Atul A. Gawande

Bio: Atul A. Gawande is an academic researcher from Brigham and Women's Hospital. The author has contributed to research in topics: Checklist & Population. The author has an hindex of 78, co-authored 281 publications receiving 33928 citations. Previous affiliations of Atul A. Gawande include University of Maryland, Baltimore & Massachusetts Eye and Ear Infirmary.

Reassessment of Parathyroid Hormone Monitoring During Parathyroidectomy for Primary Hyperparathyroidism After 2 Preoperative Localization Studies

Abstract: Hypothesis: For patients with primary hyperparathyroidism and patients with 2 localization studies showing the same single location of parathyroid disease, use of intraoperative parathyroid hormone (IOPTH) measurement does not significantly increase the success of minimally invasive parathyroidectomy. Design: Retrospective cohort study. Setting: Experience of 2 academic centers over 5 years (at Brigham and Women's Hospital, Boston, Mass) and almost 4 years (at Rhode Island Hospital, Providence). Patients: A total of 569 patients with primary hyperparathyroidism who underwent technetium Tc 99m sestamibi (MIBI) parathyroid imaging and neck ultrasonography (US). Main Outcome Measures: Incidence of correct prediction of location and extent of disease. Results: In 322 patients (57%), MIBI and US imaging identified the same single site of disease. In 319 (99%) of these 322 patients, surgical exploration confirmed a parathyroid adenoma at that site, and the IOPTH levels normalized on removal. In 3 (1%) of the 322 patients, IOPTH measurement identified unsuspected additional disease. In 3 (1%) of the remaining 319 patients, IOPTH-guided removal of a single adenoma failed to correct hypercalcemia. Therefore, the failure rate of surgery in patients with positive MIBI and positive US imaging was 1% with IOPTH measurement and 2% without IOPTH measurement (P=.50). In 201 (35%) of the 569 patients, only 1 of the 2 studies recognized an abnormality or the studies disagreed on location. In these cases, either MIBI imaging or US imaging (if MIBI imaging was negative) failed to predict the correct site or extent of disease in 76 (38%) of the 201 patients (P<.001 vs concordant studies). Conclusions: In primary hyperparathyroidism, concordant preoperative localization with MIBI and US imaging is highly accurate. Use of IOPTH measurement in these cases adds only marginal benefit. When only 1 of the 2 studies identifies disease or the studies conflict, however, IOPTH measurement remains essential during minimally invasive parathyroidectomy.

Quantity and Quality of Life: Duties of Care in Life-Limiting Illness.

Abstract: Everyone dies. Dying today typically involves a period of protracted illness, disability, and intense involvement of medical professionals. Although the experience is woefully understudied, a significant body of evidence is emerging to guide clinicians, health systems, and society toward better practices for people facing serious, life-threatening conditions. That evidence has shown, importantly, that the amount of suffering that people endure in their last year of life is considerable. Singer et al1 recently reported on the experience of 7204 adults older than 50 years who died while being followed up as part of a longitudinal study of US health and retirement. The researchers found that, during their last year, 51% of study participants were often troubled by moderate to severe pain, and 46% to 53% also experienced at least a month of depression, periodic confusion, dyspnea, and incontinence during that time.1 Furthermore, among those who died between 1998 and 2010, none of these symptoms decreased in occurrence during their last year of life, but rather occurrence of pain, depression, and periodic confusion actually increased. Medical care for the symptoms people experience at the end of life does not seem to have gotten better; it may have gotten worse. It could be argued that the findings simply reflect people following their wishes to trade the quality of their lives for therapies that extend their lives. But this is not the case. In 2014, the Institute of Medicine (IOM) published Dying in America, which included an extensive review of the medical literature on the end of life, including the efficacy of expert palliative care.2 Palliative care is a field dedicated to assisting seriously ill people with setting and achieving goals aside from just survival, which may include control of symptoms, attending to life projects, connecting with loved ones, or other vital objectives. The literature has established that when care is provided with a narrow focus on disease control, without palliative care expertise directed at eliciting these broader goals and tailoring care to include them, patients experience more pain, more anxiety, and more family exhaustion; they receive more nonbeneficial care and more hospitalization; and they do not live longer. Indeed, studies suggest that earlier involvement of palliative care specialists, either through consultation or enrollment in hospice, can produce increased survival.3,4 Another cause of physical suffering and family distress identified in the IOM report is that the majority of people reach the end of life cognitively impaired by illness, treatment, or frailty, and they are unable to make their own decisions about their care. They must rely on a proxy to make their medical choices. Only with advance planning conversations can they ensure alignment between the treatment they receive and their goals and values. But most people do not have these conversations with their clinicians or family members. Treatment therefore often violates their preferences, usually in the direction of undervaluing measures to support the quality of their remaining life. The picture of care at the end of life that emerges is therefore disturbing. A widespread perception among both the medical profession and the public at large has been that seeking palliative care consultation or hospice services, or even just having advance planning discussions, amounts to “giving up” and is only relevant when people no longer have options for disease-based therapy. This view is incorrect and harmful. It is also sometimes regarded as uniquely American. However, in this issue of JAMA, dedicated to the topic of death, dying, and the end of life, Bekelman et al5 report findings that suggest otherwise. The authors analyzed data from patients older than 65 years who died with cancer in 7 countries: Belgium, Canada, England, Germany, the Netherlands, Norway, and the United States.5 Among these countries, the United States actually had the lowest proportion of patients whose site of death was the hospital (22% vs up to 51% elsewhere). To be sure, the United States registered the highest rate of intensive care unit admission and chemotherapy administration in the last 180 days of life, indicating a mixed and still complex picture of care at the end of life. High use of intensive care and other technologies is a general characteristic of US health care,6 and the study found that use of chemotherapy in the last 30 days of life declined in the United States, just as in the other countries, to approximately 10%. All of these countries appeared to be making a radical transition away from nearly universal reliance on hospitalization at death for cancer patients, with the United States, perhaps surprisingly, having moved the farthest and fastest away from institutionalization at death. Other research shows the United States now has perhaps the highest level of hospice capacity and use, and the highest likelihood of death at home, in the developed world.7 Data from another study in this issue of JAMA, by Wright et al,8 indicate that this shift has likely been beneficial. The authors report survey data from family members of 1146 elderly patients who died with advanced lung or colorectal cancer. Patients who died in the hospital proved the least likely to be reported to have excellent quality of care near death (just 41% did) or to die where they had wished to (only 18% preferred to die in the hospital and did so). By contrast, patients who had been enrolled in hospice for at least 3 days had the best reported quality of life near death and best alignment of care with their wishes. Opinion

Complementing Operating Room Teaching With Video-Based Coaching.

Abstract: Importance Surgical expertise demands technical and nontechnical skills. Traditionally, surgical trainees acquired these skills in the operating room; however, operative time for residents has decreased with duty hour restrictions. As in other professions, video analysis may help maximize the learning experience. Objective To develop and evaluate a postoperative video-based coaching intervention for residents. Design, Setting, and Participants In this mixed methods analysis, 10 senior (postgraduate year 4 and 5) residents were videorecorded operating with an attending surgeon at an academic tertiary care hospital. Each video formed the basis of a 1-hour one-on-one coaching session conducted by the operative attending; although a coaching framework was provided, participants determined the specific content collaboratively. Teaching points were identified in the operating room and the video-based coaching sessions; iterative inductive coding, followed by thematic analysis, was performed. Main Outcomes and Measures Teaching points made in the operating room were compared with those in the video-based coaching sessions with respect to initiator, content, and teaching technique, adjusting for time. Results Among 10 cases, surgeons made more teaching points per unit time (63.0 vs 102.7 per hour) while coaching. Teaching in the video-based coaching sessions was more resident centered; attendings were more inquisitive about residents’ learning needs (3.30 vs 0.28,P = .04), and residents took more initiative to direct their education (27% [198 of 729 teaching points] vs 17% [331 of 1977 teaching points],P Conclusions and Relevance Video-based coaching is a novel and feasible modality for supplementing intraoperative learning. Objective evaluation demonstrates that video-based coaching may be particularly useful for teaching higher-level concepts, such as decision making, and for individualizing instruction and feedback to each resident.

The incidence of hypoxemia during surgery: evidence from two institutions

Abstract: Purpose The incidence of hypoxemia in patients undergoing surgery is largely unknown and may have a clinical impact. The objective of this study was to determine the incidence of intraoperative hypoxemia in a large surgical population.

Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.

Abstract: Growing demand for health care, rising costs, constrained resources, and evidence of variations in clinical practice have triggered interest in measuring and improving the quality of health care delivery. For a valuable quality assessment, relevant data on outcome must be obtained in a standardized and reproducible manner to allow comparison among different centers, between different therapies and within a center over time.1–3 Objective and reliable outcome data are increasingly requested by patients and payers (government or private insurance) to assess quality and costs of health care. Moreover, health policy makers point out that the availability of comparative data on individual hospital's and physician's performance represents a powerful market force, which may contribute to limit the costs of health care while improving quality.4 Conclusive assessments of surgical procedures remain limited by the lack of consensus on how to define complications and to stratify them by severity.1,5–8 In 1992, we proposed general principles to classify complications of surgery based on a therapy-oriented, 4-level severity grading.1 Subsequently, the severity grading was refined and applied to compare the results of laparoscopic versus open cholecystectomy9 and liver transplantation.10 This classification has also been used by others11–13 and was recently suggested to serve as the basis to assess the outcome of living related liver transplantation in the United States (J. Trotter, personal communication). However, the classification system has not yet been widely used in the surgical literature. The strength of the previous classification relied on the principle of grading complications based on the therapy used to treat the complication. This approach allows identification of most complications and prevents down-rating of major negative outcomes. This is particularly important in retrospective analyses. However, we felt that modifications were necessary, particularly in grading life-threatening complications and long-term disability due to a complication. We also felt that the duration of the hospital stay can no longer be used as a criterion to grade complications. Although definitions of negative outcomes rely to a large extend on subjective “value” appraisals, the grading system must be tested in a large cohort of patients. Finally, a classification is useful only if widely accepted and applied throughout different countries and surgical cultures. Such a validation was not done with the previous classification. Therefore, the aim of the current study was 3-fold: first, to propose an improved classification of surgical complications based on our experience gained with the previous classification1; second, to test this classification in a large cohort of patients who underwent general surgery; and third, to assess the reproducibility and acceptability of the classification through an international survey.

Cancer statistics, 2019.

Abstract: Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data, available through 2015, were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data, available through 2016, were collected by the National Center for Health Statistics. In 2019, 1,762,450 new cancer cases and 606,880 cancer deaths are projected to occur in the United States. Over the past decade of data, the cancer incidence rate (2006-2015) was stable in women and declined by approximately 2% per year in men, whereas the cancer death rate (2007-2016) declined annually by 1.4% and 1.8%, respectively. The overall cancer death rate dropped continuously from 1991 to 2016 by a total of 27%, translating into approximately 2,629,200 fewer cancer deaths than would have been expected if death rates had remained at their peak. Although the racial gap in cancer mortality is slowly narrowing, socioeconomic inequalities are widening, with the most notable gaps for the most preventable cancers. For example, compared with the most affluent counties, mortality rates in the poorest counties were 2-fold higher for cervical cancer and 40% higher for male lung and liver cancers during 2012-2016. Some states are home to both the wealthiest and the poorest counties, suggesting the opportunity for more equitable dissemination of effective cancer prevention, early detection, and treatment strategies. A broader application of existing cancer control knowledge with an emphasis on disadvantaged groups would undoubtedly accelerate progress against cancer.

Cancer statistics, 2020.

Abstract: Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data on population-based cancer occurrence. Incidence data (through 2016) were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data (through 2017) were collected by the National Center for Health Statistics. In 2020, 1,806,590 new cancer cases and 606,520 cancer deaths are projected to occur in the United States. The cancer death rate rose until 1991, then fell continuously through 2017, resulting in an overall decline of 29% that translates into an estimated 2.9 million fewer cancer deaths than would have occurred if peak rates had persisted. This progress is driven by long-term declines in death rates for the 4 leading cancers (lung, colorectal, breast, prostate); however, over the past decade (2008-2017), reductions slowed for female breast and colorectal cancers, and halted for prostate cancer. In contrast, declines accelerated for lung cancer, from 3% annually during 2008 through 2013 to 5% during 2013 through 2017 in men and from 2% to almost 4% in women, spurring the largest ever single-year drop in overall cancer mortality of 2.2% from 2016 to 2017. Yet lung cancer still caused more deaths in 2017 than breast, prostate, colorectal, and brain cancers combined. Recent mortality declines were also dramatic for melanoma of the skin in the wake of US Food and Drug Administration approval of new therapies for metastatic disease, escalating to 7% annually during 2013 through 2017 from 1% during 2006 through 2010 in men and women aged 50 to 64 years and from 2% to 3% in those aged 20 to 49 years; annual declines of 5% to 6% in individuals aged 65 years and older are particularly striking because rates in this age group were increasing prior to 2013. It is also notable that long-term rapid increases in liver cancer mortality have attenuated in women and stabilized in men. In summary, slowing momentum for some cancers amenable to early detection is juxtaposed with notable gains for other common cancers.

Cancer statistics, 2018

Abstract: Each year, the American Cancer Society estimates the numbers of new cancer cases and deaths that will occur in the United States and compiles the most recent data on cancer incidence, mortality, and survival. Incidence data, available through 2014, were collected by the Surveillance, Epidemiology, and End Results Program; the National Program of Cancer Registries; and the North American Association of Central Cancer Registries. Mortality data, available through 2015, were collected by the National Center for Health Statistics. In 2018, 1,735,350 new cancer cases and 609,640 cancer deaths are projected to occur in the United States. Over the past decade of data, the cancer incidence rate (2005-2014) was stable in women and declined by approximately 2% annually in men, while the cancer death rate (2006-2015) declined by about 1.5% annually in both men and women. The combined cancer death rate dropped continuously from 1991 to 2015 by a total of 26%, translating to approximately 2,378,600 fewer cancer deaths than would have been expected if death rates had remained at their peak. Of the 10 leading causes of death, only cancer declined from 2014 to 2015. In 2015, the cancer death rate was 14% higher in non-Hispanic blacks (NHBs) than non-Hispanic whites (NHWs) overall (death rate ratio [DRR], 1.14; 95% confidence interval [95% CI], 1.13-1.15), but the racial disparity was much larger for individuals aged <65 years (DRR, 1.31; 95% CI, 1.29-1.32) compared with those aged ≥65 years (DRR, 1.07; 95% CI, 1.06-1.09) and varied substantially by state. For example, the cancer death rate was lower in NHBs than NHWs in Massachusetts for all ages and in New York for individuals aged ≥65 years, whereas for those aged <65 years, it was 3 times higher in NHBs in the District of Columbia (DRR, 2.89; 95% CI, 2.16-3.91) and about 50% higher in Wisconsin (DRR, 1.78; 95% CI, 1.56-2.02), Kansas (DRR, 1.51; 95% CI, 1.25-1.81), Louisiana (DRR, 1.49; 95% CI, 1.38-1.60), Illinois (DRR, 1.48; 95% CI, 1.39-1.57), and California (DRR, 1.45; 95% CI, 1.38-1.54). Larger racial inequalities in young and middle-aged adults probably partly reflect less access to high-quality health care. CA Cancer J Clin 2018;68:7-30. © 2018 American Cancer Society.

2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer.

Abstract: Background: Thyroid nodules are a common clinical problem, and differentiated thyroid cancer is becoming increasingly prevalent. Since the American Thyroid Association's (ATA's) guidelines for the management of these disorders were revised in 2009, significant scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid nodules and differentiated thyroid cancer. Methods: The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles on adults were eligible for inclusion. The American College of Physicians Guideline Gr...