Gongol.com Archives: December 2021

Brian Gongol


December 16, 2021

Health Sometimes, you're just in a hole

The old adage says that when you find yourself in a hole, the first thing to do is stop digging. But sometimes, when you find yourself in a hole, you're just in a hole. One of the most thoughtful people in American medicine is Dr. Atul Gawande, a surgeon and writer whose books (like "The Checklist Manifesto") reveal a mind at work on medicine that could easily have been put to vital use in many other fields. ■ Dr. Gawande was recruited to head up a nonprofit organization with a mission to find a better way to manage the cost of health care. He was recruited to the effort in 2018 by Berkshire Hathaway, Amazon, and JP Morgan Chase -- big firms with big incentives to find solutions. But the joint venture (called "Haven") never made it very far and shut down in early 2021. ■ America is notorious for the cost of our health care: We spend more than $11,000 per person on the industry each year. That is, for the record, the same as global GDP per person. Put another way: America consumes as much in health care per person as the average Earthling produces in total each year. ■ But money isn't everything. Time, too, is money. For comparison, Canada spends less of its money on health care than does the United States (roughly 11% of GDP versus 17%) -- but Canadians also expend a lot of time in waiting for care. The Fraser Institute tracks wait times for care in Canada and finds that, on average, it takes 11 weeks to be referred from a general practitioner to a specialist and another 14 weeks from referral to actual treatment. The numbers vary by location and by specialty, but that average represents a median total wait of half a year between the first doctor saying "You need some follow-up" and the specialist actually getting treatment underway. ■ The Fraser Institute has a pro-market orientation, but criticisms of Canadian health-care waiting times aren't exclusive to people of a center-right political orientation. Nor is waiting just a Canadian problem: Even before the Covid-19 pandemic, long waiting times dogged Britain's legendary NHS, too. ■ Health care is a wicked problem in part because it requires some inputs that cannot be reduced: There is only so much that can be done to speed up an annual physical exam or to recover faster from surgery. And because health means virtually everything to the patient, everyone wants the best treatment from the smartest and most skilled people they can find: Nobody wants a "C" student performing their brain surgery. ■ The case of Haven reminds us of something else, too: A highly gifted person like Dr. Gawande is in demand elsewhere, too -- both within health care and outside it. And to both attract and retain talented people to the sector requires delivering both pay and conditions that are good enough to compete with the other things those individuals could be doing instead. Anyone good enough to be a valuable contributor to health care is probably good enough to be an attractive worker elsewhere, too. ■ The people burning out and leaving health care have other options, and unless breakthroughs are found that either substantially reduce the demand for care or radically increase the productivity of the people delivering it, there really isn't a systemic solution to be found. Just to keep enough care providers around, either costs will rise or there won't be enough people to provide the care in the volume (and at the speed) people want it. Perhaps sometimes both. ■ Maybe we'll get those breakthroughs with microrobots in our bloodstreams, android nurses, precision robotic surgery, and pills that prevent hospitalization. But certain limitations are hard to overcome (open-heart surgery will always take time), and the problems aren't getting smaller (Covid-19 won't be the last novel pandemic). ■ An ounce of prevention may indeed be worth much more than just a pound of cure, so we ought to act like it. But once people are in need of care, finding solutions may be more vexing than those who try to sell "silver bullet" solutions would want us to think. That doesn't make the situation hopeless, but it does mean we need to be clear-eyed about where to find the answers: Sometimes, you can stop digging -- but sometimes, you're just in a hole.


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