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August 16, 2012

Health care isn't cheesecake

At first, I wasn’t going to comment. The topic had been thoroughly discussed in the pediatric hospitalist listserv—and after reading all the responses there, I thought, “Well, that’s that, it’s all been said.” So I went on vacation, ignoring the slow crumbling of our health care system.

Now I’m back, tanned and relaxed, eager to join the fray. (Plus I ran into the Romney/Ryan motorcade on my way back from the beach, which cost me an extra hour of travel time. The battle has been joined!) I decided to read the article. And then I stopped.

Yes, you guessed it: I am talking about the "Big Med" article written by Atul Gawande, MD, for The New Yorker, in which he compares health care services and organizations to his neighborhood Cheesecake Factory. At first, I thought Dr. Gawande had gone off his rocker. Maybe his beloved Red Sox’s lousy season was having a deleterious effect on his logic.

Then I thought, “Gawande is a surgeon and best-selling author, who teaches at Harvard and writes for The New Yorker. What the hell is he doing eating at a Cheesecake Factory? Me, I'd eat at Le Cochon du Pink Volador every night if I was him!” (Don’t Yelp it. I made it up).

As I read more, I understood some of his reasoning: big chain restaurant, standardized workflows, excellent consumer satisfaction. I get it. I really do.

Nice try.

As I was driving to work this rainy morning, I thought, “Gawande is right. Standardization is good for medicine.” But he compared health care to the wrong industry.

Health care is not the restaurant business. It’s not the entertainment or the hotel business. Heck, health care is not even the airline industry, certainly not Southwest.

Why? Because when you go to a restaurant or a Disney resort or a hotel, you want to be there. When you eat out, you compare what restaurants have on their menu, either on your phone or by looking at what's taped on the window, and then you choose. At the end, you (or someone in your group) pay the bill, out of pocket.

Patients on the other hand don’t seek health care when they want to, but when they have to. (I recognize that cosmetic surgery is more in the “want” than “need” column, but let's ignore that for now.) Patients don’t usually pay out of pocket, except for a small deductible.

And there is no way to compare services and outcomes, although the government is trying to change that. You don’t pick among an array of options. Instead, most people go to their friendly neighborhood hospital or the one that their doctors go to, or to whichever hospital is closest to their car accident or chest pain. (Second and third opinions at so-called “destination health centers” are a different story.)

That got me thinking: What other industry operates like this, one that has a product that customers seek, but only when they have to, not when they want to? What other industry does not allow you to compare the services you receive from one provider to the next? What industry lacks choice, but still survives?

The escort industry!

Ladies and gentlemen, health care operates within the same parameters as an illegal enterprise. You call for an escort because you have to. You have a little bit of choice but you don’t know what you’ll get until he or she (let's not discriminate here) gets there. You can’t really at that point say “I don’t want you, send someone else.” And you can’t really compare. Believe me, the pictures at escort service Web sites are very deceiving—at least, that’s what my friend Carlos tells me.

Yeah, you do have to pay out of pocket, so the analogy is not perfect. But I’m trying to keep the content politically correct because this is a family-oriented blog, after all.

I’m kidding, of course, but only a little bit. We know what ails our industry. We know costs are out of control, quality is not great, patients and providers are unsatisfied. Any other industry operating with the kind of outcomes we do would fold in a very short time.

Dr. Gawande makes a well-known point, one that is common among business types: that the health care industry just needs business solutions to its problems.

Maybe. Like I said, standardization is a good way to start by promoting evidence-based evaluation and treatment tools that decrease waste and improve outcomes.

Yes, comparing one hospital to the next and being patently transparent about our outcomes can only help us improve. But hospitals are not restaurants, and health care services aren't the same as searing a steak or dusting a dish with the right amount of sesame seeds. Let's not confound the search for leisure and commodity for the search for a cure. When I heard of a hospital hiring someone from the Ritz-Carlton to function as “vice president for the patient experience,” I knew things were getting a bit out of hand.

So, sorry Atul, and all of you who think hospitals can function like a Cheesecake Factory. You got it all wrong. Next time you want to cure what ails us, compare apples to apples. Call 1-800-Friend-4-2-Nite.

Now, that’s a column I'd like to see in The New Yorker!
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4 Comment(s)

Laurie Bankston wrote:
Thanks for giving voice to what many of us felt but could not articulate. Standardization is good, but a great steak and not dying from pneumonia are fairly different outcomes ...
Dayton, Ohio | Thu, Aug 23 2012 04:28 AM

Sam Jenner wrote:
You flippantly state that, "We know what ails our industry. We know costs are out of control, quality is not great, patients and providers are unsatisfied. Any other industry operating with the kind of outcomes we do would fold in a very short time." Sounds like a situation we should all be working on to resolve ASAP, rather than joking about publicly.

Gawande is simply looking for solutions. You are mostly raising roadblocks.

We hospitalists already have a severe credibility problem with patients and our hospital partners. And blog posts like this aren't helping.
Wed, Aug 29 2012 13:44 PM

Ruben Nazario wrote:
Laurie, thanks for your comments.

Sam, like the great Muhammad Ali said: “My way of joking is to tell the truth. That's the funniest joke in the world.”

Falls Church, Va. | Wed, Aug 29 2012 14:36 PM

Kim wrote:
Well done. Thanks for sharing and shinning light on such a "cheezy" comparison. Thu, Aug 30 2012 06:17 AM

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About Ruben J. Nazario, MD
Ruben J. Nazario, MD, is now medical director at Inovalon, a health care data analytics company, and is medical editor for Elsevier's First Consult. A pediatric hospitalist, Dr. Nazario is a veteran of both community and academic pediatric hospitalist programs. All material represents his own views and does not reflect the views of his employer.
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