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Like it or not, ‘Big Med’ will be a part of cancer care
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William Wood
I always enjoy reading the books and essays that Atul Gawande, MD, writes about health care.
Besides being a lyrical and skilled writer, Gawande has an uncommon ability to transform emerging health care trends into narratives that spark national discussion.
His piece about the costs of care in McAllen, Texas, reportedly wound up on President Obama’s desk, and echoes of this essay reverberated through others’ essays, debates and even legislative activities in the months that followed.
When I saw that a new essay by Gawande, titled “Big Med,” was published in The New Yorker, I was eager to give it a read.
It didn’t disappoint. The prose flowed and moved as quickly and as enjoyably as usual. Reflecting as I read through it, though, I couldn’t help but brace occasionally. I’ve always been a Gawande enthusiast, but some of these ideas seemed a little controversial and unsettling, even to me.
Operational efficiency
In his essay, Gawande illuminates The Cheesecake Factory, of all places, as an example of how health care might function in an ideal world.
I haven’t been to a Cheesecake Factory in years, having found the inauthenticity of the experience to be a little disappointing. As I read through Gawande’s examples, though, I could understand his perspective.
As a chain, The Cheesecake Factory achieves consistency and quality in a diverse range of culinary presentations. Chefs receive effective training and work quickly and efficiently to re-create dishes with precision. Managers oversee these operations to ensure that the products turn out as they are intended to. New concepts are introduced and rapidly disseminated throughout the national infrastructure so they are quickly a reliable part of the menu at any Cheesecake Factory, anywhere.
Gawande also provided examples of all-too-familiar health care practices that often come nowhere close to such standards, around issues such as communication of treatment plans and test results, the process of hospital discharge, the incorporation of evidence into usual practice — and this list goes on.
Above this narrative of the differences in quality between The Cheesecake Factory and usual health care, Gawande wrote about size, scope and oversight. Part of what makes The Cheesecake Factory what it is — and other such chains, as well — is a process of centralized oversight that utilizes standard operating procedures and sophisticated statistical modeling to achieve remarkable operational efficiency.
There are signs that segments of the health care delivery industry may be moving in this direction, too, such as “super-regional” health care systems (hence the name Big Med), and Gawande provides specific examples of standardization (eg, the practice of an orthopedic surgeon in Boston) and oversight (eg, “tele-ICUs”).
In the tele-ICU discussion, Gawande provides a vivid picture of an ICU physician viewing the health care delivery of a remote ICU via television, then calling in by phone to discuss suggestions for ongoing care in specific cases with the treating physician.
Variations in care
My instinctive reactions to Gawande’s essay were of puzzlement and concern — The Cheesecake Factory and restaurant chains as shining examples for health care to follow? Consolidated health care systems with strict standard operating procedures that squelch risk-taking and innovation? “Big Brother” watching from a remote camera to look over a treating physician’s shoulder?
I wondered, could this really be the way forward?
In the end, of course, what is best should be measured from the perspective of the patients who receive our care.
I thought of my own areas of practice, hematologic malignancies and stem cell transplantation, and knew that “best care” doesn’t happen as often as it should. As a profession, our practices are not only nonstandardized, they are wildly idiosyncratic and subject to local tradition.
The standard approach to initial therapy for a young patient with mantle cell lymphoma, for example, varies significantly from institution to institution.
There is significant practice variation in the management of immune suppression after allogeneic stem cell transplantation.
More generally, supportive care practices after transplantation vary widely, including use of growth factors, antibiotics, precautions, monitoring and patient restrictions.
Even for some of the noncontroversial aspects of care — helping patients to get in and out of clinic rooms on time and efficiently, communicating plans and results, incorporating patient-reported symptoms and quality of life into clinical decision making — I know we are not always as effective as we would like to be.
Best practices vs. best interests
How much of the care we provide has no known or possibly known best practices associated with it? In other words, how much practice variation is acceptable in the name of innovation and continuous care improvement, and how much practice variation is random and distinct from what could conceivably be considered a best practice?
How much of what we do is inextricably intertwined with what we think it means to be a highly trained health care provider. In other words, how much of our health care delivery activities rightly fall within the realm of highly intuitive medicine, where the best approaches can only be informed by years of training and experience? Conversely, what portions might conceivably depend less on individual provider knowledge, and could be safely — and probably better — covered by standard operating procedures?
Seen this way, it seems there are some parts of hematologic malignancy and stem cell transplant health care delivery that I could comfortably turn over to a Big Med provider of these services, if this meant better outcomes for my patients and more time for me to focus on the most critical, challenging and rewarding portions of my job.
Leukemia and transplant health care delivery have almost always had their homes in individual academic institutions. Is it even conceivable that these kinds of practices — like urgent care, or perhaps ICUs — could ever be part of Big Med?
This depends on the scalability of these practices and the possibility of moving some of this work out of the highly technical and specialized environments of tertiary care centers. With the advent of lower-intensity leukemia induction strategies (eg, 10-day decitabine and others) and outpatient-based stem cell transplantation, perhaps these days are not as far off as they might seem.
Perhaps one of the most important points of Gawande’s piece is that feelings aside, like it or not, Big Med is coming. Will we be ready? And how can we ensure that our best interests and, most importantly, those of our patients are preserved?
References:
- Gawande A. Big Med: Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care? Available at: www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande#ixzz23iY0o2O3. Accessed Aug. 16, 2012.
- LaCasce AS. Blood. 2012;119:2093-2099.
- Lee SJ. Biol Blood Marrow Transplant. 2011;14:1231-1238.
- Pidala J. Biol Blood Marrow Transplant. 2011;17:1528-1536.
For more information:
- William Wood, MD, is assistant professor of medicine in the division of hematology/oncology at the University of North Carolina in Chapel Hill. He may be reached at william_wood@med.unc.edu, or follow him on Twitter (@WoodBD). Disclosure: Wood reports no relevant financial disclosures.
Perspective
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Harry S. Jacob, MD, FRCPath(Hon)
I believe the editorial by Guillermo J. Ruiz-Argüelles, MD, FACP, FCRP (Glasg), in the Aug. 25 issue of HemOnc Today may ease Dr. Wood’s concerns regarding over-standardization in our profession, at least regarding bone marrow transplantation. In Mexico and in Cuba, the opposite of high-powered ICU care of BMT patients — that is, no hospitalization, but follow-up in patients’ home environments — provides as good outcomes with less graft-versus-host disease than in our “Cheesecake Factory” units.Click Here to Manage Email Alerts