Cheese Cake Medicine

You don’t expect to find a cure for soaring medical costs in a mass-market restaurant chain.  Yet that is where Atul Gawande, an American physician known for his expertise in reducing error and improving efficiency in surgery, went searching.  His quest, reported in the August 13 New Yorker magazine, demonstrates lateral thinking that is just the kind we need much more of these days. It also reveals a fundamental flaw in the standard medical practice model that needs correcting to keep good health within the reach of the average person.

Gawande’s search took him to the Cheese Cake Factory, a leader in the “casual dining” business through its use of automation and carefully engineered kitchen work processes in all of its  restaurants.  Each kitchen is precisely laid out to the same floor plan, chefs cook each dish to exacting specifications that are the same everywhere and time and motion management are ruling principles.  But the key is the kitchen manager, who inspects each dish before it goes to the customer, rates it, and ensures any flaws are corrected.  This is a “best practices” model that does not permit variations according to the idiosyncrasies of a chef – it may not reach the sublime heights of an Emeril Lagasse, but it ensures against burnt toast or overdone steak.   And it provides good, $15 entrees.

Gawande then examined emerging medical practices at places like Brigham and Women’s Hospital (BWH) in Boston.  At many large and busy hospitals, you may encounter a half-dozen different physicians giving conflicting diagnoses and instructions, tests may be unreported or ignored, quality of care by the staff irregular, etc., etc.  Gawande counted 63 different personnel involved in his mother’s care during a recent knee procedure.  The medical profession is following what is known as a traditional “craft” model.  Doctors are self-employed and view themselves as providing a unique product using techniques, methods and materials unique to them. Major improvements in treatment in the medical profession take, on average, more than 15 years to become wide spread.  The results of this system can be lovely, but they are error prone and expensive.  At BWH, in the orthopedic surgery department, they have begun using instead a “best practices” model for knee surgery.  Specified common steps are required for all anesthesias and post-operative regimens, acceptable surgical practices are spelled out, and medical devices must be from a list of the ten least expensive devices (studies have shown no real differences in effectiveness between knee devices varying widely in cost, but each doctor, until now, had their own “pet” device).  When doctors informed their suppliers of the “ten cheapest” requirement, the reductions in price were remarkable.

The results at BMH were revealing:  length of stay was reduced by a day, patients’ pain levels cut almost in half, and measures such as distance walked, stair-climbing ability, standing ability, etc., improved about 50 percent.   And just the reduced stay by itself saves an average of $2000 per patient.  The “best practices” approach is being tried in different specialty areas at hospitals across the country, and there, too, results can be startling.  At the University of Michigan Hospital, for example, standardized “best practices” in blood transfusion produced a reduction in need for transfusion of 31 percent and a reduction of costs of $200,000 per month.  “Mass-medicine” chains are beginning to emerge across the country.  But, as Gawande reports, the pace of change in medicine can be glacial.

Resistance to change stems in large part from the traditional “craft” view of the hospital as the physician’s “workshop”, where everything is done for the convenience of the physician, not the patient.  That can be seen daily at any hospital, where very ill patients are waked at 3am for tests, so that results may be ready for the physician when he arrives.  In the emerging model at its best, the hospital is viewed as “a temporary residence for frail and very ill people”, and all activity is oriented to providing for their best possible care.  We now are at a juncture in medicine somewhat like the emergence of factories replacing cottage industries during the Industrial Revolution.   Only 25 percent of physicians report themselves as self-employed anymore, and a growing number of hospital “chains” have their quality of performance monitored electronically at a distance.  Resentful employees sometimes are reluctant to accept standards they were never trained to honor.  At this stage, good things may be either gained or lost in the change process.  Better quality at lower cost is the goal.  But in the process, either patient care or health professional job satisfaction may be at risk, also.  One danger is that health entrepreneurs may turn lower costs into higher profit margins instead of gains for the patient.  In the early industrial revolution, fringe industrial zones where horrible work and living conditions prevailed were sometimes known as “hell’s kitchens.”  We can tolerate nothing like that for treatment of the ill.  Perhaps it is appropriate that ultramodern, well-managed kitchens producing fine products to exacting standards become our new model for medicine.