Dr. Atul Gawande has written a much-ballyhooed essay in the New Yorker, entitled “Big Med.” His piece proposes The Cheesecake Factory as a model for healthcare. For me, a physician, Dr. Gawande’s message left a bad taste in my mouth.
The Cheesecake Factory succeeds because of standardization and efficiencies, with complete control over purchasing and production. What recipes work become menu items throughout the chain. What recipes don’t work are soon discarded, much as a rancher periodically culls the herd.
The Cheesecake Factory model of care seems to work best for elective surgery. It is no coincidence that Dr. Gawande uses his mother’s knee replacement surgery as his example. Her orthopedic surgeon’s efforts over the years have produced standardization, efficiency and excellent outcomes.
Cardiac electrophysiologist Dr. Richard Fogoros has written his own piece on herd medicine. Dr. Fogoros describes the dilemma involved in introducing such standardization to medical care. Regimentation is not a new concept but was introduced by our old friends in managed care:
The unifying idea behind managed care boils down to one word: standardization. Standardization is virtually a synonym for industry. In industry, standardization is the primary means of optimizing the two essential factors in any industrial process: quality and cost.
This proposition can be stated formally as the Axiom of Industry: The standardization of any industrial process will imrove the outcome and reduce the cost of that process.
So Dr. Gawande’s Cheesecake Health System should therefore yield excellent outcomes at lower cost through its uniform menus or critical pathways.
There’s a problem, however. The same standardization so successful in elective surgery breaks down for most medical care situations. Even Dr. Gawande admits that “a person is not a steak.” Patients are not food items, they are not widgets in an assembly line. Therein lies the fatal flaw for Cheesecake Health System’s doctors: the intrinsic variability of presentation, variability of response to treatment, and variability of co-morbidities.
Dr. Fogoros: “In the messy world of patient care, the variances revealed instead that industry-like standardization only works for a mniority of medical services. No amount of tweaking can standardize the management of complex patients with complex combinations of illnesses.”
Medical care cannot be viewed as a product. In Dr. Gawande’s world, a hospital chain needs to employ someone to render services. The system needs innovators and R&D, not to make a person’s health care better, more compassionate, but rather to optimize the quality/cost ratio efficiently and in sufficient volume for the bottom line. Unfortunately, when the person with the perfect knee replacement slips and falls in the normal course of life and needs re-operation. It’s doubtful the Cheesecake CEO would tolerate such inefficiency.
Dr. Gawande: “We bristle at the idea of chains and mass production … then you spend a bad night in a quaint, one of a kind bed and breakfast … and it’s right back to the Hyatt…”
There is another alternative: the quaint picturesque vacation that provides a special memory and a warm individual touch. Dr. Gawande paints with too broad a brush.
So what are physicians going to do? We must first realize that Medicine is a profession, not a commodity to be bought, sold, bribed, remodeled or reshaped. We need to acknowledge that there are redundancies, that there are times when we need efficiencies in communicating and supporting each other in caring for patients who do require that “bed and breakfast” approach to care. Physicians are a network of highly skilled, intelligent, committed caretakers in a world of different and distinct individuals.
While many people will respond to a specific protocol or set of medications, we also know, however, that variance exists within that framework. Patient care is not meal preparation. Our ingredients are alive and vibrant, requiring much time and attention, knowing that occasionally we will have to return to square one.
Therefore, this is a plea that physicians who recognize need for improvement, change, and harmony within this complex system of health care: take charge. Healthcare is messy, imperfect. Our patients recognize this as they also recognize physicians who cherish what they do. Patients know that To Serve Man is not a cookbook. When patients need care, they want a doctor, not a CEO.
As for me, give me a small bed and breakfast any day, where everybody knows my name. Cheers.
Art Fougner is an obstetrician-gynecologist. Kira Geraci-Ciardullo is an allergist and immunologist.