Gawande’s Kitchen

Atul Gawande is a fine writer and probably a good doctor. He was a key health care advisor to the Obama administration, largely based on writing very long articles mostly for the New Yorker about the problems he sees in the current health care system.

His most notable contribution to the health care debate was a major article he wrote in June 2009, which claimed to show that physicians in McAllen Texas were systematically over treating patients to enrich themselves. This article “became required reading in the White House and Congress during the health care debate and turned McAllen into shorthand for America’s medical spending problem,” according to NPR (National Public Radio).

Gawande argued that costs in McAllen are far higher than in El Paso, a town with similar characteristics. His only explanation: for some reason physicians in McAllen are greedier than physicians elsewhere.

As it turns out, he was wrong.

This notion suited the White House reformers to a tee. Most of them figured all the problems in health care are the fault of greedy doctors and the solution is to control the docs. Hence, the inclusion of Accountable Care Organizations, pay-for-performance, electronic medical records, and comparative effectiveness research — all designed to get doctors under the control of bureaucrats (and we all know what models of efficiency those bureaucrats are).

Unfortunately, Dr. Gawande failed to consider a number of other factors that would complicate his simple explanation. One correspondent who is very familiar with the medical market in Texas wrote to me saying, “It seems pretty clear that Gawande drew the wrong conclusions. The most notable difference between McAllen and ANYWHERE else, according to the published Dartmouth data, is that McAllen has far fewer physicians. The result of this is that there is very little ambulatory care, far more inpatient days and a larger proportion of the care is delivered in the emergency room. It’s the shortage of physicians in McAllen that is causing costs to be so high. I don’t know how Gawande missed it.” She added that there is also a physician shortage in El Paso, but people there tend to cross the border into Juarez, Mexico, for physician services, while there is no similar opportunity across the border from McAllen.

And the NPR story linked above was about a later study published in Health Affairs that looked at Blue Cross Blue Shield data, rather than just Medicare data, and found that Blue Cross actually pays less per person in McAllen than it does in El Paso. So the rush to find simple answers — greedy doctors — resulted in flawed policy prescriptions. I wonder if Dr. Gawande would practice medicine the same way he practices public policy.

All of this is just by way of introducing his latest offering. His most recent article in the New Yorker is called “Big Med: Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?” (See John Goodman’s previous post on this.)

Gawande looks closely at The Cheesecake Factory and is astonished at how well-organized and efficient the kitchens are in these restaurants. Costs are low, quality is superb, and customer satisfaction is high. Everything is standardized and every worker’s job is well defined and limited to just a few functions. As I said, he is a very fine writer and he made me hungry describing how food is prepared in these places.

He wonders why medical care can’t be delivered the same way, and finds a couple of examples of where similar practices are being introduced in hospital settings. He believes this is the future of medicine — centralized control by national chains that prescribe in detail what must be done by each worker and oversee how long they spend on each task.

One of his examples is the joint replacement department at his own Brigham and Women’s Hospital in Boston. Gawande’s mother needed a knee replacement, so he was able to track her progress carefully. They have standardized what they do — the parts they order, the anesthesia they use, the post-op therapy. The hospital got some resistance from the surgeons who were used to doing things their own way, so it allowed for some deviation from the “default option,” but only if they could show there was good reason for doing so. Gawande says “the start-to-finish standardization has led to vastly better outcomes.”

A couple of observations about all this:

This example reminds me of Regina Herzlinger’s concept of “focused factories,” in which a facility learns to do one or two things very efficiently. That may work well for routine and commonplace services like joint replacement, or Herzlinger’s favorite example, hernia repair, but it is hard to see it applying to the extremely wide range of maladies most hospitals deal with.
The methods this department settled on for its standards were based on a great deal of experience with a wide range of alternatives. If there had not been alternatives, they would have had no way of knowing which was optimal. This hospital had been using nine different knee prostheses. They found that all worked equally well. So they were confident in using the three least costly ones. Similarly with post-op therapy: Most of the surgeons had been prescribing passive-motion machines to exercise the knee, but closer examination found that these machines didn’t do much good. So they stopped using them. They were able to do this because no one treatment had been standardized and required for all patients. If there hadn’t been a variety of treatments used, no one would have known there was a better method available.

But there is a much more important question being ignored by Gawande — How well does The Cheesecake Factory analogy really apply to health care? We can see how similar the kitchen is to an operating room — lots of busy people rushing about in a sterile environment, each concentrated on a task. But what about the rest of the “system?”

At The Cheesecake Factory, the customer is the diner. That’s who orders the service, pays the bill, and comes back again if he is happy. That is who all of the efficient, standardized food preparation is designed to please.

In Gawande’s ideal health care model, however, the customer isn’t the patient, but the third-party payer, be it an insurer or government. Let’s call that entity the TPP. The TPP never enters the kitchen. The TTP has no idea what happens in there, and doesn’t really care as long as the steak is cooked to his satisfaction and the tab is affordable.

In this model, the patient is actually the steak. It is the steak who is processed in the kitchen. It is the steak that is cut and cooked and placed on a platter. The steak doesn’t get a vote. Nobody cares if the steak is happy. The steak doesn’t pay the bill. The steak isn’t coming back again.

So here we are in Dr. Gawande’s kitchen, where you and I are slabs of meat and Chef Gawande will cook us to the specifications of his TPP customers — satisfaction guaranteed.