... that can improve quality of life for dying patients and save the government a lot of money. Chuck C has written about the so-called “death panels”; the NYTimes and other news outlets have expanded the dialogue; now Atul Gawande has written an essay for the New Yorker.
I’d like to focus on one particular part of Gawande’s essay, where he refers to Stephen Jay Gould’s remarkable recovery from abdominal mesothelioma, which inspired Gould’s essay “The Median Isn’t the Message.”
Gould beat a normally lethal cancer. He is the exemplar patient that all physicians would like to have and treat. Gawande admits this sentiment himself:
I think of Gould and his essay every time I have a patient with a terminal illness. There is almost always a long tail of possibility, however thin. What’s wrong with looking for it? Nothing, it seems to me, unless it means we have failed to prepare for the outcome that’s vastly more probable. The trouble is that we’ve built our medical system and culture around the long tail. We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win. Hope is not a plan, but hope is our plan.
The reality, as Gawande alludes to, is grim: optimistic hope in sexy, new treatments against diseases that we don’t completely understand. The grim reality, though, funds our futures as physician-scientists. A lot of basic research in a lot of different fields is needed to know which patients will benefit from which treatments. And some times the treatments will be palliative.
Gould studied patient-survival curves. He saw “himself surviving far out in that long tail.” But what does it mean to be in the “long tail”? People are hard at working doing this, particularly with breast and prostate cancer.
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