What Dr. Gawande's New Yorker Article "Big Med" Missed: It's An Old Concept and There Are Specialty Hospitals & Population Health Management

If you're a fan of star surgeon overachiever Atul Gawande, then reading his New Yorker article "Big Med" is a must. The rest of us skeptics should still use the article to signal our health care adroitness by knowingly referring to the "Cheesecake Factory" in our policy medical meetings, conferences, PowerPoints and bloggery.

What he wrote:

Dr. Gawande uses the successful restaurant chain to extract lessons and draw health system parallels, ultimately concluding, after a visit to one of their kitchens, that the industrialization of health care delivery may not be such a bad thing. While the Factory's hibachi steak is personally prepared to the consumer's specifications, its final sizzling tasty presentation is really the product of inventory control, fine-tuned assembly line prep that leads to the expert cook, all of which are under intense quality oversight. 

The same business model of mass customization should be applied to total knee replacements and ICU stays, says Dr. Gawande.  And in order for that to happen, it'll mean transforming our small independent hospitals into big chain factories that can marshall the financial and intellectual capital to get patients out of bed, off the breathing machine and in their home with a minimum length of stay.

At the center of this value chain is the cook (surgeon or ICU specialist) who relies on standardized ingredients (devices or drugs) that are assembled (delivered) using a standard prep (guideline or protocol). That's when the cook can use his or her personal grilling expertise to gauge the doneness of the steak and properly fluff the mashed potatoes. In Gawande-World, the surgeon-cook can have his cake (professional independence) and eat it too (by reducing variation).

But here's what he missed:

The DMCB really likes the article but points out that once again (like here and here), Dr. Gawande neglected tell the entire story:

• The Soviet Union invented assembly line surgery back in 1968 when they applied it to cataract surgery.  While it never really took hold in the U.S., variations of it exist, such as this cataract factory in India. Why not have, wonders the naive DMCB, a series of surgeons who are responsible for each step of a deconstructed surgical procedure? While that sounds silly, there may be some high volume multi-step elective operations other than cataracts where this makes sense.

• Dr. Gawande seems to be unwittingly arguing on behalf of the "specialty hospital," which you can read about here.   Enterprising physicians and investors have been prepared, long before this New Yorker article, to double down on the value chain of organized production line medicine, figuring that they can not only control costs, minimize complications and minimize hassles, but also make a tidy profit. Ironically, it seems, the concept has drawn the ire of policy makers, based on irksome concerns about for-profits cherry-picking high margin business from well-connected institutions like Dr. Gawande's home base, Brigham and Women's Hospital.

• Last but not least, a version of the enlightened assembly-line approach has been long applied by the U.S. health care system outside the big hospitals' operating rooms. In population health management, persons with chronic conditions are "inventoried" (risk stratified via mail surveys, insurance claims and the electronic health record). Non-physicians manage the "prep" with education, engagement and coaching, getting the patient "warmed up" for the primary care doc.  The doc then personalizes things.  That's all accompanied by ongoing assessments of contracted quality and cost versus a baseline or comparator leading to a perfect product. Of course, this Cheesecake Factory style population health management will likely never garner the attention of The New Yorker.