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| 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).
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| 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.
Reference
Gawande A (2012) Big Med. http://www.newyorker.com/magazine/2012/08/13/big-med
Accessed 28/1/2015
