tag:blogger.com,1999:blog-3503957686158274288.post8463480463302221555..comments2024-03-12T12:32:15.598-05:00Comments on On Health Care Tech & Policy: Dr. Gawande’s New Shiny ThingMargalit Gur-Ariehttp://www.blogger.com/profile/08777722834145614546noreply@blogger.comBlogger5125tag:blogger.com,1999:blog-3503957686158274288.post-18505779915479543752012-08-12T16:39:49.328-05:002012-08-12T16:39:49.328-05:00Hi John,
This is not an indictment against Dr. Gaw...Hi John,<br />This is not an indictment against Dr. Gawande's writings, although I know it seems so. His Hot Spotters article is one of my all time favorites.<br /><br />The problem is that his "thinking out loud" has a tendency to turn into policy and I disagree with his rather unfounded conclusion that "chains" are a good solution to our health care problem.<br /><br />First, because chains also have tremendous variability in both costs and quality, as I am sure you know, and I can just imagine which populations will be relegated exclusively to the cheap chains (read Walmart) and which populations would have ample choices (read Neiman Marcus and everything else).<br />In health care today, the major drivers of cost increase on the provider side are exactly those chains, and not necessarily because quality is better, but because they can. When the little independent practices are all gone, and all doctors are employees, there will be nothing to stop the chains and their hordes of managers.<br /><br />Second, and this applies to Christensen's "prescription" as well, there are still too many soft variables in health care to allow full comparison to industries where the product or service usually comes with an exact blueprint. Perhaps some day we'll know enough to standardize medical care, but not today, and we need solutions right now, in this flawed environment where flawed standardization could be worse than no standards at all.<br /><br />You are right though... Time will tell....Margalit Gur-Ariehttps://www.blogger.com/profile/08777722834145614546noreply@blogger.comtag:blogger.com,1999:blog-3503957686158274288.post-18014540622164836672012-08-12T15:23:58.043-05:002012-08-12T15:23:58.043-05:00This is a stinging indictment of Big Med. The poin...This is a stinging indictment of Big Med. The point is well-taken and the caveats are appropriate. But as a retired cafeteria manager I watched the food business from the inside my whole working life and it is an incomplete analogy. <br /><br />There is a role for Big Med but it need not be at the expense of small practices and everything in between. The medical ecosystem is diverse enough for all. To press the food service comparison, lots of mom-and-pop places have been around a long time, often for generations. Think country doctors, alternative medicine, etc. The one-of-a-kind high-end fine dining places have medical counterparts in cosmetic dentistry and surgery. And selected places will always be taking part in clinical trials and other deviations from "best practices" simply to see if this or that new drug or procedure is an improvement over the norm (whatever that is). <br /><br />Big Medicine is not likely to be busted up like Ma Bell was when telecommunications were all under one umbrella. So I don't see streamlining, standardizing, expediting, scrutinizing and simplifying the production line as having much of a downside. Instead I see the possibility of eliminating unnecessary steps, lowering costs (read "wages"...hello) and making the whole process more transparent and businesslike.<br /><br />Cut Dr. Gawande some slack. We all think out loud sometimes. And time will tell if his ideas have merit. Besides, I was very impressed with another piece he wrote about solitary confinement as torture. <br />http://www.newyorker.com/reporting/2009/03/30/090330fa_fact_gawande<br />And the practice continues nevertheless.Johnhttps://www.blogger.com/profile/11858939352263715787noreply@blogger.comtag:blogger.com,1999:blog-3503957686158274288.post-713846699172667442012-08-11T11:02:01.529-05:002012-08-11T11:02:01.529-05:00Pardon my impertinence, but it feels to me like yo...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. <br />Similarly impertinently, I'd like to suggest that you re-read Dr. Gawande. How did small private practice, or Big Medicine, rein in costs in McAllen? Is his 'generalized conclusion' that there a huge amount of wasted money out there that can be brought back into the system to provide needed care correct? You bet. This extrapolates to Big Medicine how? Agriculture has morphed for a variety of reasons, virtually none having to do with Agricultural Extension agents. His 'generalized conclusion' that best practices may vary by area and be extrapolatable elsewhere is wrong, how? Spreading Best Practices is not inherently Big Medicine and to conflate them is inaccurate and misleading. You may want your lap Nissen ["Pit Crew" references--read 'tire changed'] done by the cowboy who does a little bit of everything including neurosurgery [read 'fuel added'], but I don't, thanks. As he has agreed, pit crews need a boss [read, usually, 'Doctor'] to provide The Big Picture and help things run well. And this is wrong, how? <br />Don't be so quick to defend your turf and strike at Big Medicine, though a lovely target it is. Read, in particular, Christensen and Arnold Relman. Will your 'solution shop' be part of Big Medicine? Guess that depends on how good a shop you run! <br />Lastly, I'd argue that the real reason to fear Big Medicine is because of your reaction; physicians have decided that hunkering down, taking shots at Big Medicine, and resisting change is their only possible salvation. So the insurance companies, large companies, and maybe even the Feds will force Big Medicine on us because doctors have not not only not led the way forward but persist in trying to make sure that we never move any direction at all. We'll have only ourselves to blame.RobertL39noreply@blogger.comtag:blogger.com,1999:blog-3503957686158274288.post-53591892503263976332012-08-10T15:55:02.275-05:002012-08-10T15:55:02.275-05:00Perhaps I am :-)
But if we are comparing little r...Perhaps I am :-)<br /><br />But if we are comparing little restaurants or Bed-and-Breakfasts to private practices, than the equivalent to a doctor in each practice, should be a fully credentialed and fully experienced Chef or Hotelier in each establishment. Once that's in place, we can have a fair comparison between Big Hospitality and Big Hospitals vs. Little ones. <br /><br />I don't think a certified food safety person can whip up the perfect "beet salad with goat cheese" :-)Margalit Gur-Ariehttps://www.blogger.com/profile/08777722834145614546noreply@blogger.comtag:blogger.com,1999:blog-3503957686158274288.post-78287318949755236632012-08-10T14:28:49.385-05:002012-08-10T14:28:49.385-05:00Don't you think you're being a little melo...Don't you think you're being a little melodramatic with your proposition "to require that each mom-and-pop restaurant should have a Parisian Cordon Bleu graduate in order to open its doors?" That is effectively the equivalent of claiming that every clinic have a John's Hopkins graduate on staff. A much more reasonable proposition might be something like California's requirement that every restaurant have someone food safety certified or a ServSafe accreditation, which are both fairly common and really hasn't lead to huge public subsidies or bailouts of the restaurant industry.<br />Not to say that your argument is invalid; I think you've hit on something, I just think your argument would be better served by a more appropriate analogy.Anonymousnoreply@blogger.com