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In the current issue of The New Yorker, surgeon Atul Gawande provocatively suggests that medicine needs to become more like The Cheesecake Factory – more standardized, better quality control, with a touch of room for slight customization and innovation.
The basic premise, of course, isn’t new, and seems closely aligned with what I’ve heard articulated from a range of policy experts (such as Arnold Milstein) and management experts (such as Clayton Christensen, specifically in his book The Innovator’s Prescription).
The core of the argument is this: the traditional idea that your doctor is an expert who knows what’s best for you is likely wrong, and is both dangerous and costly. Instead, for most conditions, there are a clear set of guidelines, perhaps even algorithms, that should guide care, and by not following these pathways, patients are subjected to what amounts to arbitrary, whimsical care that in many cases is unnecessary and sometimes even harmful – and often with the best of intentions.
According to this view, the goal of medicine should be to standardize where possible, to the point where something like 90% of all care can be managed by algorithms – ideally, according to many, not requiring a physician’s involvement at all (most care would be administered by lower-cost providers). A small number of physicians still would be required for the difficult cases – and to develop new algorithms.
A variant of this view, discussed by technologists such as Vinod Khosla, and commentators such as John Goodman, imagines that one day even the low-cost providers can be cut out of the loop, and patients (consumers) can do most of the work with their computer and perhaps a few gadgets.
Doctors, as you might expect, tend to reject this vision of standardization, as it ruthlessly undercuts the view that physicians are particularly wise, special, insightful – and worthy of autonomy – and instead seems to assert that medicine should be run like an assembly line, with limited opportunity for customization.
The patient perspective may be more complicated: on the one hand, it’s absolutely true that the current system generally fails even the most basic standards of customer service. There’s virtually nothing in the current system that appears to be designed around patients; Gawande shares an example about the care a patient received in the emergency room that could have been told, with few modifications, by virtually everyone I know, and holds true whether you’re talking about a small community hospital or one of the nation’s leading teaching centers.
In other words, learning a bit about customer service from The Cheesecake Factory – or a number of other industry-leaders – would do medicine a world of good.
On the other hand, I worry that a lot of medicine really isn’t quite as reducible, as standardizable, as many of the advocates and management gurus would like to believe, and by doing the classic economics trick of “assuming a can opener” – assuming medicine is standardizable because, gosh, wouldn’t it be nice if it were – these experts may not be helping as much as they’d like to imagine.
Patients deserve and increasingly demand far better “customer service” than they currently receive; at the same time, at least the patients who are fortunate enough to have physicians tend to give them surprisingly high marks. Critics contend this is how the system is harmful to patients – patients can be suckered by good bedside manner, and not realize how poor the care actually is.
Yet, I’d argue that given the incredibly limited amount of solid evidence for most things in medicine, the individual relationship between physician and patient can be of remarkable therapeutic value (although perhaps less so in surgery than in internal medicine).
Thus, while Gawande claims that “Patients just won’t look for the best specialist anymore, they’ll look for the best system,” I wonder whether this is generally true and realistic. While Romney was roundly criticized for suggesting that “corporations are people,” I wonder if Gawande is overreaching in making the reverse claim: essentially, that “doctors are systems,” and that patients should, and will, reach for the best system, not the best person.
I certainly appreciate where Gawande’s coming from here, but I also worry that if we might lose something important by accepting this premise – something vital and distinctive about the patient-doctor relationship that is unlikely to be captured with the same depth and nuance if it’s instead between a patient and a system.
As I’ve previously discussed, it’s a challenge to balance consistency and innovation, and it’s difficult to know how best to remove the “bad” variability in care delivery while still supporting the customization of care so central to medicine, and to healing. We might want our $15 dinners to look the same, but I doubt most of us want our medical care delivered in as rote a fashion.
The question is whether there’s a way to improve care and preserve individualization, and avoid imposing what is effectively centralized control and a litany of standardized processes.
Doctors may be running out of time to figure this out. The writing is on the wall (and, it seems, everywhere else as well). If doctors don’t want to wind up as commoditized participants in a Taylorized vision of medicine they will need to recognize their limitations and seriously up their game.
I’ve too much respect for the practice of medicine and too much concern for the care of patients to believe that the Cheesecake Factory really defines how we want American medicine to be served.
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