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Friday, August 10, 2012

More on Atul Gawande's Cheesecake Factory metaphor--how to not eat there all the time, but still improve medical care

Atul Gawande, a surgeon who writes for the New Yorker magazine, recently wrote an article about how the medical profession might learn from a large restaurant chain how to provide really good service inexpensively. I was intrigued, because I would very much like to see medical care get better and cheaper, and find it very frustrating that progress is so slow. But I was also a little horrified by the vision of my profession becoming another mindnumbingly reproducible chain restaurant.

One of the reasons that medical care has been expensive and not successfully focused on customer satisfaction is that physicians, at least good ones, are kind of scarce and have been trained in a culture that makes us consultants rather than service personnel. (Also, of course, the fact that we are usually paid by a deep pocketed third party without much consciousness of what the consumer really wants is a major issue.) If we, as physicians, are available to help solve a person's medical problems we need not concern ourselves with details like making the process easy or pleasant. We regard our individuality as an asset and dislike being told what to do.

Still. It would be really nice if we could learn to utilize the hard won data about which practices work to make people healthier and which do not, and adopt practice patterns accordingly.

One of the ways to make us doctors practice medicine in a certain way is to pay us well only when we toe the line. Another is to make the practice settings where we work encourage such behavior and make other behaviors very difficult. Both of these things happen. The first is called "pay for performance" and doesn't necessarily work that way, and irritates us. The second can be done via computer systems that make standard pathways fall easily from diagnoses, and non-standard ones be technically more difficult. This is also irritating, especially when the right approach falls somewhere outside of the box.

And yet many of us do medicine that is outdated and ineffective, out of habit, laziness or inattention, and our patients suffer and pay money for it.

Recently physician's organizations have worked on helping us to focus on the most stupid things we do in order to pick the low hanging fruit of waste. (See my post on the Choosing Wisely campaign Besides not doing stupid useless things, there is also research about how to take care of patients in ways that actually make them better. So someone, but not everyone, knows what generally works and what generally does not. We theoretically could know which tests help answer what question in the least time and resource consuming ways, which medications or treatments are most likely to work, and which ones to try when they don't. Some medical practices have refined the art of communication, with doctors, specialists and patients and are happy to share their processes with other groups.

Physicians behaviors are best changed by teaching them new ways of doing things that really work. We are lifelong students. We complete a minimum of 24 years of schooling by the time we go to work and have to document ongoing education throughout our careers. Mostly we do way more education than we ever document, following new developments by computer or print journals and by talking to our colleagues. What we see and hear, though, is spotty, not necessarily exposing us to the most important new information.

I would propose that we create a curriculum for physicians that teaches us stuff about delivering high quality care upon which there is good consensus. I'm sure we could cover the big items in a few days a year. There are already "update" courses in nearly every specialty, taught by all sorts of organizations, but they hit on whatever the individual teachers think is valuable with varying teaching success. The big item curriculum would be like the menu of a successful restaurant chain, giving us excellent but standard fare. We would also keep learning, like we do now, interesting and non-standard information. It would feed my soul if, at the big item update course, we had a final speaker point out ways in which what we had just heard was not actually the gods' own truth and would probably look significantly different the next year, and required some level of customization to serve our own patient populations.

Innovations in medicine happen when somebody tries something that is different and it works. These wonderful and game changing shifts in practice can only happen when we can all feel free to give medical care that is outside of the box, paying attention to how our individual patients look, feel, sound, and what they say they need from us.


BarbaraW said...

DNR has probably become too well entrenched to be changed at this point, but just saw another post on Kevin MD which referred to the alternative AND, Allow Natural Death, which sounds a whole lot better and might be an easier/better way to communicate what we want to happen.

Janice Boughton said...

I think the comment was meant for the next post, but in any case, good point. I do like the Allow Natural Death terminology since it is worded positively and is more accurate, since what we DO NOT do is not resuscitation but CPR and intubation. Resuscitation is anything we do to enliven someone, including giving fluids or medications or smelling salts or whatever.