If Doctors Can Do It...?

Last week I tweeted out the arrival of Atul Gawande’s recent New Yorker article about what the medical industry could learn from the restaurant chain called the Cheesecake Factory, suggesting that maybe there were things that the education industry could learn from the article as well.  If you’re anything like me you’ll experience recognition, rage, and some sense of what the education debate is missing when you read the full piece -- some of which is below.

“Our costs are soaring, the service is typically mediocre, and the quality is unreliable. Every clinician has his or her own way of doing things, and the rates of failure and complication (not to mention the costs) for a given service routinely vary by a factor of two or three, even within the same hospital.”

First and foremost, Gawande’s description of the struggles the health profession has had in improving and equalizing outcomes – and the slow pace of change — will ring familiar in the ears of anyone who’s been around the education issue for more than a few days.  Even in an environnment in which there are conclusive studies and centralized recommendations for best practices (around preventing migraine headaches, for example), doctors and hospitals still don’t do what they would, ideally, do — or at least not for a long time afterwards.

“Physicians were always predominantly self-employed, working alone or in small private-practice groups. American hospitals tended to be community-based…The consequence is the system we have, with plenty of individual transactions—procedures, tests, specialist consultations—and uncertain attention to how the patient ultimately fares.”

Nearly as familiar will be the stories of resistance, active and otherwise, from practitioners who consider themselves to be autonomous (and indeed worked independently for many decades) and don’t want to be supervised, managed, or even tracked — and the resulting inefficiencies, enraging bureucracies, and lack of care that can result.

Says one of the characters whose mother has just gone through an infuriating hospital visit” “It is unbelievable to me that they would not manage this better,” Luz said. “I’d study what the best people are doing, figure out how to standardize it, and then bring it to everyone to execute.”

“Customization should be five per cent, not ninety-five per cent, of what we do,” says another of the characters in Gawande’s story.

It can seem almost childish, the “don’t tell me what to do” mentality that’s seen in medecine and education, given the vulnerabilities of children and patients and the ostensible goal of service to others, but it’s real and has to be addressed.

The political issues aren’t all that different, either:

“For the changes to live up to our hopes—lower costs and better care for everyone—liberals will have to accept the growth of Big Medicine, and conservatives will have to accept the growth of strong public oversight.”

But not all is hopeless, at least in health care reform.  A handful of group practices and networks have revamped their treatment protocols with great results in terms of costs and outcomes — setting clear standards for results but leaving practitioners some wiggle room.

“To prevent revolt, he learned, he had to let them deviate at times from the default option. Surgeons could still order a passive-motion machine or a preferred prosthesis. “But I didn’t make it easy,” Wright said. The surgeons had to enter the treatment orders in the computer themselves. To change or add an implant, a surgeon had to show that the performance was superior or the price at least as low… About half of the surgeons appreciate what he’s doing. The other half tolerate it at best. One or two have been outright hostile. But he has persevered, because he’s gratified by the results.”

Ditto for the Cheesecake Factory:

“The instructions were precise about the ingredients and the objectives… but not about how to get there… There might be recipes, but there was also a substantial amount of what’s called “tacit knowledge”—knowledge that has not been reduced to instructions.”

What makes this all have any chance of working, according to Gawande, is the presence of a knowledgeable supervisor — a former practitioner now tasked with watching his or her former colleagues and praising and prompting them throughout the day. Both the hospitals and the restaurants have them. (There’s also some high-tech remote supervision being tried .)

Of course, closer supervision of practitioners is a delicate business, as Gawande makes clear, and neither restaurants nor hospitals have (most of them) wholly unionized workforces. But shared efforts, and group responsibility, seem necessary.  It makes me sad there’s so little of it we read about in schools, or that it’s so occasional rather than common.

Cross-posted from TWIE.


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  • Essentially the author has made an analogy between hospitals and the Cheese Cake Factory. Alexander is right that if this analogy were to hold up that a second could be made with our educational system (what Alexander tellingly calls the "education issue" whatever that is). A simple mapping of the analogy is that the hospital is like the restaurant, the doctors are like the chefs, the hospital admin are like the restaurant management, making each dish is like providing medical services, etc.

    One inference that is supposed to be drawn from this analogy is that the management style that has made the Cheese Cake Factory a successful chain is the same one that should be employed to make hospitals successful. Now with every analogy there are inferences that hold true and others that don't. The crux of using an analogy is being able to identify which inferences hold up and which don't. The author (and Alexander) have missed on this step. While, it could be said that these industries provide services the products and raw materials are so different that inferences made from their similarities are necessarily very limited.

    Regardless of the technicalities of analogical thought I still think there are some major issues translating this article over to education. While medicine (and the dishes at Cheese Cake Factory) might be 5% customization and not 95% I'm not sure the same can be said for education. While every patient has a different medical history doctors are dealing with the human body, which can be broken down into chemical reactions and biological processes. In education we're dealing with the human mind. It's like saying that 95% of a psychologist's practice should be standardized, which I think is pretty clearly absurd. In addition to dealing with the mind educators teach in a social context each of which is different from the next.

    While, I'm certainly not saying that improvements cannot be made to education I don't think that making the classroom more like a factory is the answer.

  • In some fields of medicine the analogy is pretty good. How one accomplishes some steps may be different from patient to patient, but the steps themselves can be pretty standardized. Here's an article on the issues around adoption of checklists: http://ccforum.com/content/13/6/210/. One can see how the issues described around development and adoption would play out in education.

    Yes, education is complex. Yes, attempts to describe best practices and quantify outcomes are difficult. That doesn't mean we shouldn't make every effort to do so.

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