The Gawande Pick: Incrementalism not Amazonification for American Health Care

Peter Wehrwein

Atul Gawande is a splashy choice to head up the Amazon–Berkshire Hathaway–JP Morgan Chase health care initiative. Stat called the 52-year-old surgeon, Harvard professor, and prolific New Yorker staff writer an “all-around health care celebrity.”

Gawande is royalty in Boston’s high-powered health care circles, and those folks have to be thrilled that one of their own has been picked—and that the initiative is going to be headquartered in the hub of the universe (who needs the headaches of HQ2?).

Twitter gushed, pretty much, about Gawande’s selection. Those on the scorn–skepticism end of the spectrum shelved the attitude —at least for today.

“Darn, now we have to stop making fun of it,” tweeted Julie Rovner.

But the selection of Gawande does make you wonder how earth shattering this endeavor will be. Notions of the creation of a brand-new player in health care that would—cliché trigger warning—“disrupt” the industry now seem inflated. Gawande is one of American health care’s finest public intellectuals. His New Yorker writings are immensely satisfying smoothies of firsthand observation, analysis, personal reflection, with clever turns of phrases thrown in. But you wouldn’t pick someone like Gawande if your vision was full-on Amazonification of American health care and an entity that would take on existing insurers and health care systems.

Gawande himself seems to be hedging the bet. Stat reported that he wrote a note to friends and colleagues saying that he would not be giving up his positions at Harvard and Brigham and Women’s Hospital and that he will continue to write for the New Yorker. He is, though, stepping back some from Ariadne Labs, which he founded.

In his prepared statement today, Gawande seemed to be talking about Amazon, Berkshire Hathaway, and JP Morgan Chase employees when he said he now has “ backing of these remarkable organizations to pursue this mission [“scalable solutions for better health care delivery”] with even greater impact for more than a million people, and in doing so incubate better models of care for all.”

Overhauling health care delivery for a million employees and, presumably, how it is paid for—well, that ain’t nothing And say Gawande does come up with a fresh mix that brings about better outcomes while squeezing out expense….well, hasn’t that been the holy grail for decades?  

There may be some clues about what Gawande will be trying to accomplish in a piece he wrote for the New Yorker early last year titled, “The Heroism of Incremental Care.” Showing his deft touch as guide through the health care system, Gawande begins the piece talking about people with migraines and the treatment they get at a headache program at Brigham and Women’s Hospital. He expresses admiration for the pragmatic approach of the program’s director, Elizabeth Loder: no magic bullets or grand theories, some lowering of expectations, lots of trial and error and then going with what works.

"Success meant that the headaches became less frequent and less intense, and that the patients grew more confident in handling them. Even that progress would take time. There is rarely a single, immediate remedy, she [Loder] said, whether it was a drug or a change in diet or an exercise regimen. Nonetheless, she wanted her patients to trust her. Things would take a while—months, sometimes longer. Success would be incremental."

Then Gawande elegantly switches the topic to primary care. The clinic he visits has a “teeming variousness” (the writer in him at work). The clinicians tell him that primary care is built on relationships. And, once again, a recognition of the efficacy of moving inch by inch:

"Success, therefore, is not about the episodic, momentary victories, though they do play a role. It is about the longer view of incremental steps that produce sustained progress."

He makes a final pivot into broader sermon about health care system while also bringing in his son, Walker, who was born with congenital heart condition that needed surgery (“rescue medicine” in Gawande’s taxonomy) but also benefited tremendously from a relationship (“incremental medicine”) with a cardiologist who monitored his heart and other related conditions. In Gawande’s view, the oceans of health-related information we are swimming in have new opportunities for prevention and “care that takes time to pay off,” but that is precisely the kind of care that the current health care system isn’t organized to reward. “We have the chance to transform the course of our lives,” he wrote. “Doing so will mean discovering the heroism of the incremental.”

Even though one of Gawande’s employers is perhaps the most successful retailer of all time, the heroism of baby steps, even if they pay off in the long run, could be a hard sell.