in patients with type 1 diabetes.” (London Online News)
That is just one example. Let’s see, another recent article explains the potential for CRSPR to cure HIV outright.
Tyler doesn’t mention these advances probably because 1) in total, they destroy his Great Stagnation out to 2040 prediction. 2) He isn’t that interested in medical science. Just a guess.
Who are the “experts” who form the universal consensus that health care costs will continue to rise? A bunch of economists like Tyler Cowen without science backgrounds and/or not interested in medical science. Krugman on the left has been as bad as Cowen. In 2007, the CBO projected health care costs would rise to 2085 because “technological innovations have led to rises in costs in the past.” Not one social scientist should take these decades into the future predictions seriously.
Keep in mind that a main driver of these advances is the continuing exponential increase of computer power that all researchers depend on. The Mac II wouldn’t cut it.
What is on your list of things to do today?
1. Why is he not more interested in obesity, considering its the mother of all ills. In my mind every doctor should really study it deeply and have their personal philosophy of it.
2. Does he belive type 2 diabetes is curable or not, 10% of china has it, gonna gobble up every bit of healthcare money regardless of system used.
Focusing on obesity is only really useful if you can do something about it, right? If your best advice for a fat patient is “Well, here are some diet books–occasionally, people manage to lose a lot of weight following one of these and keep it off, but mostly, they lose a few pounds and then gain them back within a couple years–best of luck!”, it’s not obvious what you should be doing about obesity. If doctors had a treatment to offer obese patients that performed as well as Prozac or the flu vaccine (neither one all that great!), things would be very different.
Agree that we do not have a magic pill that makes people lose weight, or a shot that decreases apetite. The advice you describe is proably the normal view of obesity, but since is has such a an impact on everything else, it should be more discussed . Stephan Guyenet is the Tyler Cowen of obesity research, and has just published a book. He presents the best and comprehensive understanding we have of obesity now, and more importantly, how to lose weight. He also have a magnificent blog. I still believe that obesity should be higher on the priority reading list for healthcare professionals like him.
I have type II diabetes. It is controlled via diet, especially avoiding carbs, and exercise. _If_ I can control my environment I do very well. But I don’t think it’s curable. If I veer off the diet the blood sugar will spike.
Nice that you have found lowcarb, but all the research points to the case that type 2 diabetes can be cured, but it requires hard work. If you have the genetics for it, type 2 diabetes is caused by going over your personal fat threshold. Lose weight so you go below this threshold, and you will be cured.
http://www.ncl.ac.uk/magres/research/diabetes/reversal/#publicinformation
Roy Taylor is a medical proffessor at Newcastle university in the UK, used to hold your view, Type-2 was not curable and so forth.
But he made people lose weight, and now he claims is curable. Read the research and if you want stories of people that have cured themselves, just comment me back. Good luck
What he perceives as the positive externalities and broader economic benefits of ACA beyond just heath care.
I would want to ask him just how important is high tech American healthcare. Life expectancy is higher in Costa Rica, Chile and Slovenia and not much lower at all in Viet Nam and India. In other words, how much , if at all, does all the mris and surgeries in this country add to life expectancy.
What is his margin on the extent of ‘healthcare’ that should be public funded and why does he believe that is the right margin.
Poor handwashing rates by US hospital staff lead to 1.7 million hospital acquired infections and 100,000 deaths per year putting hospital acquired infections above most other causes of death – including most of the cancers or car accidents. Applying the FDA’s value per life of $7.9 million plus the cost of treatment, lost wages etc you approach $1 trillion in economic costs. Hospitals, doctors and nurses have known since the the 1800’s that handwashing prevents infections and saves lives. And yet, hospitals and staff efforts to increase handwashing compliance remain very poor. Is this a solvable problem? Is it a problem that will be solved using using newer technology or applying behavioral psychology or other methods? The ROI for any spending in this area seems like a no brained, doesn’t it? Is there an underlying reason why hospitals don’t do more to address this issue?
Why he was so wrong about McAllen.
As economics predicts, and completely incompatible with his story, the higher Medicare spending there is complemented by lower private spending.
Regional variations in Medicare cannot be explained by a culture of greed, but rather partly by differences in payer mix based on relative profitability of Medicare vs privately insured.
Also whether he has any regrets that a piece so wrong ended up being so influential in shaping US health care policy.
Overrated or Underrated:
– Health Care in Britain (or Singapore, Canada or Japan)
– Health Savings Accounts
– A single payer system
– Insurance covering prevention (as opposed to catastrophe)
What must a federal health care bill contain before you would vote for it?
What would make you be against a health care bill, all else being acceptable, if it were included.
There’s research (the Oregon and Rand studies) that strongly suggests that having good health coverage doesn’t have much measurable impact on health or lifespan. At the same time, we have the paradox of the US spending incredible (and always-growing) amounts on health care, without much apparent benefit in health outcomes.
I’m curious if he thinks these are related. Is it that our cost-spiral is overwhelmingly spent on unhelpful medical interventions (either unnecessary stuff, or stuff where the expected benefit is small because the probability of injuring the patient is about the same as the probability of helping him)? That would explain how we can spend more every year without seeing outcomes get better.
This makes sense if you think in terms of diminishing returns. Going from zero health care to the level just about everyone in the US gets (vaccines, ERs for emergencies, seeing a doctor if you’re really deathly ill), you probably get a big improvement in your health outcomes. Going from that point to what you get with good medical insurance, maybe you’re down to the point where you’re getting very little benefit from each additional doctor’s visit/procedure. At the margin, that extra screening test decreases your risk of dying of cancer by *just exactly* the amount that it increases your risk of dying from unnecessary treatment or an infection from the biopsy or whatever.
One thing that makes this seem plausible to me–for most of human history, almost *all* medicine was either useless or actively harmful. And yet, it seems like just about every society had their physicians or witch doctors or whatever, who would try to treat your illnesses despite having no idea what they were doing. Whatever psychological need led us to have physicians back when they’d purge and bleed you to treat your pneumonia, it’s probably still there, leading us to demand medical treatment even when it’s not actually helping as much as it’s hurting.
^ These are good.
I would be very curious to hear him respond to the following questions:
1) Why is the correlation between sickness-care spending, access, insurance etc. with life expectancy or other measures of health so weak?
2) The study currently running in Oregon in which 10,000 uninsured were chosen by lottery to receive free health insurance seems to show a clear increase in happiness with no otherwise measurable improvement in physical health indicators. Does this result comport with the intentions of the physicians treating them or with what Dr. Gawande was taught in medical school? Does this seem like a success or a failure to him?
3) How much does he or his employer spend on access to medical journals for him and /or his department? Does he belong to a journal club? How much time/money does he or his employer invest on trips/ seminars/ conferences etc?
4) How does his department decide what new treatments or procedures to include in their practice?
5) Is Cochrane Collaboration-style evidence-based medicine making a significant difference in how his hospital/department make decisions? how they adopt new procedures or determine their recommendations to patients? Does clinical experience or medical gestalt have a greater or lesser import than it did fifteen years ago? Why or why not?
6) Is it naive to think that Dr. Iain Chalmers deserves a Nobel Prize?
A couple more questions for Dr. Gawande occurred to me last night.
7) Is the purpose of a good insurance system for sickness treatments to charge everyone a modest amount in order to give a small number of people (those born with Cerebral Palsy, hit by buses or infected with Ebola for instance) enormous amounts of expensive care while encouraging the majority of the population to consume only de minimus amounts of doctors’ time and attention?
If so, might it be the case that we could improve the system by making medical care less pleasant? Is the trend to treat patients like customers, keep them happy and worry about “customer satisfaction” encouraging over-consumption? Instead of making medicine taste like candy should we make it all taste like cod liver oil in order to ensure that the majority of the system’s capacity is free to be utilized by the small group that need tremendous care?
8) If the goal is to give huge amounts of valuable expertise and attention to a small number of patients who need it, is that compatible with people’s natural, egalitarian sentiments? By making the system more responsive to democratic preference, are we necessarily making it less efficient? Could we make the distribution of resources more efficient by making it less transparent and less responsive to political control?
How far are we from having an AI capable of most diagnosis, second opinions, and able to disseminate realistic probabilities for appropriate treatements.
If it exists, should doctors have to consult such a system. Should patients have access to such a system. Why/why not?
Also, please ask for his perspective on “cost disease.” How does he see it in his work, incentives around it, and ways to address it.
1) He writes in praise of checklists; in a more classical presentation, a checklist is really just a strategy in rhetoric: tricolon, tetracolon, etc. Does he think of The Checklist Manifesto as a manual of rhetoric? Why do some rhetorical strategies succeed at certain times in certain areas?
2) A lot of the MDs I know spend time running regressions and working with data sets. What part of the virtuous doctor of the 1970s is continued in the doctors of today, particularly the use of data.
3) Common avocations for MDs I know include interest in wine, interest in coffee, interest in the study of opioid use; why are doctors drawn to these commodities?
He has written about the importance of experience for the effectiveness of surgeons, and how surgeons try to make sure their family members are not operated on by inexperienced surgeons.
At the margin, would it be better to have fewer surgeons working longer hours and retiring later, or to have more surgeons with less job experience?
What is missing from medical (and premedical) education? What do medical institutions recognize as missing, and what are they ignoring?
What’s the worst application of a checklist? Can the idea be abused and if so how?
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