Atul Gawande is at it again. The acclaimed health issues writer at the New Yorker, whose day job is as a general surgeon at Partners Health Care in Boston, wrote a provocative piece in the Aug.13 issue of the magazine. In it, he addresses what health care can learn from the standardized practices, processes and measuring at chain restaurants; in his case the Cheesecake Factory.
A lot of what Gawande writes about has to do with scale – the ability of large organizations to create systems that work predictably for the thousands of employees and millions of customers at a chain restaurant.
Gawande draws analogies between chain restaurant best practices and the interaction of people and systems within large health care institutions. And I am sure most independent primary care physicians would be aghast at the level of standardization and oversight being pursued by a few innovative hospitals, even though the results are remarkably promising.
Dig behind the inside-the-hospital stories, however, and there are lessons for independent primary care physicians too. Gawande has for some time been pushing a conversation around “cowboys vs. pit crews.” There is an urgent need to coordinate care and care management across venues, across disciplines and over time, and – in his view – the time of the doctor as the lone hero, the cowboy on the range, has passed. Patients need pit crews, teams that have disciplined approaches to the coordination of tasks, to the necessary hand-offs, to seamless communication, backed by measures and analytics to effect change when the evidence points that way.
The phrase “heath care system” is a contradiction in terms, a bit like “jumbo shrimp.” Health care is actually the world’s largest cottage industry, and its fragmentation leads to poor communication, the repetition of tests and the lack of continuity, all of which have an enormous impact on both outcomes and cost. Gawande is right that primary care physicians, like all providers, need to consider themselves part of their patients’ pit crews.
Where I diverge from his perspective is his conclusion that the health care ecosystem needs to converge at an organizational level to access the benefits of scale and integration of a Cheesecake Factory. I believe that the trend to employed physicians and consolidated primary care groups is cyclical, and a fairly blunt response to the challenge of fragmented care. I am much more excited and optimistic about the role the right technology will play (and in some cases, is playing now) in creating the linkages and continuities required to defragment care and create virtual teams, while maintaining the vibrancy of the independent practice.
The recent Institute of Medicine report mentioned in a previous post lamented the amount of time it takes evidence-based best practices to disseminate through the system. Connected technology can provide us not only the Electronic Health Record, but also the Best Practices Record (BPR). A BPR would be invaluable in helping a physician and her staff learn almost in real time what works and what doesn’t from peers, adopt the proven, standardized procedures that they really don’t want to fuss over on their own anyway and focus on the specific challenges faced by each patient.
Learning from the Cheesecake Factory doesn’t mean depersonalizing care. In fact, it can mean precisely the opposite.
Hello Health follows Gawande on Twitter: @Atul_Gawande.