A Response to Atul Gawande's "Big Med"

In Atul Gawande’s latest article for The New Yorker, he writes about the benefits of “Big Medicine,” anticipating that hospitals will increasingly give out medical care to patients as The Cheesecake Factory gives food to customers—efficiently and with high customer satisfaction at a low cost. He rightly notes that medical facilities are moving in this direction, citing Partners Healthcare and its competitors (Care Group and Steward Health Care System) as examples of large healthcare chains overtaking community-based hospitals. And this change makes sense, given that this increase in scale lowers costs while offering hospitals access to the up-to-date (expensive) technology we have come to rely upon. However, patient care would be better improved without the formation of these conglomerates, and without perpetuating our problematic reliance on medical interventions to fix personal, multifaceted problems.

Though Gawande mentions possible problems involved with the growth of large healthcare chains, these significant issues are mentioned only cursorily—and there are still others left unsaid. As he mentions, there is the significant problem of the savings from Big Medicine being reserved for the few, contributing to the ever-widening gap between the rich and the poor. As hospital chains expand, they will gain power over individual health care employees and patients, who will have trouble finding employment opportunities or services elsewhere (should they so desire). And they may want to if employees are treated similarly to the “frontline worker” Gawande mentions, who follows exact orders—creating the successful outcomes he touts—without reaping any of the financial benefits.

Having set standards of care, and people like Christina Monti (the Steward tele-I.C.U. nurse) checking in to make sure they are followed, is more than an annoyance; it may change the way health care professionals think for the worse. In “Don’t Fear The Cybermind,” a recent New York Times opinion piece, Daniel Wegner (professor of psychology at Harvard) explains how human minds remember only information that they alone are responsible for: his wife remembers where house things are while he remembers where care and yard things are, and they rely on each other to fill in individual deficits. He uses this evidence to describe how our computing devices help us to specialize, rather than hampering our capacity for storing information. But I wonder how it applies to jobs in which people are intently supervised. If doctors know someone else is checking to make sure everything is done properly, will they (intentionally or not) be less diligent and more careless? Who will ultimately take responsibility for ensuring patients are tended to? While having safety checks in place is a good thing (especially in vulnerable patients), if they come at the expense of initiative and thoughtfulness in those personally administering the care, they aren’t serving their purpose.

More important than hiring outside administrators to ensure procedures are followed is determining what mistakes are being made, and preventing them. If the issue is one of attentiveness, one fix would be to follow the advice outlined in Gawande’s The Checklist Manifesto: How to Get Things Right: have every employee write down a list of tasks to complete before, during, and after entering a patient’s room (a list that could be evaluated and updated at set intervals to ensure that it was up to date). If long term problems are due to employees avoiding inconveniences in place of caring for patients (another problem Gawande mentions), then employee training and workplace culture must be altered considerably.

The incentive to adapt and improve practices would be much stronger if patients could make informed decisions regarding where they sought care, and took responsibility for their own health. For example, what if patients had access to information regarding the possible hospitals and doctors they could visit prior to making an appointment? People other than Gawande’s mother should be able to select a talented doctor that matches their needs. Granted, the information sharing would have to be done carefully, so as not to unjustly inflate the successes of physicians practicing in wealthy areas on patients with fewer concurrent issues. And the focus should be on finding a doctor that matches a patient’s needs and priorities—maybe someone with experience in integrative medicine for someone interested in complementing traditional Western medicine with Eastern practices, for example—rather than on constant, unjust questioning of doctors’ capabilities. But with patients (and their families) more involved in their care—aware of their needs and willing to hold care teams accountable for meeting them, or else seek them elsewhere—these workers may be more motivated to make important improvements.

Please don’t equate my promotion of patient empowerment with requiring hospitals to achieve high “customer satisfaction,” as though healthcare is comparable to a business abiding by the Golden Rule “the customer is always right”. The fact is patients often aren’t right: they want to be able to eat before a procedure, even if it requires fasting for several hours beforehand; and they want enough medication to feel no pain, forgetting that pain is an important gauge of the body’s internal state and functioning. And some people are just more content than others, who (especially in stressful circumstances) may be prone to finding issue with everything and anything. To ask hospitals to please these people is to ignore what they were hired to do in the first place: to heal patients, even if at the expense of temporary discomfort. Though doctors would do well to listen to their patients—and some empathy and reassurances couldn’t hurt either—patients should also trust their respective doctors; the patient-doctor relationship is just that—a relationship.

This discussion of patient involvement leads to a larger discussion of patients’ role in their health—something fundamental to Gawande’s piece that is never addressed explicitly. When someone goes to The Cheesecake Factory, they choose to order whatever they please, whether or not the choice is good for their health. They may enjoy this freedom, and I don’t doubt that the food tastes good, which is certainly pleasing. But using this scenario as an analogy for healthcare is problematic. Healthcare isn’t about delivering patients what they want (though some would argue with me here); it is about facilitating healing and promoting health. Many people want to look and feel young indefinitely—a desire that is not only unachievable, but also works against their ability to deal realistically with the natural evolution in their capabilities that comes with age. Many people also want quick fixes to their problems, choosing to take medication for their chronic fatigue and stress-related diseases rather than work to improve their quality of life. Some want more than they need—more scans, more medications, more attention—while others (out of stubbornness or fear) avoid seeking out help. The doctor’s role is to recognize these differences in desires and behavior, and to work with each individual to improve their health appropriately.

The Wikipedia page for The Cheesecake Factory includes a category labeled “Controversies,” in which is written the following: “The Cheesecake Factory has been criticized for their heavy promotion of large servings of high calorie and high fat foods, and a corresponding lack of healthy menu options. For these reasons, the chain was dubbed the ‘worst family restaurant in America’ for 2010 by Men’s Health magazine. The average sandwich at the restaurant contains 1,400 calories.” People have the right to consume however many calories they choose, and to eat wherever they please. But, as this controversy demonstrates, catering to people’s immediate, instinctual desires (i.e. good tasting, inexpensive food) can have negative consequences in the long term. The Cheesecake Factory isn’t meant to engage in conversation with its customers about the potential issues resulting from their choice of menu item—that’s not why customers choose to eat there, and that’s not their role. Healthcare professionals are.