Wednesday, February 2, 2011


A terrific essay in the New Yorker ( a couple of weeks ago, written by writer/surgeon Atul Gawande, reveals a major factor in today's surreal healthcare costs.

Gawande points out that a small fraction of patients with chronic and multiple illnesses uses a grossly disproportionate share of healthcare. For example, one percent of the patients in Camden, NJ uses thirty percent of the city's total healthcare. Many of these "superusers" are indigent, so guess who pays for their services.

This occurs all over the country. People who are too poor to pay for healthcare and can't find a doctor who accepts Medicaid (after the doc's overhead, remuneration often amounts to minimum wage) simply go to the nearest emergency department. Necessarily tooled for genuine life-and-death crises, EDs are costly to run. But most of the patients present with colds and flu and rashes, so they generate great expense for minor conditions.

Fortunately, Gawande reports, a number of experiments currently address this problem. Some people are opening care centers within housing projects and nursing homes. These low-cost operations are in some ways low-tech as well, as practitioners visit patients in their homes, offer classes, see them in groups. And it seems to work: where these strategies are tried, medical visits plummet.

Twenty-five years ago, when I worked for an agency for the disabled, we obtained a grant for a similar project. We enrolled the agency's clients--forty of them, all with disabilities--into a class that met weekly for seven weeks. Here we discussed common human processes, including disability, sickness, relationships, work, expression, spirituality, and death and dying. In other words, we just talked about life. We had inventoried participants' healthcare use before the class, did so afterward, and again six months later. Their medical visits dropped forty percent after the class, a figure that held after six months. When we reported our findings to the granting entity, we weren't believed and our grant wasn't renewed. Yet our findings paralleled what Gawande now describes.

What these interventions have in common is, I suggest, less medical than social, and that would make sense in regard to chronic illness. When you find you're sick in a way that's incurable--that's what chronic means--you need to make changes in your life to accommodate the illness. Your family and friends ache for your well-being, but often don't understand your situation (A guy in my cancer support group says, "My family doesn't speak cancer."). So if you're to make adaptive changes you'll need to consult experts, and the experts are other folks similarly afflicted.

Call it a "support group," but I believe it's more. Some call it a "navigation group." Am I doomed to see my situation as exclusively medical the rest of my life and be dependent on pills and surgeries, or is there another way to address it, too, a way that actually empowers me?

I don't know if those who do the experiments Gawande describes realize yet that their interventions are more social than medical, but they will. During these next few decades, the most effective therapy for people with chronic conditions will be compassionate, creative human contact.


  1. Myself and so many other people have benefited from Dr Kane's work. I am a cancer survivor of 15 years. I initially joined a "support" group thinking,OK I will try this but really didn't have a lot of confidence that this sort of thing would really work. How lucky was I to stumble into Dr Kane's "support group" In so many ways that support group saved my life. Dr Kane's ability to allow a person suffering from a chronic illness to explore and understand the process of the illness.To be able to discuss your fears and pain with people experiencing similar life situation. I am not saying anything new hear, so many have benefited from his work and I am grateful that I can count myself as one of the lucky ones!

  2. Thanks for the heads-up, Jeff. I subscribe to the New Yorker but rarely get a chance to read it. I love "My family doesn't speak cancer" - or rather I love the saying not the reality.

    And, as always, thanks for your terrific insights and all you do.