Gawande’s topic is efficiency in the delivery of healthcare. The means he uses to provide focus is a comparison of the way a large restaurant chain (Cheesecake Factory) provides services, and the way traditional physicians and hospitals provide services.
The traditional means of dispensing medical care might be considered the exact opposite model.
But the times are changing. The independent physician with his/her own office has been overcome by events. Whether or not one likes the details of the recent healthcare legislation, it has wrought dramatic changes in the healthcare system just by generating the universal conclusion that something must be done about runaway costs. Irreversible changes are occurring even before full-implementation of the law.
Gawande uses his mother’s need for knee replacement surgery to provide an example of how the old way of doing things compares with the developing "new’ way. The first task is to choose a hospital and then a surgeon to perform the operation.
Gawande choose his own hospital because it had a surgeon, John Wright, who believed that there was a knowable "right" way to do things. Gawande doesn’t use the term, but what he describes as the set of procedures Wright derived, could best be referred to as a protocol.
This intent to focus on and use best practices produced an improvement in outcomes and in costs.
Gawande described a process that provided benefits in one hospital. The protocol arrived at was based on a limited set of data. A chain of hospitals can coordinate the accumulation of data and should be able to arrive at more precise recommendations by having better statistics. A government agency could collect nationwide data on symptoms, treatments, and outcomes and provide an even more powerful data base.
The description of how the restaurant chain introduces new meals might be compared to the introduction of a new medical procedure. A few experts work out the details of the most labor and cost effective way to arrive at a product with the desired quality. The rest is all in the training. Representatives of individual restaurants arrive and are given training in the selected procedures. They return to their restaurants and train the kitchen workers. The result is that each time one orders a specific dish one always gets the same dish, no matter what specific restaurant one might be in.
There is now no equivalent in healthcare. An individual physician will encounter thousands of situations. There is no way for an individual to know "best practice" based on their own experiences in more than a few instances. That is the function of scale and of the databases that come with it.
One of the issues raised by extending medical coverage to 30-40 million additional people is the rise in workload for an essentially constant number of doctors. This is usually considered in the context of the traditional physician model. How much more efficient would physicians be if they had a suite of protocols to assist them? A patient comes in with a set of symptoms. That set brings up a protocol that defines the likely causes of the problem and defines the most efficient way to sort through the possibilities and arrive at a diagnosis. The diagnosis will be accompanied by a recommended optimal course of treatment.
This sort of approach is not needed in all cases. Most things are easily recognized and treated. It is the complex cases that could indicate a serious threat to the patient’s health that require a more orderly approach. These are the situations where wasting time guessing at probable causes can be dangerous to the patient and expensive to the healthcare system.
If one believes that this approach is not needed, and that one is comfortable trusting in the competence of the individual physician, consider this comment from Gawande.
One other aspect of scale that Gawande mentioned was quality control. Each restaurant has someone responsible for examining the meals pouring out of the kitchen and verifying that they have the desired characteristics. If a worker is not performing well he/she will learn about it and mend their ways. The trick will be to learn how to apply this principle to a herd of physicians.
Gawande describes one approach to quality control that is becoming common in hospitals: remote monitoring of intensive care units. A remote observer has several functions, including providing specialist advice. Some emergencies in the I.C.U. can draw attention from other patients that can be covered by the remote observers. Mistakes in treatment can also by recognized by having a backup observer.
This type of quality control requires scale to be efficient. It also requires physicians to leave behind their independent-operator model and recognize that they have become members of a team.