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For Many People, Medical Care Works Best When It's Incremental

Migraine headaches are one example of a chronic illness that typically doesn't respond to quick fixes.
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Migraine headaches are one example of a chronic illness that typically doesn't respond to quick fixes.

There's the heroic, lightning-quick medical care that saves us from crises. And then there's the slow-but-steady incremental medical attention that doctors provide for weeks, months, years, even decades in the attempt to heal complex conditions.

As a surgeon, The New Yorker's Atul Gawande practices the heroic type of medicine. In his new article, "Tell Me Where It Hurts," Gawande examines the quieter side of health care. Chronic diseases including heart disease, cancer, Type 2 diabetes and arthritis have become the leading causes of death and disability in the U.S. Gawande argues that it's time for the health care system to discover the heroism of "the incremental."

Gawande discusses his article with NPR's Robert Siegel, touching on the status of incremental medicine and what a shift in healthcare might mean for primary care in upcoming years. The interview has been edited for length and clarity.

Interview Highlights

On a case that shows the importance of incremental medicine

"I start out the story with a man who has the worst chronic migraine headaches imaginable. He has suffered for decades with headaches on almost a daily basis: More days of the month with a terrible headache than not, to the point of throwing up. It's hard to keep your job, hard to make things work. He'd seen all kinds of doctors who offered all kind of fixes, and nothing ever worked. But then he found a physician who saw him regularly over three years. Dr. Elizabeth Loder, whose career has been built on paying enormous attention to 'Let's try a little something now, see what happens, tweak it again, tweak it again.'

The problem in our existing health care system is that it's not made to put great value in opportunities that take time to pay off. What [the migraine patient] would have received in an emergency room would be a shot of morphine, a CT scan...and be sent on his way. Cured for an hour or two only to have it come back again later. But after three years [of working with Dr. Loder,] at the age of 62, his headaches were cured. And that's the opportunity we're missing."

On who decided emergency care should be most valuable

"We all decided it. If you go back to the 1940s or 1950s, medicine was really only able to rescue. It was an amazing thing that we could bring on antibiotics like penicillin to cure bacterial diseases, or do operations to take care of problems like heart conditions. Primary care physicians couldn't do much. We didn't know high blood pressure was one of the biggest problems we have, much less how to address it. Fast forward to where we are now. Only half of people [with high blood pressure] have their blood pressure controlled and are receiving adequate treatment for it. And what it takes to control blood pressure is step-by-step incremental investment. And we don't make it. We wait for the heart attack or kidney failure caused by the high blood pressure. It's too little too late, and at great expense. We raid our commitment to maintenance and prevention to put money into that expensive back end rescue. And that's what has to shift."

On what a rollback of Obamacare might mean for primary care

"Obamacare put incentives in [health care] that strengthen and give resources to primary care clinicians to have more team oriented care, and even for people to reach outside the clinic and serve you virtually. Some areas of the country are already doing the majority of their visits by virtual means. [Clinicians] are in touch with you in many different ways. But that's what we miss, that's what's at stake if we repeal legislation without replacement that keeps this kind of direction moving."

Copyright 2020 NPR. To see more, visit https://www.npr.org.

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