Big (Box) Medicine

Screen Shot 2014-10-30 at 1.40.57 PM

Let’s see a show of hands. Who among us, doctor, nurse, patient, family member, wants to give or get health care inspired by a factory—Cheesecake or any other?


I didn’t think so.

True confession: I have never actually eaten at a Cheesecake Factory (hereinafter referred to as the Factory). My wife, Mary, and I did enter one once. We were returning from a summer driving vacation. Dinnertime arrived, and we found ourselves at a mall walking into a busy Factory.

It seemed popular. The wait was long—really long. We got our light-up-wait-for-your-table device. We perused the menu. There was a lot there. Portions seemed gigantic. We looked at each other and, almost without speaking, walked back to the hostess, returned our waiting device and left.

You got me—I cannot say 100 percent that I wouldn’t love Factory food. We were so close that one time!

A young woman in our small New Jersey town recently opened a new restaurant here. We tried it the other night. She and her business partner tended us and all the other patrons with such attention and care. We waited some, true, but she seated us near the bar while we waited—brought over pieces of cheese (no light-up device) for us to enjoy. The menu was ample and varied—not enormous. It’s also true that two items on the menu—including my first choice—were no longer available that evening. The chef however crafted the dishes that we did select with flare and pride. Dinner was a delicious, wonderful, relaxing experience—made better because of the human touch.

It’s probably not fair to contrast my one near-Factory dining experience with this other. Big chain restaurants have clearly figured out a way to provide a consistent meal for millions of satisfied customers. But the Factory way is not for everyone. People, I think, crave customized, attention-to-detail service experiences—in their dining choices. And—I’ll go out on a limb—in their health care too.

Renowned health care experts and superb writers, each in his own right, Bob Berenson and Atul Gwande teamed up in the recent Urban Institute/RWJF brief, “Is Bigger Better? The Implications of Health Care Provider Consolidation.”Atul is an enthusiastic soothsayer for what he sees as the coming era of big medicine. He has been since his popular article published two years ago, “Big Med.” In that New Yorker article, Atul cast his bright light on the virtues of the Factory as a model for health care. In this latest interview, Atul continues to carry the Factory flag. He observes that two years hence, we now have about 90 super-regional medical centers across the country. These centers bristle, he says, with advantages like information systems and access to standardized measurement and improvement approaches—not bad things, of course. In the interview he also notes that “[w]e’re in the process of shifting from what I call ‘cowboys’ to ‘pit crews’ in medicine….”

Hard to disagree that a shift to smart team-based care is a strong positive. The lone, isolated, unconnected physician working on his or her own providing care based on what he or she learned years prior in school or residency is, thankfully, rapidly becoming a thing of the past.

Still, these are our choices? Lone, isolated, ill-informed cowboy on the range care versus Factory care? I think there’s almost certainly another way.

I definitely get it. The Factory ideal is enticing. It’s a successful vision imported from the Industrial Age—i.e., the 20th century. But—brace yourselves—we are no longer in that century or age. We’re in a new one—a new machine age.

Think, for instance, about the waves disrupting or wiping away industries—cloud computing, disintermediation (e.g., video), unbundling of services (e.g., music, newspapers), the sharing economy (e.g., Uber, airbnb), new networking organizational approaches, democratization of knowledge (e.g., Khan Academy).

Consider the potential for customized care with predictive analytics, the range of new -omics data and the proliferation of health data from ever more sophisticated devices—not to mention the emerging power of DIY care from those same devices. Don’t forget the coming cognitive agents and artificial intelligence, robotics and 3D printing. Incidentally, we’re just starting up the Moore’s Law driven escalation.

The opportunities of our new age open novel ways, I believe, to improve care. We can create vibrant, joyful, human care relationships in small, intimate, connected settings that also deliver informed, smart cutting-edge treatment when, where and how people want it. One key aspect of our new age tools: They proliferate and get cheaper and better, year after year. That means that most of the exotic soon becomes commonplace. It may be ironic, but our new machine age is going to free us to reclaim our humanity. I fervently believe that.

At RWJF we are working on a range of projects exploring this sort of vision. Perhaps the most obvious is Flip the Clinic —essentially the anti-Factory. There, we’re inviting human beings to come together and explore what it might be like to co-create new caring relationships (not factories) fitting for the new age.

I understand. Many may find the Factory approach suitable, even desirable. That’s OK—the door for that is swinging wide open over there. If, however, you hunger for another way, you are not alone! Granted, the door this way is still a little hidden—you have to look for it a bit—but trust me, it’s there, and it’s big.

Michael Painter, MD is a senior program officer with the Robert Wood Johnson Foundation and a regular contributor to THCB. 

36 replies »

  1. I’m a member of the healthcare localvore movement. Technology can be used to enhance the patient physician relationship. This is happening in Direct Primary Care. I’m leading the development of an electronic health record, InLight, that facilitates this valued relationship. http://www.InLightEHR.com

  2. “when providers can focus on care rather than on billing ”

    The ACO doesn’t help the physician focus on care instead of billing. The ACO eventually has to rely upon managers to see to it that the profits exceed the losses and that each person’s individual profit exceeds what he can get elsewhere. One of the dangerous incentives of the ACO is to deny necessary treatment to increase profits.

  3. I think you are a brilliant doctor. Your comments are perfectly true.

    Another irony in the Lucy episode: Despite decades of time, lack of color television and having seen it many, many times, it is still quality television and still worth the time to watch and laugh again. It will always be funny.

    I think the doctor patient relationship is the same thing: a unique private exclusive relationship in a society intent on and insisting on knowing everything about everyone all the time. It will always be desirable.

  4. I agree – it is a false choice. I have some experience working in the ACO world and there is a world of difference in orientation when providers can focus on care rather than on billing (because they’re in a capitated payment model). Ultimately, I think the best care delivery is the combination of well-organized and evidence-based team care enabling caring providers to connect with people at a personal level.

  5. I have to say I think of “Job Switching” (the Lucy/Ethel candy factory ep from season 2 of ILL) every time I confront the medical-industrial complex at its worst. When I started seeing the discussion rising on Atul Gawande’s “healthcare can learn from the Cheesecake Factory” piece, I almost choked on my coffee. Standardization of care is terrific, but unfortunately human beings aren’t cast in 12″ springform pans.

    That said, several comments have mentioned the elephant in the room: the Benjamins. Medical debt, byzantine insurance games via “proprietary reimbursement rates,” the overall arms race that is US medical care, all add up to a crushing overhead. Even with factory standardization, we’ll likely end up with “meh” outcomes and a continuing fall in trust in the healthcare delivery system.

    Combine that with the unfortunately common American expectation that everything should be (a) cheap (b) fast and (c) “free market,” and you wind up where we are.

    The Sabbath gasbags love to intone about how we’re drowning in “entitlements,” while remaining mute about the entitlements handed over to corporatized healthcare, and corporations in general. Not sure we need more “factory” here.

    Maybe what’s needed is a couple of cans of gas, and a match. I think we need to start again, from scratch.

  6. “I don’t eat at Cheesecake Factory either, but because I don’t like the food. But that was never the point of Dr. Gawande’s article.”

    That was the image Dr Gawande wished to project. The process at the Cheesecake Factory doesn’t translate to good healthcare. It was an oversimplification of a process presented for mass appeal to one’s emotions instead of one’s intellect.

  7. mjmd–I place my face in both. I think it’s a false choice. Especially now–we do not have to choose between personal high touch interactions and evidence based practice. We should be able to have connected, collaborating, highly informed professionals who provide personalized care of the highest possible value–in small intimate settings.

  8. Tom, thanks for the very much for your comment. I think you may have misunderstood my point though.

    I did not in any way criticize team based care–far from it. I know first hand how important professional collaboration is for great care. You mentioned our diabetes program–that is a perfect example of the importance of team based care in a community health center with limited resources serving patients of limited means. In spite of the challenges we put together a team of people who collaborated well–shared information–used the best tools at hand–and provided demonstrably improved care. We also, by the way, knew our patients, their families, their grandparents, their community well. They were also our colleagues–we walked with them every step of the way through their illnesses and on their journeys toward health. We admitted them and attended them in the hospital if they needed hospital care. When they were ready, we discharged them back to our care at our clinic. If they got sick enough to be in the ICU–we followed them there and helped attend. If they got pregnant-and had a baby–we delivered the baby and took care of mom. If they had to go to a nursing home–we attend them there. If they got a terminal illness that ended in death, we were with them to the end. And we grieved with them and their families at their funerals.

    We did that as a committed group of doctors, nurse practitioners, physician assistants, nurses, outreach workers, medical assistants and others at a small clinic. We were many things–what we were not, though, was a factory.

    So, I have the greatest respect for personalized, high touch, collaborative team care. What concerns me is the message that we somehow must trade the intimacy and satisfaction of high touch care relationships-and that means collaborative, smart, connected team care human relationships–for factory care. Big is not necessarily better. I know that to be true because I experienced it first hand.

    Importantly, we now have many new opportunities to create those kinds of relationships with our patients that I did not have at my clinic some years ago. We have our new machine age technology to help us.

    We do not have to settle for some Lucy or Charlie Chaplin 20th century caricature of what care could or should be. We can do better than that. Hopefully our patients and their families will understand that too–and demand it.

    I don’t care who tells you differently.

  9. This country may be run by politicians, but healthcare is not. They create a complex web of regulations, that’s true, but healthcare is also the arena where insurance companies and middlemen test their ingenuity in carving their personal profit slices out of the same pie that medications, medical tests, physician and support staff salaries come from.

  10. Most of the staff time in primary care practices, as well as most of the technology cost, is spent on billing and compliance activities. The reason you can’t afford quality time with your doctor is that your encounter fees have to support $85,000 worth of billing for a doctor that generates perhaps half a million dollars of revenue. Then add all the things he/she has to do to avoid Government penalties and comply with Meaningful Use. Your sore throat or belly pain has to support a lot of other stuff you don’t necessarily care about and may never think of as related to quality healthcare.

  11. What planet are some of the usual commenters here living on, this country is run by politicians who are the “representatives” of the constituency that votes them back every 2-6 years. The politicians live by the adage “popular, easy and convenient”, and the constituents at the end of the day demand, not even ask any more, for what is popular, easy and convenient. Patients aren’t, as a sizeable majority, interested to participate in health care interactions and interventions to do what is right and effective, but what is quick and gets rid of the symptoms NOW.

    Come on, colleagues, while I am a psychiatrist, I know what to be telling patients who have high blood pressure what to be doing, and it is not about getting the right medication first. How many of you really spend more than the obligatory 10 seconds saying “yeah well watch your diet, exercise, and avoid stress please, as well as salt”. I’m sure that is done before you are typing in the script to the pharmacy. NOT!

    As what I do with patients who come in wanting the “cure” for their depression or anxiety. No, I don’t write the script for the antidepressant du jour after they note their symptoms and concerns, but I do spend the time telling them to be in therapy, to be problem solving, to work on coping skills, and to exercise and eat as best possible and then, if it fits, to consider taking a medication.

    But, do many of them want to hear the truth, and do the work, and realize that at the end of the day, no pain is no gain? Nah, and a lot of you non psychiatrists out there sell the quick fix and convenience ahead of referring them to me, so, to bring it back to the point of the post at the top, people like the Factory because they are the living embodiment of the Factory, garbage in, and garbage out.

    The irony of the use of the Lucy episode with the chocolate is rich, and not with candy. The point of the story was neither Lucy or Ricky appreciated that their “job responsibilities” had validity, and they had to spend a day in the other’s shoes to realize that there was an expectation to expend the effort, time, and trouble to get satisfaction and results.

    But, most docs these days fall into the same traps as the patients they bitch about, wanting it popular, easy, and convenient. Oh, and cheap too.

    Maybe doctor offices should think about using those lighted coasters, just alter the design for being at a doctor’s office.

    I know what could substitute! A lighted apple!?!?

  12. It all depends on how important you believe the personal touch and interaction is in the medical process. If you place most of your faith in evidence based application of medical knowledge, then you can get by without the traditional doctor-patient relationship.

    I think many people will desire that relationship, and will seek it mainly from alternative practitioners, whose practices will boom as the teams take over traditional medicine.

    The point is not that teams and evidence based care are bad, it’s that the traditional relationship adds something that isn’t easily replaceable.

  13. I’m puzzled. Why would someone with Dr. Painter’s background see the benefit in taking cheap shots at an article about delivering medical services through a well-honed team model? Is this supposed to be building support for Flip the Clinic? The economics of medical services in the U.S. (crushing med student debt, for example) make it infeasible for people to have an old-style 1:1 relationship with a primary care physician who spends a lot of time talking to them whenever they feel sick. Concierge medicine is an option only for the well-off. The only effective way to delivery care to our population is through team care, including care provider professionals in addition to physicians. And if you want high-quality evidence-based care, you want your care team doing things in a systematic way, from the receptionist to the web portal to the physician to the pharmacist and soon to the personal data collection devices. Having lead an institution that had a solid diabetes management program, Dr. Painter must have seen the need to deliver care through a well-organized data-drive process supported by a well-trained team.

    I don’t believe personalized care is necessarily at odds with delivery through team care either. I have been seen standalone physicians and been a member of a integrated delivery network and I far prefer the latter. I know that the whole team has access to my data as need be and know the progression of my health. I know they have access to proven best practices that apply to me. They – the team, including my doctor, and anyone else I see – have taken great care of me.

    Can we get more from the brief interactions we have with our physicians, as Flip the Clinic suggests? Certainly we can. But we will have team care if we’re going to care for everyone without bankrupting everyone. Throwing stones at good process seems kind of silly to me…

    I don’t eat at Cheesecake Factory either, but because I don’t like the food. But that was never the point of Dr. Gawande’s article.

  14. The Cheesecake Factory provides more food than is necessary or healthy at an inexpensive price. Their idea is to impress the consumer with quantity and price basing their profit on volume.

    Is that what we are looking for? More than we need to impress, but low quality?

  15. I think most big medicine is more golden corral then cheesecake factory, I work at golden corral and am certifed in every ncqa, pcmh etc. that you can get. High volume practice that says they value value over volume but my paycheck is still 95% volume driven….go figure.

  16. Not many factories get built with a goal of reducing sales and profits.

  17. I agree with Hans, the factory approach may have some benefits in certain cases, but I don’t think it’s the way to run medicine globally in this country. Those “factories” cost a lot to run, and it appears are not that beneficial in curbing costs, in fact increasing them in most cases.

  18. Changing from a trusted and therapeutic relationship with a personal physician to “someone from the team will see you now,” is quite a shift.
    I wonder what’s going to happen to all the teaching in medical school about the importance of developing a personal relationship with the patient over time and how it leads to better medical care?

    (The sooner you realize it’s simply a disguise to get someone other than a physician to care for you the sooner it will start to make some sense. )

  19. The commercials say “Discuss with your doctor…”
    My friends say “Maybe you should see a doctor…”
    My mother says “Did you see your doctor?”

    Nobody says “I am going to see my health team.”
    Until that changes, the Factory model more resembles a mall with a bunch of little specialty shops.

  20. What Dr. Duvefelt said…

    A good idea in healthcare goes around the world seven times in a second, before someone realizes its narrow applicability.

    The Cheesecake factory idea has been destroyed by the meme plague, which is currently thrashing the latest fashion statement remorselessly, disruptive innovation.

  21. I think it’s like a race between the people who are old enough to remember what personal, individual medical care was like and those who are just entering the healthcare system with only the Factory model in their experience.

  22. The Factory model may have some advantages when choosing where to have your hip or CABG surgery. In my arena, primary care, I never hear patients speaking favorably about provider size. The more patients see of the new world order of Factory medicine in primary care, the more certain the backlash will be, and the more vitality the disrupters will have. The DPC and micro practice movements will flourish more as the Factory mandates tighten the chokehold on patients and doctors.

  23. Big data, big medicine, big bellies, big government go hand in hand. What in the world is this country coming to? Not good.

  24. The key point is that insurers pay CheeseCake medicine about 400% more than they pay Chef-Owner medicine.

    “Flip the Clinic” will accomplish nothing if they don’t address the payment system.

    I’m not optimistic.

  25. Michael

    I think you should go back to the Cheesecake Factory sometime and sit and observe.

    If you spend a little time in a corner with a notebook and watch what people are consuming and how they’re consuming it, you’ll get firsthand evidence of the drivers that are overwhelming the healthcare system

    I actually have a great story about a brawl at the Cheesecake Factory, involving all of the line staff and the cooks coming out en masse to defend their manager from an unruly customer, but totally off topic : )