Monday, August 13, 2012

Would you like fries or cheesecake with your family medicine?

In "Big Med," his latest article on health care in The New Yorker, surgeon-writer Atul Gawande added the Cheesecake Factory to his running list of health care analogies (which have included, among others, farming, pit crews, and airline safety). Observing that the Cheescake Factory and other upscale restaurant chains successfully lower costs and improve quality by "studying what the best people are doing, figuring out how to standardize it, and bringing everyone in to execute," Gawande asked why this strategy couldn't be applied to fix the shocking amount of disorganization and waste that exists in U.S. health care:

This is not at all the normal way of doing things in medicine. ... But it’s exactly what the new health-care chains are now hoping to do on a mass scale. They want to create Cheesecake Factories for health care. The question is whether the medical counterparts to Mauricio at the broiler station—the clinicians in the operating rooms, in the medical offices, in the intensive-care units—will go along with the plan. Fixing a nice piece of steak is hardly of the same complexity as diagnosing the cause of an elderly patient’s loss of consciousness. Doctors and patients have not had a positive experience with outsiders second-guessing decisions. How will they feel about managers trying to tell them what the “best practices” are?

The Cheescake Factory model of quality and cost control may work well in intensive care units, where, despite the how sick the patients are, there are a finite number of clinical situations that are for the most part amenable to evidence-based protocols (e.g., how to safely insert or remove a central line, what to do for a patient in respiratory failure). That's not the case for much of family medicine, where aside from health maintenance and hospital follow-up visits, patients generally present with undifferentiated problems. (See my previous post on how checklists could be used to avoid diagnostic errors.)

I have spent time in one area of family medicine that functions with restaurant-ish efficiency, however: the urgent care setting. In between leaving my non-clinical position at AHRQ and returning to academic medicine full-time, I moonlighted at a respected chain of urgent care centers, where patients receive walk-in care for minor illnesses such as respiratory infections, sprains and strains, and uncomplicated lacerations. The layout of each facility was identical, so that a clinician, nurse, medical assistant, laboratory assistant, radiology technician, etc. could seamlessly fill in at any location. Senior physicians had integrated evidence-based protocols into the electronic medical record for almost every conceivable clinical situation that physicians might encounter, suggesting medications, follow-up studies, and referrals depending on the diagnosis. Physicians regularly received feedback on their quality of care and were sometimes followed on selected shifts by an "efficiency expert" (typically a registered nurse) who observed them in action and made suggestions about how to improve their performance.

Most patients, accustomed to long waits for doctors' appointments and the glacial speed of the emergency room for non-critical medical problems, left the center satisfied. So why not extend this model to non-urgent primary care? Well, we profited for the most part from dealing with patients with clearly defined complaints who wanted quick fixes rather than long-term healing relationships. Put another way, seeing me for care was something like visiting a McDonalds - a predictable and satisfying experience, but one that you don't want to have on regular basis (much less every day for a month, like Morgan Spurlock in the 2004 documentary Super Size Me).

Like entering a sit-down restaurant that you've never visited before, meeting a new primary care physician is more of a gamble than going out for fast food. Your expectations are higher, and the possibility of disappointment far greater. But the payoff, if you're fortunate, will be better health and improved quality of life, as documented in detail by researchers such as the late Barbara Starfield. The trouble is that today's U.S. health environment consistently pays the best family physicians (Gawande's equivalent of Cheesecake Factory managers) the equivalent of McDonalds wages: my hourly take-home pay was about one and a half times higher doing urgent care than it is today, doing mostly primary care. So it's no wonder that medical students continue to pass on family medicine.