While researching surgery's history for the New England Journal of Medicine's bicentennial, Gawande noted that the definition of surgery was unclear, so he developed his own: "A profession defined by its authority to cure by means of bodily invasion." He also outlined the profession's history of innovation made possible by anesthesia and infection control.
He said surgical mentions in the journal peaked in 1862, 1892 and 1922 and that since 1972, only 10% of the journal's articles have been about surgery.
"Surgeons are still traversing remarkable frontiers," Gawande said, noting that surgical incisions have gone from half a meter to half an inch to a mere puncture. And he described the more than 2,500 available surgical procedures as an "explosion of capability."
"This explosion has brought profound societal concerns," about appropriateness of treatment, care access, cost management and other issues, he said. "We can't underestimate these worries. Health costs are by far the largest source of government debt.”
That said, evidence shows that the best care is not always the most expensive care, and that there is no correlation between cost and the outcome of care delivered, Gawande noted.
"It means there is hope," he said, adding that healthcare systems can lead the way in improving quality and reducing costly overtreatment. Referencing his recent New Yorker article, he explained how the Cheesecake Factory uses a systematic approach to achieve reliable quality, eliminate waste and bring good ideas into practice quickly.
Gawande also mentioned systematic tools such as surgical checklists, and noted that surgeons including Drs. Delos "Toby" Cosgrove, Brent James and Glenn Steele Jr. are leading innovative systems at the Cleveland Clinic, Intermountain Healthcare and Geisinger Health System.
He closed by stating that making the new available healthcare techniques work across systems for every patient was "the great task of our generation of clinicians."