In 2016, President Barack Obama presented the National Humanities Medal to physician and author … [+]
The future of American medicine is locked in debate. For decades, healthcare leaders have held diametrically opposing views on key issues, grappling over dichotomous questions that carry huge implications.
- Public or private health insurance?
- For-profit or nonprofit care providers?
- Lower medical costs or increase healthcare access and equity?
- Improve patient satisfaction or physician satisfaction?
Proponents of each side believe they’re right, refusing to consider the competing opinion. As a result, innovation and progress are at a standstill. The consequences of this inaction are well documented.
Americans have the most expensive and poorest performing healthcare system in the developed world. Compared to other wealthy nations, the United States has the highest mortality from chronic disease and childbirth, along with the lowest life expectancy. Ours is a healthcare system plagued by racial disparities, extreme physician burnout and no clear direction forward.
To untie this Gordian knot, healthcare leaders would be wise to borrow a page from Abraham Verghese: accomplished author, renowned physician and advocate for humanism in medicine. His newest work of fiction, “The Covenant of Water” sits at No. 4 on The New York Times bestseller list and was recently named an Oprah book-club pick.
What stood out to me about the novel, and throughout my recent conversation with the author on the Fixing Healthcare podcast, was Verghese’s utter lack of dichotomous thinking. Though his fiction is filled with conflict and difficult choices, Verghese’s characters consistently discover answers beyond the obvious, binary options presented.
To give you an example of his unconventional outlook, I asked him, “Why did you choose the word ‘Covenant’ for the book’s title?”
It seemed an odd, possibly malapropic, choice. What is an agreement of water, anyway? I expected Verghese to reply with either a dictionary subsense of the word or its biblical etymology.
Instead, he said this: “I have a thesis, completely unvalidated, that titles need to be a bit mysterious and that the nature of a novel is that the writer provides the words, the reader provides their imagination, and somewhere in the middle spaces a mental movie takes shape.”
This wasn’t an attempt to evade the question. It was, in fact, a better answer than either one I’d considered. Here, Verghese posits that meaning is formed through the imagination of both the author and reader rather than being handed down from the author on high.
Listening to him, it was clear this method of thinking could help resolve the many dichotomous debates plaguing medicine today. Instead of picking one side of a healthcare clash, or mindlessly splitting the difference, leaders would benefit by seeking a third option—one that proves better than either mutually exclusive choice alone.
Here are three dichotomies that healthcare leaders could effectively solve by using Verghese’s approach:
1. Is medicine a science or an art?
Though most patients wouldn’t even think to ask this question, it underlies a fundamental debate within the medical profession, highlighting the competing roles a doctor must play.
As practitioners of applied science, physicians are taught to remain objective, weigh the evidence and render logical conclusions. In science, there is but one correct answer, be it related to a biological process or chemical reaction. The art of medicine, by contrast, is far more subjective. Physicians reject the notion that there’s only one way to treat a patient. They believe there’s an unlimited number of answers available, each based on the preferences of the doctor.
Today, these perspectives are at war: One correct answer (science) and an infinite number (art) can’t coexist. But this dichotomy can be resolved by asking when it is best to use each.
This century’s massive leaps in medical knowledge have yielded clear, evidenced-based approaches to clinical practice. When and where they exist, doctors should follow them rigorously to achieve the best clinical outcomes. But when it comes to addressing the anxiety and fear patients experience, the art of medicine should rule supreme.
2. Should doctors always save a life at any cost?
Until the second half of the 20th century, physicians could do little to save the lives of severely ill patients. That’s why, when an opportunity to save a life arose, doctors were instructed to do so at any cost.
But now, clinicians have the ability to extend a person’s life—through assisted breathing, intestinal feeding tubes and urinary catheters—far beyond the point that life is worth living. As a result, for many patients, the line between treatment and torture has blurred.
When I asked Verghese for his thoughts on end-of-life issues, he affirmed the challenge of helping patients come to grips with dying. “A lot of people say, ‘I love your work, but I wish you wouldn’t have so much death in it. I keep saying, ‘[Death] is not something I’m making up. Life is a terminal condition.’”
As doctors, we convince ourselves that it’s in the best interests of the patient to proffer hope—even when the chances of a positive outcome are miniscule. Contrary to this false-hope approach, what patients actually desire is the truth.
People who are dying want to know their doctors will help them control the pain. They want the doctor to provide them with a full list of medical options. And when treatments prove futile, few patients desire to prolong the suffering.
Most Americans believe that “life” is more than merely having a beating heart. Knowing that, physicians have an obligation to (a) engage in conversation with the patient long-before the person requires life-saving intervention and (b) respect that individual’s preference.
3. Is new technology friend or foe?
In almost every industry outside of medicine, information technology has been used to provide consumers with more convenient, lower cost products and services. Healthcare remains the exception.
Patients still find it difficult to schedule a visit with a doctor or book a diagnostic test online. Telemedicine usage, which boomed during the pandemic, has receded in all areas but mental health. Despite its great potential to improve 21st-century medicine, technology hasn’t lengthened life expectancy, bettered our healthcare experiences or lowered the cost of care.
Generative AI technologies like ChatGPT have the potential to empower patients and radically improve clinical outcomes. Future generations of AI will have the power to provide patients with 24/7 access to medical information without overwhelming doctors.
And yet, many clinicians remain hesitant to embrace technology that seeds control to patients and replaces their expertise.
One reason for their skepticism is concern over patient safety. Medical professionals insist that, in order to be deemed safe, technology must be perfect (zero harm tolerated).
And yet, in other areas of medicine, clinicians use a different criterion. They accept that surgical complications are inevitable and that medications will have harmful side effects. They judge procedures and drugs by their net effect on the health of patients. In these situations, when the benefits exceed the risks, doctors embrace these treatments.
Why not use the same criteria for technology in medicine? Instead of starting with a zero-risk threshold, begin by quantifying the potential benefits of information technology against today’s reality. Research demonstrates that patients have a very difficult time obtaining convenient, high-quality, 24/7 care. Technology can ameliorate those problems, but only if the medical world shifts its perspective and allows AI to take an appropriate place in patients’ lives.
Thinking outside the binary
In Verghese’s novels, characters faced with enigmatic problems find positive solutions by avoiding the limitations of dichotomous thinking. He believes that reading fiction can help leaders make better decisions.
“I get impatient with my colleagues who only read nonfiction and biography,” he told me during our interview. “Many of the most powerful leaders I know read fiction. I think there’s a part of the brain, there’s a part of the cortex, that stays alive by taking these little signals we call words on the page and making our mental movies.”
I concur with him that fiction helps expand our minds. And with greater imagination, healthcare leaders can discover better solutions—ones that avoid the traps of binary thinking and, ultimately, benefit patients. I encourage everyone to read “The Covenant of Water.” I promise those who do will be moved by the beauty and power of Verghese’s words and grateful for the insights he provides.