Atul Gawande

CONTEXT: Assessing thyroid nodules for malignancy is complex. The impact of patient and nodule factors on cancer evaluation is uncertain. OBJECTIVES: To determine precise estimates of cancer risk associated with clinical and sonographic variables obtained during thyroid nodule assessment. DESIGN: Analysis of consecutive adult patients evaluated with ultrasound-guided fine-needle aspiration for a thyroid nodule ≥1 cm between 1995 and 2017...

BACKGROUND: A coaching-based implementation of the WHO Safe Childbirth Checklist in Uttar Pradesh, India, improved adherence to evidence-based practices, but did not reduce perinatal mortality, maternal morbidity, or maternal mortality. We examined facility-level correlates of the outcomes, which varied widely across the 120 study facilities. METHODS: We did a post-hoc analysis of the coaching-based implementation of the WHO Safe Childbirth Checklist in Uttar Pradesh...

In the opening lecture of the congress of the American Society of Clinical Oncology (ASCO), the famous US surgeon Atul Gawande addressed the issue of the role of the doctor, focusing on the care of patients with terminal illnesses. Prolonging life should not represent the goal of the doctor's decision-making, who must instead pay attention to preserving the patient's quality of life as much as possible. The relationship between doctor and patient must be based on some fundamental questions that the clinician must address to the patient in order to know his goals...

BACKGROUND: Strong primary health care (PHC) is essential for achieving universal health coverage, but in many low- and middle-income countries (LMICs) PHC services are of poor quality. Facility management is hypothesized to be critical for improving PHC performance, but evidence about management performance and its associations with PHC in LMICs remains limited. METHODS: We quantified management performance of PHC facilities in Ghana and assessed the experiences of women who sought care at sampled facilities...

OBJECTIVE: To describe the strategies used by a collection of healthcare systems to apply different methods of identifying seriously ill patients for a targeted palliative care intervention to improve communication around goals and values. METHODS: We present an implementation case series describing the experiences, challenges and best practices in applying patient selection strategies across multiple healthcare systems implementing the Serious Illness Care Program (SICP)...

Is it virtuous for someone to try to live to 100? Casting aside questions of intergenerational justice and internal obligations in families, what about the basic desire itself? Discussions of longevity and aging in bioethics are skewed to controversial end-of-life decisions, largely avoiding questions of how to age well before such decisions arise. Respected writers such as Atul Gawande, Daniel Callahan, and Ezekiel Emanuel champion accepting a natural life span and not trying to live beyond it. The Stoic Seneca says a desire to live to 100 is foolish because, however long people live, they waste most of their lives, so if they lived a thousand years, they would still waste most of it...

Importance: High-quality conversations between clinicians and seriously ill patients about values and goals are associated with improved outcomes but occur infrequently. Objective: To examine feasibility, acceptability, and effect of a communication quality-improvement intervention (Serious Illness Care Program) on patient outcomes. Design, Setting, and Participants: A cluster randomized clinical trial of the Serious Illness Care Program in an outpatient oncology setting was conducted...

Importance: Earlier clinician-patient conversations about patients' values, goals, and preferences in serious illness (ie, serious illness conversations) are associated with better outcomes but occur inconsistently in cancer care. Objective: To evaluate the efficacy of a communication quality-improvement intervention in improving the occurrence, timing, quality, and accessibility of documented serious illness conversations between oncology clinicians and patients with advanced cancer...

BACKGROUND: Objective criteria are lacking to determine whether a laparoscopic transabdominal (LA) or retroperitoneoscopic (RP) approach to adrenalectomy is optimal. We hypothesized that imaging characteristics could predict patients for whom RP adrenalectomy is the optimal approach. MATERIALS AND METHODS: Retrospective cohort study of all patients undergoing minimally invasive adrenalectomy between 2014 and 2016 (n = 113) at one institution. Imaging measurements included distances between the skin and Gerota's fascia (S-GF), upper borders of adrenal and kidney (A-K), adrenal and 12th rib (A-R), 12th rib and iliac crest (R-IC), and perinephric fat (PNF)...

No abstract text is available yet for this article.

BACKGROUND: Maternal and neonatal outcomes in the immediate post-delivery period are critical indicators of quality of care. Data on childbirth outcomes in low-income settings usually require home visits, which can be constrained by cost and access. We report on the use of a call center to measure post-discharge outcomes within a multi-site improvement study of facility-based childbirth in Uttar Pradesh, India. METHODS: Of women delivering at study sites eligible for inclusion, 97...

Objectives Vital to implementation of the World Health Organization (WHO) Safe Childbirth Checklist (SCC), designed to improve delivery of 28 essential birth practices (EBPs), is the availability of safe birth supplies: 22 EBPs on the SCC require one or more supplies. Mapping availability of these supplies can determine the scope of shortages and need for supply chain strengthening. Methods A cross-sectional survey on the availability of functional and/or unexpired supplies was assessed in 284 public-sector facilities in 38 districts in Uttar Pradesh, India...

PURPOSE: To investigate the impact of the nomenclature change to "noninvasive follicular thyroid neoplasm with papillary-like nuclear features" (NIFTP) on reported malignancy rates following thyroidectomy. METHODS: Retrospective cohort study of patients with thyroid nodules sampled preoperatively with fine-needle aspiration (FNA) and subsequently removed at one tertiary-care hospital from 4/2016 to 2/2017. Surgical procedure, anatomic pathology, thyroid cytopathology classification, and demographic characteristics were recorded...

Earlier this year, Amazon, J. P. Morgan, and Berkshire Hathaway announced plans to launch a joint health care company with more than a million covered lives. Dr. Atul Gawande, the prominent Boston-based surgeon and health care thought leader, will become the first chief executive officer of this health care venture, with a mission to get the best results at the lowest costs and remain free from profit-making incentives and constraints. In this presidential column, the author explores what this has to do with the mission in the Collaborative Family Health care Association (CFHA) and the promulgation of integrated health care...

OBJECTIVE: To evaluate whether integration of the Opportunity-Ability-Motivation plus Supplies (OAMS) framework into coaching improved the delivery of essential birth practices in a low-resource setting. METHODS: This prospective mixed-methods study used routine coaching visit data obtained from the first eight intervention facilities of the BetterBirth trial in Uttar Pradesh, India, between December 19, 2014, and October 21, 2015. The 8-month intervention was peer coaching that integrated the OAMS framework to support uptake of the WHO Safe Childbirth Checklist...

BACKGROUND: Few studies have focused on racial and ethnic differences in advance care planning other than advance directives among population-based samples of adults across the lifespan. METHODS: Using data from a statewide random-digit dial telephone survey of adults 18 years or older (n = 1851), we investigated racial and ethnic differences in (1) designation of a healthcare agent (HCA); and (2) communication of goals, values, and preferences for end-of-life care with healthcare providers, a HCA, or other family members and friends...

OBJECTIVE: Traditionally, surgical educators have relied upon participant survey data for the evaluation of educational interventions. However, the ability of such subjective data to completely evaluate an intervention is limited. Our objective was to compare resident and attending surgeons' self-assessments of coaching sessions from surveys with independent observations from analysis of intraoperative and postoperative coaching transcripts. DESIGN: Senior residents were video-recorded operating...

No abstract text is available yet for this article.

BACKGROUND: In older patients, thyroid nodules are frequently detected and referred for evaluation, though usually prove to be benign disease or low-risk cancer. Therefore, management should be guided not solely by malignancy risk, but also by the relative risks of any intervention. Unfortunately, few such data are available for patients ≥70 years old. METHODS: All consecutive patients ≥70 years old assessed by ultrasound (US) and fine-needle aspiration (FNA) between 1995 and 2015 were analyzed...

No abstract text is available yet for this article.