Big Healthcare and Cheesecake

I always get a little giddy when a new article by Atul Gawande appears. The latest, in which he compares the quality control and cost efficiency at the Cheesecake Factory with that of Big Healthcare, does not disappoint:

The neurologist, after giving her a two-minute exam, suggested tests that had already been done and wrote a prescription that he admitted was of doubtful benefit. Luz’s family seemed to encounter this kind of disorganization, imprecision, and waste wherever his mother went for help.

“It is unbelievable to me that they would not manage this better,” Luz said. I asked him what he would do if he were the manager of a neurology unit or a cardiology clinic. “I don’t know anything about medicine,” he said. But when I pressed he thought for a moment, and said, “This is pretty obvious. I’m sure you already do it. But I’d study what the best people are doing, figure out how to standardize it, and then bring it to everyone to execute.”

This is not at all the normal way of doing things in medicine.

I’d strongly recommend that you go read the whole thing. There are so many things to discuss that it’s hard for me to pick one. But in answer to the biggest and most obvious question–why aren’t best practices standardized in modern healthcare?–I offer this theory: Because doctors, by and large, are smart and ambitious people. And smart, ambitious people vigorously resist rule by committee.

That is not at all what Gawande or the Cheesecake Factory are suggesting. But in order for best practices to be evaluated and implemented within a large, complex system, communication has to be far more nuanced and, ironically, less hierarchical than has ever been the case in human history. One of the more fascinating parts of the article is his description of a successful interaction between a remote monitoring facility and a suspicious doctor:

Half an hour later, Hayes called Mr. Karlage’s nurse again. She hadn’t received the orders. For all the millions of dollars of technology spent on the I.C.U. command center, this is where the plug meets the socket. The fundamental question in medicine is: Who is in charge? With the opening of the command center, Steward was trying to change the answer—it gave the remote doctors the authority to issue orders as well. The idea was that they could help when a unit doctor got too busy and fell behind, and that’s what Hayes chose to believe had happened. He entered the orders into the computer. In a conflict, however, the on-site physician has the final say. So Hayes texted the St. Anne’s doctor, informing him of the changes and asking if he’d let him know if he disagreed.

Hayes received no reply. No “thanks” or “got it” or “O.K.” After midnight, though, the unit doctor pressed the video call button and his face flashed onto Hayes’s screen. Hayes braced for a confrontation. Instead, the doctor said, “So I’ve got this other patient and I wanted to get your opinion.”

Hayes suppressed a smile. “Sure,” he said.

When he signed off, he seemed ready to high-five someone. “He called us,” he marvelled. The command center was gaining credibility.

Notice: this is not an authoritarian system. This is negotiation by persuasion, using facts, mutual respect, and good manners.

Woo hoo.