Atul Gawande’s recent New Yorker online article, Big Med: Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?, has presumably completed all stages of hypertweetilation so we can proceed to discuss it with more than 140-character thought bytes.
Gawande’s choice of The Cheesecake Factory was a brilliant way to get right up in the face of Traditional Medicine and highlight the putative advantages of Big Medicine. Then again, maybe it missed its target. Upon my mentioning the article one physician friend wrote back, “Interesting article, not sure people’s health can be managed in the same way as restaurants though; diseases are too unpredictable, cheesecake is not.”
The key words are “how” and “should be like.” Each of the items he discussed was an example of ideas we all accept as virtuous goals in medicine:
- Finding means to reduce unnecessary variability in procedure
- Finding means to reduce unnecessary variability in ingredients (implants, medicines, etc.)
- Using the purchasing power that comes from reduced variability and organizational size to control costs and standardize the quality of ingredients
- Standardizing and monitoring the process from front to back (pre-op through rehab)
- While the Cheesecake Factory menu of 350 items seems trivial when compared to the total number of services offered in a medical center, it is huge compared with most franchise restaurants. Its ability to achieve standardization and tight quality control over that menu should give pause to those who dismiss the idea that variability can be controlled by saying “medicine is too complicated.”
- Innovation within a strict framework. New menu items come along every six months, but the current batch has been in the pipeline for more than 18 months. When comparing that to the quoted 15 years for widespread use of beta blockers one can’t help but note that the CF has built innovation into its routine.
- Large investment in training is the key to accelerated innovation. Brain surgery is often cited as using the “see one, do one, teach one” paradigm for training. CF takes it one step further by evaluating the trainees on the “teach one” phase. I doubt that neurology residents get graded on how well they teach a procedure.
Gawande is a practicing surgeon at Partners that has long since proved his chops on actually bringing simple solutions to reduce errors in medicine. No one would accuse him of not understanding the complexities. There can be no doubt he chose the Cheesecake Factory as a deliberately in-your-face means of exploring (a) the benefits of big medicine, and (b) the opportunities to reduce variability and thereby increase quality. The fact that it manages to do so with a menu that is maybe 10 times more complex than its competitors provides a skosh of credibility that Gawande is on the right track.