Friday, August 10, 2012

Dr. Gawande’s New Shiny Thing

Dr. Gawande has a new article in the New Yorker suggesting that hospital chains may very well be the solution to our health care problems. Dr. Gawande has a very engaging writing style and in addition to writing for the New Yorker, he writes books and delivers memorable speeches and he is also a surgeon at Brigham and Women’s hospital in Boston. In recent years, Dr. Gawande’s writings have become the cornerstone of health care policy and none more so than his 2009 New Yorker article explaining the inexplicable health care cost explosion and the variability of medical expenditures across the nation. As the New Yorker itself proudly noted, President Obama himself had a most fortuitous epiphany after reading the New Yorker article, and summarily decided that “This is what we’ve got to fix.”

In “The Cost Conundrum” Gawande explored the differences in expenditures for Medicare beneficiaries in two Texas towns whose names became synonymous with our health care issues, the expensive McAllen and the rather cheap El Paso, concluding that “across-the-board overuse of medicine” induced by “a culture of money” was the root cause for the “extreme” expenditures in McAllen. The article, accompanied by an illustration of a patient dressed like an ATM machine, quickly became the foundational axiom at the base of health care reform efforts, and Peter Orszag (the then OMB Director) immediately adopted this axiom and translated it into hard dollar amounts: “The result is an estimated $700 billion a year spent on health care that does nothing to improve patient health, but subjects you and me to tests and procedures that aren’t necessary and are potentially harmful – not to mention wasteful.”

One could identify here the beginnings of the currently undisputed rhetoric about a 30% waste in health care, the associated slogans of “more care is not better care”, “pay doctors for value not volume”, and the need to rein in greedy doctors who are knowingly harming patients to enrich themselves through the unfortunate fee-for service payment model. It didn’t matter much that respected researchers like Drs. Robert Berenson and Jack Hadley from the Urban Institute repeatedly disputed the findings of the Dartmouth Atlas on which the Gawande axiom was based. It didn’t even matter that Medicare itself came up with different numbers which show that McAllen is not really that expensive after all. Once the President decided that “this” is what we’ve got to fix, by golly “this” is what we are going to fix, whether it needs fixing or not.

Next Dr. Gawande turned his attention to learning from other industries and applying lessons learned to the troubled health care system. The first such industry was Agriculture, which has come a long way from “strangling the country” at the turn of the 20th century to today’s seemingly bottomless pit of cheap, genetically altered, antibiotics, pesticides, preservatives and other carcinogens laden foods, produced by sub-minimum wages illegal immigrants, and pushed by vertically integrated agribusinesses to every supermarket and every 7-11 across the land. Dr. Gawande is crediting this major development to Government intervention in the form of local extension services to diffuse experimental technology innovations to uneducated and initially resistant farmers, and to various assistive regulations. He sees a similar experimental approach being taken by the Affordable Care Act (ACA) and is hopeful that current health care initiatives will have the same beneficial effects as observed in agriculture.

Aviation with its almost perfect safety track record was the next industry to attract Dr. Gawande’s attention. The checklists used by pilots in commercial aviation seem to have some applicability to medicine. Although checklists were used by others with great success in health care, Dr. Gawande published an entire book on the subject and called it a Manifesto. Next came the race car industry, and in a commencement address at the Harvard Medical School, Dr. Gawande informed the class of 2011 that medicine needs them to be “pit crews” instead of traditional “cowboys”. I don’t know if Dr. Gawande watches too many John Wayne movies or too few car racing events, but old-time cowboys, although versatile and capable of performing many tasks, always worked in coordinated groups of various sizes and compositions, depending on the size of the outfit that employed them. By contrast in a pit crew, one member’s responsibility, which is strictly defined by regulations, starts and ends with the left rear lug nut even if the entire car is on fire. Despite the poor choice of words, the message is the same: standardized, repeatable protocols of care delivered by “medical systems” are superior.

In this month’s issue of the New Yorker, Dr. Gawande takes the systems approach to its logical conclusion. We need Big Medicine. We need chains of hospitals and clinics. Big chains, like the Cheesecake Factory. It seems that health care can also learn from the restaurant industry or retail in general, since CVS and Walmart are also fondly mentioned in the article. According to the story, Dr. Gawande and his children had a lovely dining experience at the local Cheesecake Factory establishment, ergo chain restaurants when managed well, can deliver a fantastic culinary experience for a rather affordable price. Of course, we all know that there are hundreds of other chain restaurants that cannot, and Dr. Gawande himself seemed very protective of his reservations at Per Se, but maybe the reason the Cheesecake Factory is so successful is the automation and team approach to food preparation. No Iron Chefs here. A well-oiled (no pun intended) machine of  managers and sub-managers and workers at various stations of cooking, cleaning and learning on the job, eerily similar to pit-crews, each responsible for a prescribed piece of work, manage to create in aggregate a consistently repeatable faux upscale dining experience for people who have no idea what Per Se is.

Exploring the excellence of chain establishments is not unique to Dr. Gawande, although he may have just turned it into official policy. Similar arguments were made recently by Dr. Peter Pronovost, comparing health care to the exclusive Capella hotel chain, an offshoot of the Ritz-Carlton glitzy chain, and reached similar conclusions. One could wonder how these learned essays would address what most people recognize as hospitality chains, such as Applebee’s, Chili’s, Holiday Inn or Motel 6. One could also observe that anybody with no particular credentials could open a restaurant or a Bed-and-Breakfast, or work at such “one-of-a-kind” place, just like there are no particular education and licensing requirements for working on a farm or for becoming a cowboy. A very interesting experiment would be to require that each mom-and-pop restaurant should have a Parisian Cordon Bleu graduate in order to open its doors, or that every Bed-and-Breakfast would need a Glion graduate on staff. I wonder if in that case, anecdotal evidence from hand-picked hospitality chains would still compare favorably to the one-off little establishments. I suspect not.

Dr. Gawande is proposing that medicine should become Big Medicine and doctors become broiler “chefs” with a computer monitor controlled by “headquarters” hanging above their “station”, or perhaps we don’t even need those super educated doctors and scullery maids can work their way up to “management”, just like his protagonist in the New Yorker story did, because he knew of no other place where he “could go in, know nothing, and learn top to bottom how to run a business”. They used to teach medicine that way before we had medical schools too.
So based on one dining experience at one chain restaurant, “liberals will have to accept the growth of Big Medicine, and conservatives will have to accept the growth of strong public oversight”. Just like we had to accept the growth of Big Farms, Big Banks, Big Automotive, Big Retail and Big Corporate everywhere, all with strong lobbying oversight and strong public subsidies and bailouts as necessary, and a slowly evolving definition of quality to mean cheap enough to keep the nouveau poor from jumping out of the experimental pot of boiling water.


  1. 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.
    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.

    1. Perhaps I am :-)

      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.

      I don't think a certified food safety person can whip up the perfect "beet salad with goat cheese" :-)

  2. 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, 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?
    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!
    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.

  3. 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.

    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).

    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.

    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.
    And the practice continues nevertheless.

    1. Hi John,
      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.

      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.

      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).
      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.

      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.

      You are right though... Time will tell....