Did Atul Gawande unwittingly support specialty hospitals?

If you’re a fan of star surgeon overachiever Atul Gawande, then reading his New Yorker article “Big Med” is a must. The rest of us skeptics should still use the article to signal our health care adroitness by knowingly referring to the “Cheesecake Factory” in our policy medical meetings, conferences, PowerPoints and bloggery.

What he wrote

Dr. Gawande uses the successful restaurant chain to extract lessons and draw health system parallels, ultimately concluding, after a visit to one of their kitchens, that the industrialization of health care delivery may not be such a bad thing. While the Factory’s hibachi steak is personally prepared to the consumer’s specifications, its final sizzling tasty presentation is really the product of inventory control, fine-tuned assembly line prep that leads to the expert cook, all of which are under intense quality oversight.

The same business model of mass customization should be applied to total knee replacements and ICU stays, says Dr. Gawande.  And in order for that to happen, it’ll mean transforming our small independent hospitals into big chain factories that can marshall the financial and intellectual capital to get patients out of bed, off the breathing machine and in their home with a minimum length of stay.

At the center of this value chain is the cook (surgeon or ICU specialist) who relies on standardized ingredients (devices or drugs) that are assembled (delivered) using a standard prep (guideline or protocol). That’s when the cook can use his or her personal grilling expertise to gauge the doneness of the steak and properly fluff the mashed potatoes. In Gawande-World, the surgeon-cook can have his cake (professional independence) and eat it too (by reducing variation).

But here’s what he missed

I really liked the article, but Dr. Gawande neglected tell the entire story:

  • The Soviet Union invented assembly line surgery back in 1968 when they applied it to cataract surgery.  While it never really took hold in the U.S., variations of it exist, such as this cataract factory in India. Why not have, wonders the naive DMCB, a series of surgeons who are responsible for each step of a deconstructed surgical procedure? While that sounds silly, there may be some high volume multi-step elective operations other than cataracts where this makes sense.
  • Dr. Gawande seems to be unwittingly arguing on behalf of the specialty hospital.  Enterprising physicians and investors have been prepared, long before this New Yorker article, to double down on the value chain of organized production line medicine, figuring that they can not only control costs, minimize complications and minimize hassles, but also make a tidy profit. Ironically, it seems, the concept has drawn the ire of policy makers, based on irksome concerns about for-profits cherry-picking high margin business from well-connected institutions like Dr. Gawande’s home base, Brigham and Women’s Hospital.
  • Last but not least, a version of the enlightened assembly-line approach has been long applied by the U.S. health care system outside the big hospitals’ operating rooms. In population health management, persons with chronic conditions are “inventoried” (risk stratified via mail surveys, insurance claims and the electronic health record). Non-physicians manage the “prep” with education, engagement and coaching, getting the patient “warmed up” for the primary care doc.  The doc then personalizes things.  That’s all accompanied by ongoing assessments of contracted quality and cost versus a baseline or comparator leading to a perfect product. Of course, this Cheesecake Factory style population health management will likely never garner the attention of The New Yorker.

Jaan Sidorov is an internal medicine physician who blogs at the Disease Management Care Blog.

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  • http://twitter.com/PatientSafetyMD Michael Appel

    Dr. Gawande is not arguing for a SERIES of surgeons, inasmuch as Cheesecake Factory does not use a SERIES of chefs to produce Hibachi steak. Rather, the point is that we must streamline and standardize the ENTIRE process of healthcare delivery to allow for customization where necessary, and standardize everything else.

    Why would this apply only to a “specialty hospital”? The type of surgery is the “customization.” The underlying process, common to ALL surgeries, is what needs to be standardized.

    Finally, “population health management” is hardly an example of a Cheesecake Factory-styled “enlightened assembly line.” In the clinical healthcare setting, there is virtually no industry-wide (nor local healthcare system-wide) standardization of medication orders, medication administration, medication reconciliation, patient handoff, charting, transportation, procedure prep, paperwork, rapid acuity assessment, training of healthcare workers, quality oversight, equipment, supplies, inventory management, infection control, risk reduction, incident investigation, etc. Each of these items has an analogous component at Cheesecake Factory, and they all function as finely-tuned and well-controlled system.

    I believe that is what Dr. Gawande wishes we would all understand.

  • bmniac

    There is a tendency reject anecdotal evidence but with no attempt to study larger samples. A otherwise healthy man of 65(parameters- re lipids, hypertension, blood sugar levels optimal) was admitted in a 5 star Bangalore hospital and underwent surgery for colon cancer. the polyps were removed and 2 days later he died of septicemia. When he was admitted the family was told that a surgeon specializing in colon surgery would perform the surgery. Later it turned out that the surgeon was called away and a substitute who was a surgeon but not a specialist performed the surgery. there was a pro forma inquiry within the hospital and the matter was predictably closed.If the man had gone to a specialist hospital(and there are excellent cancer centres in India) the man would probably be alive. there is no doubt in my mind that like most professionals there seems to be an aversion to change among doctors too. It is fortunately probably less than in the case of engineers and economists two professions I have dealt with extensively.
    I for one fully support Dr Gawande’s views.

  • http://twitter.com/jimjaf jim jaffe

    Luddite is a harsh and overused term, but wonder whether it is relevant here. For those of us in the civilian population, the argument against transparent protocols is a rather obscure one. no one denies that they’re an imperfect solution, but few of us believe there is a perfect solution and they do appear to be a constructive step.

  • Dorothygreen

    Dr. Gawande has some good ideas. However, it seems a bit insulting to the intelligence of those in the medical community who really try to improve, to keep using comparisons of cars, widgets or restaurants to explain how to fix what is wrong with health care.
    Happen to see the IOM report that we waste $750 billion a year of $2.5 trillion? Here again were some comparisons to banks and other private, market driven industries – even when it is the IOM who has brought together the “choose wisely group” to “recommend” stopping some unnecessary tests.
    Most of the waste reported by the IOM can’t be related to the production of cars or the efficiency of restaurants from farm to fork. Overpricing and unnecessary services take the biggest chuck of waste (physicians? hospitals?), then excessive administrative costs (insurance companies?) lack of standardization (with 1200 EMR programs, that are controlled by vendors and don’t communicate with each other in the name of “choice and free market”? how are we ever to have an EMR system that functions as good as France, Germany, Switzerland or Taiwan.).
    How about looking at the many reports of increased efficiences have been developing in health care delivery over the last decade and are escalating as a result of the ACA The “bundled services model” accountable care organizations. I just started in one – I was able to check it out on my insurance network for quality. The nurses and physicians all had laptops and in no way did this interfer with my ability to communicate. I was happy to have all my medical information in the computer and be in “a system” where physicians talk to one another. I could tell by the initial questions that were asked that these were the “quality measures”.
    Also, there is one variable that Dr. Gawande and most leave out when discussing our inefficient, costly health care – the patients. For example, all the countries mentioned here have obesity rates of less than 20% AND are implementing taxes and other efforts from farm to fork – the real prevention – to lower their epidemics of chronic preventable diseases understanding full well the impact on health care costs. There is little effort in the US to reform our eating culture largely because Big AG and Big Food have so much lobbying power again any effort – the major focus of the Bigs is to keep Amercans addicted to sugar, salt and fat and “frack” public health.
    Finally, the Government’s main role in Switzerland is to provide subsides for insurance, assure their citizens are not being overcharged by insurance companies and that physicians and hospitals are not preforming unnecessary services. All administration is done by non-proift insurance companies – tfor profit is outlawed for essential services but can be made on supplemental. We are closer to such a model with the ACA. It is a better model for the US than a single payer system because the government is out of the administration business. But, we cannot get there unless we get rid fo profit at the expense of patient care and reform our eating culture.

    • http://www.facebook.com/profile.php?id=100000345896514 You Isee

      You seem to forget the psychology of litigation. People want perfect and when they don’t get it, they want millions. People’s right for pain/suffering need to be taken away to allow the system to work well. Most of these unhealthy bastards are just as selfish as the people they criticize. Pseudoliberalism.