Blog | Wednesday, September 5, 2012

Practicing medicine isn't like ordering from a menu

Atul Gawande, MD, is a technophile and a believer in the checklist, and he yokes these ideologies to an attractive metaphor in his newest essay for the New Yorker. The article is worth reading in its entirety, but it can be easily paraphrased.

The Cheescake Factory, like other successful restaurant chains, has "brought chain production to complicated sit-down meals." They've done it by far-reaching standardization of the best possible processes, but not all the way down, since some freedom is left for the front-line practitioners, for example, the line cooks, to get the job done according to their personal practices. Flexibility is built into the restaurant's practices, which change regularly according to new data. And customers are satisfied.

Health care in the United States, on the other hand, does none of this currently. Practices are incredibly diverse, often for no good reason. Particularly touching, as in so many of Gawande's articles, was a story that he elicited from a Cheesecake Factory employee, Dave Luz, a Cheesecake Factory regional manager in the Boston area. Luz's mother, aged 78, had a fall and was subjected to the depressingly normal dysfunctions, malfunctions, miscommunications, and screw-ups of an American hospital. And, when it was time for her to go home, no one coordinated anything. It was up to Luz to do everything, even get her dressed.

An aide was sent. She was short with him and rough in changing his mother's clothes. "She was manhandling her," Luz said. "I felt like, 'Stop. I'm not one to complain. I respect what you do enormously. But if there were a video camera in here, you'd be on the evening news.' I sent her out. I had to do everything myself. I'm stuffing my mom's boob in her bra. It was unbelievable."
A terrible story. Gawande concludes eventually with a not unexpected conclusion. Standardization should change American medicine. Best practices do not make it down to the medical equivalent of the line cook. Doctors bristle at being told to do things better. "Already, there have been startling changes," Gawande reports with excitement. "Big Medicine is on the way."

He tips his hat to the obvious objections. Are we ready to make medicine into Walmart? What about accountability and transparency? "Some will see danger in this. Many will see hope. And that's probably the way it should be."

But one problem doesn't make its way into the article in more than dribs and drabs. Does it work? Does massive standardization do the trick? Of course, we know that checklists work wonders in the critical care setting (from which Gawande presents most of his anecdotal evidence).

But in nearly every other area of medicine, people are still hotly debating whether standardization, or as Gawande puts it, quality control, makes people less sick or helps them live longer. Does giving antibiotics within a specified timeframe actually keep people from dying from pneumonia, or increase the unneeded use of those medications? On a larger scale, do the incentives provided to accountable care organizations actually improve care?

There's an even deeper problem. What do we do about the majority of medical concerns for which there is no standardization? What happens when clinical judgment, often based on little more than anecdote, meets patient preference? Perfecting the mashed potato tower and slicing the avocado to a quarter of an inch is perhaps quite like fine-tuning the ventilator settings or turning down the oxygen. Critical care involves many quantifiable judgments. But what about all the non-quantifiable judgments?

And what about all the parts of medicine which are not strictly quantifiable? That aide who manhandled Luz's mother: what standardization would have kept that person from acting like a jerk? Employees are only as good as the organization hiring them, but human beings act only as humanely as their capacity for compassion allows. The technophile's faith will always let him believe in the perfect cheesecake in the next concession over. But the astute skeptic, the careful consumer of metaphor will realize that sometimes a patient is a patient, not a dish off the menu.

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.