When I drive down a street and see only national chain restaurants and retail stores, I am sad. Can we do no better than this, to make everything the same, supporting certain foods, certain products at the expense of the tremendous variety of such things that exist?
Atul Gawande just wrote a very compelling article in which he explored the chain restaurant The Cheesecake Factory as a model or metaphor for good health care. He not only ate there, but toured the facility and observed the processes that allow this huge place to provide food that is interesting, delicious and affordable. His main thesis is that an industry that standardizes excellent practices can provide high quality care, and that it is not unthinkable that medicine could be substantially improved by adopting such a model. He also looked at some excellent hospitals that have begun to standardize such things as patient care in the ICU and total knee replacements.
There are many things that, through scientific inquiry, are known to be VERY GOOD IDEAS. Things like preventing blood clots in the legs with certain medications, elevating the head of the bed of patients on ventilators to prevent pneumonia, handling central venous catheters in such a way as to avoid catheter infections can save lives and should be done routinely. There are certain practices that are agreed to be “best practices” by either evidence or expert opinion, such things as maintaining quiet in patient care areas, numbing up arterial puncture sites, preserving normal sleep wake cycles, which significantly improve quality of care for patients. Both inpatient and outpatient medicine are positively crawling with “best practices.”
Surgery is a field that is absolutely ripe for protocol driven procedures, because so many things can go wrong when a person is anesthetized and cut open, and so many things must be remembered and performed perfectly and quickly. Atul Gawande is a surgeon. His checklists (see his book, The Checklist Manifesto) seek to make the multiple complexities of practicing medicine and surgery easier to navigate.
The Cheesecake Factory is a fully realized real world example of well performed standardized processes, and therefore more delicious even than checklists. I am often frustrated as I watch, via medical charts, the variety of inattentive and thoughtless medicine that passes for OK in hospitals and clinics. It would be really nice if everybody knew and could practice in a way that actually made sense when there is really believable evidence to support these processes. In addition, I often find myself functioning at the very edge of my abilities due to the complex coordination of what seems to be nearly infinite data in the setting of real patients actually getting super sick and flirting with death. In these situations I long for processes that make it easy for me to be smart or impossible for me to be very stupid. I look for computers to help me focus on the important information and remind me when I forget something that needs to be done. I look for nurses to pay attention to things that were, at some point in the past, the private realm of doctors, such as tests and medication interactions and recommended prevention strategies.
But I don’t want medical care to resemble a meal at the Cheesecake factory, though I hear the salmon is delicious.
Much of medicine is practiced on people who are as different from each other and as individual as snowflakes. My patients are never the same as one another, and the problems and stories they bring me require of me a different responses based on so very many things. A patient might come in with a numb toe, having recently split from her husband, with a lump in her throat. Or he might come in with “heartburn” and Asperger’s syndrome and a notable suspicion of the medical profession. Not only are the possible diagnoses for each of these people myriad, so are they ways I might start to investigate them and the ways I might treat them while waiting for more data. These are the real patients who are difficult to treat with “evidence based medicine” since nobody ever did a study on them looking at what worked and what did not, because each one is unique.
When a physician is encouraged to use protocols and pathways in treating patients, he or she is tempted to force patients into artificial categories which lead to these protocols. Patients know when this is happening and they feel like herd animals, and they experience not being heard. And yet I am not against pathways and protocols in general since they can help us avoid some egregious mistakes and obscene waste. The trick, I think, is to avoid being too impressed with The Cheesecake Factory, to use protocols in situations where they really are indicated and to preserve a sense of creativity and curiosity when faced with real people with really interesting problems.