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When Will We Grasp the Power of Incremental Care?

In the January 23, 2017, issue of The New Yorker, in “Tell Me Where It Hurts” (p. 36), Atul Gawande explores the state of health care in America, particularly our emphasis on rescue medicine and neglect of the kind of steady, intimate care over time that often helps people more. Our health-care system was built at a time when illness was experienced as a random catastrophe, so hospitals and heroic interventions got the large investments.

Dr. Atul Gawande calls for greater value to be placed on steady, intimate medical care. (Photo by Kelly Davidson)
Dr. Atul Gawande calls for greater value to be placed on steady, intimate medical care that improves people’s lives over extended periods of time. (Photo by Kelly Davidson)

But today, medical discovery is making it so incrementalists—practitioners who produce value by improving people’s lives over extended periods of time—are demonstrating ever larger benefits for people’s lives. Today, the highest-paid specialists in American medicine are interventionists, such as orthopedists and cardiologists, while the lowest-paid specialists are incrementalists, such as pediatricians, internists, and psychiatrists.

Gawande writes, “as an American surgeon, I have a battalion of people and millions of dollars of equipment on hand when I arrive in my operating room. Incrementalists are lucky if they can hire a nurse.” But fields like primary care, he says,  do “a lot of good for people—maybe even more good, in the long run,” than he will as a surgeon. Studies have found that states with higher ratios of primary­ care physicians have lower rates of general mortality, infant mortality, and mortality from specific conditions such as heart disease and stroke. Having a regular source of medical care, from a doctor who knows you, has a powerful effect on your willingness to seek care for severe symptoms. Success 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,” Gawande writes. Asaf Bitton, an internist and Ariadne Labs researcher, tells Gawande, “It’s no one thing we do. It’s all of it.”

In the next few months, if Congress repeals the Affordable Care Act, people like Gawande’s son Walker, who was born with a heart condition, will be unable to find health insurance. And research indicates that twenty-seven per cent of adults under sixty-five are like Walker, with past health conditions that make them uninsurable without the protections of the A.C.A. But the rising power of predictive, individual data on everything from our genome to our living patterns means, Gawande writes, “life is a pre­existing condition waiting to happen. We will all turn out to have . . . a lurking heart condition or a tumor or a depression or some rare disease that needs to be managed.” This is a problem for our health system, which  doesn’t put great value on care that takes time to pay off—but it is also an opportunity.

Gawande writes, “We can give up an antiquated set of priorities and shift our focus from rescue medicine to lifelong incremental care. Or we can leave millions of people to suffer and die from conditions that, increasingly, can be predicted and managed. This isn’t a bloodless policy choice; it’s a medical emergency.”

Media inquiries: Contact Natalie Raabe, director of communications, The New Yorker, natalie_raabe@newyorker.com