The Heroism of Incremental Care

February 18, 2017

The Heroism of Incremental Care, by @Atul_Gawande Positively compares GPs-v-surgeons to bridge inspectors v rescuers

“For a long time, this would have seemed as foolish as giving your money to a palmist. What will happen to a bridge—or to your body—fifty years from now? We had no more than a vague idea. But the
investigation of the 1967 Silver Bridge collapse marked an advance in our ability to shift from reacting to bridge catastrophes to anticipating and averting them.

Around the same time, something similar was happening in medicine. Scientists were discovering the long-term health significance of high blood pressure, diabetes, and other conditions. We’d begun collecting the data, developing the computational capacity to decode the patterns, and discovering the treatments that could change them. Seemingly random events were becoming open to prediction and alteration. Our frame of medical consideration could widen to encompass our entire life spans.

Our ability to use information to understand and reshape the future is accelerating in multiple ways. We have at least four kinds of information that matter to your health and well-being over time: information about the state of your internal systems (from your imaging and lab-test results, your genome sequencing); the state of your living conditions (your housing, community, economic, and environmental circumstances); the state of the care you receive (what your practitioners have done and how well they did it, what
medications and other treatments they have provided); and the state of your behaviors (your patterns of sleep, exercise, stress, eating, sexual activity, adherence to treatments). The potential of this information is so enormous it is almost scary.

Instead of once-a-year checkups, in which people are like bridges undergoing annual inspection, we will increasingly be able to use smartphones and wearables to continuously monitor our heart rhythm, breathing, sleep, and activity, registering signs of illness as well as the effectiveness and the side effects of treatments. Engineers have proposed bathtub scanners that could track your internal organs for minute changes over time. We can decode our entire genome for less than the cost of an iPad and, increasingly, tune our care to the exact makeup we were born with.

Our health-care system is not designed for this future—or, indeed, for this present. We built it at a time when such capabilities were virtually nonexistent. When illness was experienced as a random catastrophe, and medical discoveries focussed on rescue, insurance for unanticipated, episodic needs was what we needed. Hospitals and heroic interventions got the large investments; incrementalists were scanted. After all, in the nineteen-fifties and sixties, they had little to offer that made a major difference in people’s lives. But the more capacity we develop to monitor the body and the brain for signs of future breakdown and to correct course along the way—to deliver “precision medicine,” as the lingo goes—the greater the difference health care can make in people’s lives, as well as in reducing future costs.”