OP-ED

Do You Believe Doctors Are Systems, My Friends?

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 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 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.

David Shaywitz is co-founder of the Center for Assessment Technology and Continuous Health (CATCH) in Boston.  He is a strategist at a biopharmaceutical company in South San Francisco. You can follow him at his personal website. This post originally appeared on Forbes.

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Peter EliasNoel ColemanMichael SlavinskiDenise VincentTodd Recent comment authors
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Peter Elias
Guest

I do not need a personal relationship with my airline pilot or air traffic controller when I fly, because I have a relationship built on trust and a consistently high quality product. I propose that, to a significant degree, the current emphasis on the need for a *personal* relationship to a health care provider represents a compensatory mechanism. Since we (both patients and clinicians) know how unreliable the medical product is, instead we demand faith in the fact that our clinician will try hard and be nice to us. If AI and medicine ever reach the point where medical diagnosis… Read more »

Michael Slavinski
Guest

Alright, this a repost from inside Linked In, Uncle Sam needs your input and I am really impressed wiht the “passion”! To all of you who commented on this thread, “thank you very much”! Very little do I know about the medical industry but now, thanks to your input, I am a little better off! The first twenty years or so running our humble company were spent being “schooled” and here as I develop an advocacy for the “prevention” of Hospital Associated Infections (HAI) in our Veteran’s Hospital’s, “school” begins, I should be getting pretty good at it by now!… Read more »

Denise Vincent
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Denise Vincent

90% of care could be managed by algorithms because of the huge load of BS that caregivers are forced to wade through due to waste and ineffeciencies, not because anyone is questioning physician expertise. Dr. Shaywitz completely misses that the best reason to standardize care is to more fully leverage physician brain power. I suspect that Dr. Shaywitz believes that physicians are the line workers in the Cheesecake Factory Scenario, not realizing that in healthcare, the support staffs are the line workers, while physicians are the managers.

Todd
Guest

RobertL39, I respectfully disagree with your assertation that small medical practices can’t pursue Continuous Improvement. Please check out Dr. Sami Bahri (there’s a blog about his incredible work at theleancorner.com), practicing dentist and author of Follow The Learner. He and his team have absolutely incorporated CQI concepts (primarily Lean) and his patients adore what they’ve done.

RobertL39
Guest
RobertL39

Thanks for your comment. “Can’t” and “never” are too definitive. Of course there are docs, office managers, and staff who CAN do CQI. But, realistically, what percentage of small, private practices will this ever represent? Not enough to make any significant difference. If, however, the practices get help with it, in its many forms, from an IPA or ACO, then it might happen. Having just spoken to the medical director of our local IPA, I can tell you that it’s the proverbial herding of cats and doesn’t go very well.

Art Papier
Guest

It’s between the waiter and patron at the restaurant table of medicine Hospitals can be dangerous and inefficient; therefore it is easy to connect with Atul Gawande’s recent New Yorker essay “BigMed” suggesting that the streamlined, production processes found at the Cheesecake Factory can and likely will be applied to healthcare. Yet hospital care should not be confused with the full spectrum of healthcare. One must make the distinction between the cognitive process of medical diagnosis occurring in exam rooms, with the procedural basis of surgical care and hospital recovery. While Dr. Gawande has provided a wonderful revealing portrait of… Read more »

RobertL39
Guest
RobertL39

Lovely, well-considered comment. Thanks! Changes such as the ones you see in the last part of your comment will be a godsend to cognitive practitioners. It seems to me, as it does to “Denise Vincent” below, that a great deal of what ‘cognitivists’ do now could be managed as well or better by para-professionals, either alone or in groups. The next step in your analysis would seem to be how to leverage those changes to make the life of the cognitivist not only more accurate [using your new tools] but more satisfying and productive as well. See Christensen’s “The Innovator’s… Read more »

Cory
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Cory

RobertL: You might assume that but I’m far from convinced the people doing it will assume that.
Therein lies the whole debate.

RobertL39
Guest
RobertL39

Which leads back to my main point: you/we will get ACOs whether we help them or not. The choice is to help them, being sure they “know something about clinical medicine”, or don’t help and cross your fingers. Are doctors going to lead this, or continue their rear-guard actions of the past?

Cory
Guest
Cory

Robert L says: Sure sounds like an ACO to me. Is that BIg Medicine? Here are the DHHS regs: Incorporating DHHS final regulation adjustments on October 20, 2011, Section 3022 outlines the following requirements for ACOs: The ACO shall be willing to become accountable for the quality, cost, and overall care of the Medicare fee-for-service beneficiaries assigned to it The ACO shall enter into an agreement with the Secretary to participate in the program for not less than a 3-year period The ACO shall have a formal legal structure that would allow the organization to receive and distribute payments for… Read more »

RobertL39
Guest
RobertL39

Read your first regulation:

“…become accountable for the quality, cost, and overall care of the Medicare fee-for-service beneficiaries assigned to it”
If you don’t know any clinical medicine, I’d suggest you might not want to assume accountability for the quality and overall care of the beneficiaries assigned to your ACO.

Syed Hussain, MD
Guest
Syed Hussain, MD

“This post really gets my goat. “, said someone. Patients are not cheese cake or meat or goat cheese or lettuce wraps. And, they, well you know then but, do not want to be eaten. So then, the infamous writer Atul has it wrong. He and most of the bloggers and commenters here have not read on the Cerner outage that eliminated the medical records of thousands of the sickest patients in one fell swoosh. If there is a need for process control and improvement, imust be devoted to the HIT vendors who have zero process control cause they answer… Read more »

Cory
Guest
Cory

“Dr. Shaywitz and Cory have a romanticized notion of medicine, but the truth is that with the right incentives, a welcoming, patient-centered delivery orientation and clinical decision support tools, the patient experience can vastly improve, the quality of care become predictably far better and the cost drop precipitously.” On your first point, that’s true. Some romanticized medicine is good some is bad. Let’s not forget medicine has been going on far longer than CQI and there were some pretty smart people doing 50, 100, 500 years ago who established certain principles we are willing to abandon without much thought. On… Read more »

RobertL39
Guest
RobertL39

And to Margalit Gur-Arie (thank you for your comment!): Would one of you please translate what you mean by “Large Systems Medicine” or “Big Medicine”? There are many different definitions, some of which we should probably avoid and some of which perhaps embraced [e.g., would you call Mayo Clinic “Big Medicine”?] And where is it written that we must “…accept Big Medicine.”? Do you imply that this means everything else is excluded? from Cory above “…people with medical experience who are willing to take a disinterested look at these things from a patient care standpoint, taking in to account all… Read more »

Margalit Gur-Arie
Guest

I think there is a subtle point getting lost in this exchange. Nobody ( I presume) is debating the advantages of performance improvement, evidence-based decision support, data and information technology, team work, coaching and training and all the good stuff that could be applied, to a certain extent, to medicine today and to a much larger extent to medicine tomorrow…. but what does this have to do with Big Medicine? The problem, IMHO, with this cheese thing is the same problem with many other Gawande articles: he picks one facet of a multifaceted situation, analyzes it and then proceeds to… Read more »

BobbyG
Guest

Gotta say, you never disappoint.

Though, I would take issue with this:

“If so are there any other chains that are better than individual establishments? Why are all one-of-kind restaurants lumped together? Surely, one can identify certain factors that make one-of-kinds infinitely better than others and than chains? Without clear answers to these questions, why must we accept Big Medicine?”
___

You’d have to actually read Toussaint to understand that that is not what’s HE’s calling for. Quite the converse, beyond some general principles that are by now time-tested in clinical settings..

Margalit Gur-Arie
Guest

Bobby, I am not arguing with Toussaint’s writing. I am not even arguing with Dr. Gawande’s suggestions for CQI. I am just arguing with his unfounded assertion that something must be Big in order to be good.

All the conveniences that Big things brought us, came at a steep price, sometimes financial other times worse than that. I’m not sure we can afford the collateral damage associated with Big Med.

RobertL39
Guest
RobertL39

Pardon my impertinence, but it feels to me like you are creating a false dichotomy between Big Medicine [not defined except as ‘Partners’] and “one-of-a-kinds”, by which I presume you mean independent private practices. Small offices simply can’t/won’t do extensive process improvement. That’s not their job, unless they’d rather do that than practice medicine. Each form has something to offer, just as Per Se has something to offer that Cheesecake Factory doesn’t. And vice versa. “One size don’t fit all.” The dichotomy is false. Similarly impertinently, I’d like to suggest that you re-read Dr. Gawande. How did small private practice,… Read more »

Margalit Gur-Arie
Guest

I welcome your “impertinence” because it is not impertinence at all. You are right. This is a false dichotomy. Good medical care looks to me like it has very little to do with size, so why is the conclusion that we must accept Big Medicine? There is no evidence to support that conclusion, so perhaps one should not be so quick to offer it as a solution.

And I agree with Cory below.

Brian Klepper
Guest

As Dr. Gawande describes so engagingly, most modern doctor’s offices and health systems are brimming over with dysfunction, and this is very often reflected not only in the patient experience but the quality of care. Dr. Shaywitz and Cory have a romanticized notion of medicine, but the truth is that with the right incentives, a welcoming, patient-centered delivery orientation and clinical decision support tools, the patient experience can vastly improve, the quality of care become predictably far better and the cost drop precipitously. We are doing these things in my firm’s health centers, which is why we recruit in more… Read more »

BobbyG
Guest

“There is plenty of good – vast enhancements in cost, quality and safety – than can come from active process improvement.”
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Dr. Toussaint and others with established cred peg this at at least 30% in savings (process improvement side). Moreover, this is no longer QI “theory.” See the long Thedacare experience in particular.

With respect to “loss of physician autonomy,” Lawrence and Lincoln Weed have demolished that lament (“Medicine in Denial”).

But, yeah, let’s just add the “restaurant” analogy to the hated “aviation” analogy (and, by extension, anything touting “high-performance teams”).

Cory
Guest
Cory

No one would argue that our medical system is perfect, and all too often it is less than good. Streamlining and improving some processes would be a good thing, but the idea that medical care should be just like Cheesecake Factory is pretty ridiculous when you think about it. Consider- if Cheesecake Factory was so good, why doesn’t everyone go there? Why do we have other restaurants? Why is it likely that someday, Cheesecake Factory, like most restaurants and franchises, will go under? It’s not a commentary on Cheesecake Factory but on the restaurant analogy. MacDonalds would have been a… Read more »

Noel Coleman
Guest

3 challenges with your thoughts: 1. You ask if the Cheesecake Factory system is so good why are there other restaurants. You are mistakenly comparing one chain with an entire industry. That would be like saying if Johns Hopkins is so good, why are their other healthcare facilities anywhere near them? No one is making the argument that we should all move to one system that is housed under one parent company with no competing systems. 2. You ask if anyone at the Cheesecake Factory knows your name or cares about you. You’re making a broad generalization that big/systematized =… Read more »

bev M.D.
Guest
bev M.D.

This post really gets my goat. It completely misunderstands, perhaps deliberately, the role of the physician in a well-designed system of medical care. It seems to me that if Dr. Shaywitz has actually practiced in a hospital, the dysfunction of what we now call a system would be blindingly obvious. I have experienced it as both doctor and patient. The idea of standardizing care is far from what he describes. Yes, it seeks to eliminate the variations in physicians’ care which are entirely unexplainable, such as geographic variations for which there is no other explanation. But the truly terrible variation… Read more »