There’s this crotchety old guy in his 80s whom I’ve known for years who never misses the opportunity to send me anything he happens to read about health care delivery. And when I say “send me”, I mean it literally: a paper copy of Atul Gawande’s New Yorker article Big Med sent by snail mail. For anyone who either hasn’t read it or is disinclined to click the link, suffice it to say the good doctor (surgeon, actually) explores the standardization processes of the restaurant chain The Cheesecake Factory and suggests that applying those principles to medical care would be a good thing.
This article, while engaging, has already been deconstructed a couple of places (here and here, for example). Cheesecake factory standardization is basically quality control, and patients often don’t present as uniformly as a shipment of ground beef. Furthermore, there’s already a great deal of checklisting and standardization going on in areas such as surgery. Nowhere, however, have I seen mentioned the key difference between the practice of medicine and the restaurant business: no one at the Cheesecake Factory has to make a diagnosis.
Presumably everyone who comes into the restaurant is hungry and wants to order food to eat. There is no role for anyone in the Cheesecake Factory organization either to question the customer about whether or not they are truly in need of food at this time, or to recommend for or against specific menu choices. Compare that with the practice of medicine, concisely paraphrased as, “It’s the diagnosis, stupid.”
It seems ridiculously obvious to state that without making the correct diagnosis, it is not possible to provide appropriate treatment. I’ve said this before in the context of tweaking our payment schemes. To quote myself:
Performing a flawless appendectomy won’t do a thing for an ovarian cyst, nor will a PPI prescription do much for an acute coronary syndrome. Performance measures that look at treatment without addressing diagnosis are somewhere between misguided and ludicrous.
Let’s think about what a doctor’s office would look like using the Cheesecake Factory paradigm:
Patient — sorry, Customer: Hi, I’d like a coronary artery bypass procedure this afternoon.
Doctor: Certainly, sir. Would you like that with an open technique or mediastinoscopically?
Customer/patient: Scope, please. And can I have the cheesecake for dessert?
Doctor: Excellent choice, sir.
Ridiculous, right? How about this one (which occurs regularly in my office):
Patient/customer: I’d like some antibiotics for my cold.
Doctor: Of course, ma’am. Will amoxicillin do, or would you prefer a Z-pack?
Patient/customer: I guess the z-pack. Can I get fries with that?
Doctor: Of course.
How’s that for customer service!
I am all for standardization and quality control AFTER making a correct diagnosis and choosing an appropriate treatment. This occurs more often in the surgical realm than in the medical (although things like chemotherapy and other oncology therapies could also probably benefit). Coincidence that Gawande is a surgeon? I think not. But until the Cheesecake Factory is mandated to interview their customers (patients) to determine what the best dietary choices are for each individual — and then counsel/convince people to accept (and pay for) those recommendations — neither the restaurant industry nor any other non-professional service industry should be held up for medicine to emulate, Atul Gawande be damned.