Thursday, January 29, 2015

Medicine and cheesecake

cheesecake dog
Bosca eyeing off a bit of cheesecake.

What does cheesecake have to do with medicine? If you give yourself too much time to answer the question, potentially quite a lot. For example, it’s very high in glucose and if consumed in high quantities might contribute to the development of diabetes mellitus. Or someone might choke on a cheesecake, requiring a deft Heimlich manoeuvre to dislodge the would-be assassin. It could be contaminated with some sort of pathogen, resulting in violent food poisoning.

In this case it’s really not about the cheesecake but the Cheesecake Factory, a resterant chain in the US that serves more than 80 million people a year. In his essay “Big Med”, surgeon and writer Atul Gawande explores the commonalities between an organisation such as the Cheesecake Factory and medicine itself.

“In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost with a consistent level of quality,” Gawande says.

It’s a thought-provoking, humble reflection that applies to any aspect of health care, including veterinary medicine and surgery. While Gawande agrees that “good medicine can’t be reduced to a single recipe”, he provides some compelling arguments for standardisation of care (I recommend reading the article in full here).

cheesecake with rasberry sauce.
Cheesecake with rasberry source. Potentially, cheesecake may enhance the reading of this article.

Historically, healthcare has been provided by individual doctors and surgeons who, we hope, are the best at their area of expertise. For example, if you need a knee replacement you want to go to the best orthopaedic specialist. If you have cancer, you want to go to the best oncologist. You want them to treat you their way, the best way.

The danger is there is so much variation in treatment, and this emphasis on the individual doctor can drive egos a bit far. Some of these “experts” are not receptive to new ideas, or may resist taking them on (Gawande points out that on average it takes more than FIFTEEN YEARS for major medical discoveries to be applied in practice – even if that discovery is about an application of a treatment that is already registered and widely available).

Gawande persuasively argues that standardisation of care can improve outcomes (for example, more consistent and effective analgesia for people) and the patient experience of the totality of care. I had a friend who had major surgery last year, and whilst the surgeon was charming and wonderful and the absolute best at that particular surgery, the follow-up was appalling. He’d done his job and was busy doing his amazing surgeries on the next patient. How can someone be so awesome yet the system so flawed, allowing my friend to slip through the cracks? No one was overseeing the totality of her care.

The Cheesecake Factory approach is to ensure that the entire dining experience – or the entire healthcare experience – is quality-controlled.

So why don’t all doctors, hospitals and even veterinarians take this approach? While we are seeing, more and more, development of standard treatment protocols for common conditions, there is still scope for improvement. For example, we can’t seem to reach a consensus on vaccination protocols, despite the fact that the World Small Animal Veterinary Association (WSAVA) working committee has put together evidence-based guidelines.

We need to measure outcomes – not just in studies but real clinical cases. This data can be used to tweak the protocols. We need to think about the whole of the patient-client experience.

We are seeing more veterinary hospitals, for example, chains, where customer service, record-keeping, treatment protocols etc. are standardised.

One difficulty, and a source of much resistance to standardisation among vets and doctors, is that standardisation is so easily conflated with corporatisation. As Gawande points out, “Whatever the industry, an increase in size and control creates the conditions for monopoly, which could do the opposite of what we want: suppress innovation and drive up costs over time. In the past, certainly, health care systems that pursued size and market power were better at raising prices than at lowering them”.

The increase in the proportion of insured pet owners means that the gold standard of care is an option for more and more, but there will always be clients who cannot pay for or do not wish to pursue the gold standard of treatment. That doesn’t mean that the alternative/s can’t be standardised either. The aims of standardisation need to focus on clinical outcomes.

Gawande argues that the Cheesecake Factory chefs remain creative, retain autonomy and provide a better, more consistent service than some chefs in boutiquey restaurants. Definitely food for thought.


Gawande A (2012) Big Med. Accessed 28/1/2015