Want to industrialize health care? Ask how well it has worked for pharma R&D

Reuters

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  • Discovery isn’t ideally performed in an industrialized fashion. @DShaywitz

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  • Retaining the individuality that is essential to medicine is key. Do not impose standardization simply for its own sake.

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If you enjoyed the recent discussion around whether medicine should emulate the Cheesecake Factory, be sure to have a look at this interview in Fortune with Ralph de la Torre, former surgeon at the BIDMC and now CEO of the private equity-owned Steward Health Care System (h/t Ellen Licking). 

The key quote:

"You have to look back at America and the trends in industries that have gone from being art to science, to being commodities. Health care is becoming a commodity. The car industry started off as an art, people hand-shaping the bodies, hand-building the engines. As it became a commodity and was all about making cars accessible to everybody, it became more about standardization. It's not different from the banking industry and other industries as they've matured. Health care is finally maturing as an industry, and part of that maturation process is consolidation. It's getting economies of scale and in many ways making it a commodity."

There, in a nutshell, is the basic argument: industrialization of medicine is not just inevitable but also desirable; this process will improve average quality and make healthcare more broadly affordable.

I hope two other experts I associate with the BIDMC will weigh in on this: former BIDMC CEO Paul Levy, who just published this savage critique of private-equity-backed for-profit healthcare systems, and Drs. Groopman and Hartzband, who have written so thoughtfully about the false charms of best practice guidelines.

I also wonder whether the experience of big pharma is relevant here; a decade or so ago, flush with the excitement of the genome project, big pharma was certain that they knew enough to effectively industrialize R&D, to discover new treatments essentially at scale. 

Like medicine, drug discovery was described as something that used to be an art but now was a science, and thus amenable to industrialization, and well-positioned to reap the associated benefits: economies of scale, benefits of standardization, robust metrics, etc.

Of course, biology turned out to be far more complicated than most had appreciated, and discovery remains something that we've now recognized isn't ideally performed in an industrialized fashion - indeed, most big pharmas are now trying, in many ways, to "deindustrialize" their discovery process, and break it down into smaller and more individualized teams, with less central control and direction.

The point here isn't to argue by analogy - obviously pharma R&D isn't delivery of healthcare - but rather to question the progress vector implicit (and often explicit) in the argument of many advocates of healthcare standardization.  Progress doesn't always equal a move towards standardization, and there are clearly instances where the harms of such industrialization far outweigh the benefits, however appealing (and measurable, and attainable) they might be.  In some cases, to paraphrase Nassim Taleb, it's better to be generally correct than to be precisely wrong, and turning the nuance of medicine into rigidly defined processes strikes me as more likely to offer false precision than true insight.

The essential issue here is whether attempts at industrializing medical care will result in the broad improvements the Taylorists seem to envision, or whether the result will be the evisceration of a system that, while imperfect, has a great many extraordinary strengths, and once destroyed, will be difficult or impossible to re-establish. 

My strong preference would be to retain the individuality I view as essential to the practice of medicine, and to incorporate - aggressively - the use of evidence where it's available, but not to impose standardization simply for its own sake, metrics for the sake of metrics. 

Patients - in all their blessed complexity - deserve better.

 

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David
Shaywitz

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