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Archive for the ‘Ethics’ Category

Saturday, December 7th 2013

Novel Treatments

The history and evolution of novel clinical research is interesting. The old ideal, “Don’t think; try is, perhaps rightly tempered by the new ideal of not just the informed and consented patient but protected patient. Such is interesting considering our move, otherwise, away from paternalism.

The development of the smallpox vaccine or the first artificial heart would have never happened today as is. Of course, neither would these horrific syphillis experiments hopefully.

Not to argue that IRBs and government agencies have made clinical research too burdensome and are hampering progress.

It’s just that a focus and regulations beyond guaranteeing informed consent seems counter to the way the rest of medicine is moving.

I’m not sure many are arguing three glioblastoma multiforme patients of Drs. Muizelaar and Schrot were at UC-Davis were ill informed. But the treatments they undertook for those patients, without approval, have cost both men their jobs. Dr. Muizelaar was in fact chairman of Neurosurgery at UC Davis prior to this scandal bringing him down.

I’ve covered this previously. But with both men resigning earlier this year its worth bringing up again now that we have some resolution.

Two UC Davis neurosurgeons who intentionally infected three brain-cancer patients with bowel bacteria have resigned their posts after the university found they had “deliberately circumvented” internal policies, “defied directives” from top leaders and sidestepped federal regulations, according to newly released university documents.


The most contentious issue between the doctors and the university – and even within the university – was this: Were the surgeons performing research? Or were they providing “innovative care?”

Research on humans is tightly controlled in the United States and, according to federal regulations and university policy, must undergo a rigorous approval process to ensure that participants are protected from harm. Innovative treatment, more commonly known as compassionate care, gives a doctor more latitude in offering nonstandard care to a single patient where evidence of safety or success is limited.


Muizelaar and Schrot called their novel approach “probiotic intracranial therapy,” or the introduction of live bowel bacteria, Enterobacter aerogenes, directly into their patients’ brains or bone flaps. The doctors theorized that an infection might stimulate the patients’ immune systems and prolong their lives.

The first patient lived about 5 1/2 weeks. The second survived another year, an outcome that buoyed the doctors and seemed to bolster their theory, they said.

The institutional trouble began in March 2011, when a newly diagnosed third patient developed sepsis, became unresponsive and died two weeks after being deliberately infected. The university’s first internal investigation soon followed.

What they did was highly unethical and dangerous.

But I have trouble with this paternalism later in the article,

“I think sometimes surgeons and doctors can get caught up in the enthusiasm for what they really believe is going to work,” said Caplan, head of medical ethics at New York University’s Langone Medical Center. “That is exactly why we have FDA oversight and approval and the research ethics requirement we do.

“Every time somebody dies or is injured or we have to recall a product, what we find ourselves saying is, there is no short-cut to innovation,” he said. “Finding the truth is a long, slow, arduous process.”

Informed consent for novel treatments can be difficult. “Informed” consent for proven standard of care is difficult. But maybe the focus should be on that and not necessarily on impeding access to even highly dangerous and unproven treatments.

Wednesday, October 23rd 2013

Healthcare Of The Rich & Famous

People sometimes try to generalize the care that famous people receive. There’s been some controversy after Angelina Jolie revealed she was BRCA positive and opted for a double mastectomy. Another example might be when other patients try to rush back to imitate the rehab of a professional athlete.

Or when we look to the care received by Presidents.

If even our most prominent and well-connected citizens can’t get the best evidence-guided care, where does that leave the rest of us? Though doctors are some of the most hypereducated professionals around, they frequently don’t deliver care that has stood up to the most rigorous research.

I would argue though that often times patients don’t want evidence-guided care however. They want the hi-tech and most informative care; the care they saw on television.

Evidence-based care is for the population as a whole. If you do it for everyone the population sized outcomes will be better. But patients are individuals and they have trouble understanding in terms of such epidemiological measures.

No that cardiac CT scan likely won’t change our individual outcome and there are low risks. But we want to know what it shows and what it adds to the prognosis and in the off chance we’re one of the unique where it finds something.

No this microdiskectomy with two weeks of pain won’t lead to a better outcome at a few months compared to being conservative but we want the chance of relief now.

I’m not sure that sometimes it’s a matter of better informed consent or communication with patients. Not just sometimes but perhaps often patients perceive more as better and no office visit or computerized informed consent it going to disuade that.

Wednesday, October 23rd 2013

Empathy In Medical Training

I think I lost some empathy during medical school when I started my clinical rotations. There’s some evidence I’m not alone in the literature. Danielle Ofri has written a book on physician empathy and what it means for patients. And she’s commented on the loss of empathy during the third year of medical school over at Slate,

Students are not just learning medicine during the third year of medical school; they are learning how to be doctors. Despite the carefully crafted official medical curriculum, it is the “hidden curriculum” that drives the take-home messages. The students astutely note how their superiors comport themselves, how they interact with patients, how they treat other staff members. The students are keen observers of how their supervisors dress—and how they may dress down those around them. They figure out which groups of patients can be the object of sarcasm or humor, and which cannot.

On a daily basis, the students witness fear, anger, grief, humiliation—in patients and doctors alike—all of which are largely unacknowledged. They see egos rubbing up against each other, hierarchies at play, bureaucracies in action. They observe that many of the niceties of patient care fall prey to the demands of efficiency and high patient turnover. Much of what they learned about doctor-patient communication, bedside manner, and empathy turns out to be mere lip service when it comes to the actualities of patient care.

It’s no wonder that the third year of medical school figures prominently in studies that document the decline of empathy and moral reasoning in medical trainees.

Very true. A first year medical student is something more optimistic and bright eyed than most attending physicians and these initial years of clinical training seem to play a lot into that change.

While it seems to level off in the evidence as physicians go through training, I personally have found empathy a difficult thing to preserve. I imagine much of that has to do with the patient populations I’ve worked with, especially early in my training.

Like many interns and residents my early training has dealt with individuals often times with significant social stresses, poor socioeconomic factors, poor medical compliance and poor health literacy. There are many self inflicted health problems. These can be frustrating interactions for any physician, especially new ones.

But what perhaps is more unique to my training and has perhaps dealt my empathy a larger blow is the trauma population I’ve cared for. I spent the vast majority of my early years of training a the large trauma center for a sizable encatchment. It is one thing to see patients do harm to themselves by refusing to comply with medical advice or by daredevil stunts that end in injury. That is trying enough. It is, at least for me, considerably more stress on my optimism and faith in humanity to see people injure others either intentionally or even by negligent stupidity.

And while it must not be the case, it always seems those at fault get the easy end of it and the innocents take the brunt of the injury. That drunk driver has some contusion he’s going to be fine from it always seems; it’s that nine year old in the car he hit who is struggling.

Empathy is tough to preserve during the early years of training; especially really early in that third year of medical school. But it’s important and schools are starting to pay more attention to such and trying strategies to try to preserve it in their students and trainees. I know those programs are going to grow and I think they’re worthwhile.

Tuesday, October 22nd 2013

Bias & Poor Communication Skills

Patient advocate Steve Wilkins has an interesting personal story up at his blog Mind The Gap. It is really worth a read.

In short he reports poor communication and planning with several physicians who appeared to hold a relatively poor opinion for his wife’s future with recurrent NSCLC.

It sounds like really terrible communication between multiple physicians and his family.

He promised to discuss the biopsy options with my wife’s oncologist the next day and call us with the “game plan.” The doctor never called us back.

He reports his wife is improving back on a tyrosine kinase inhibitor, despite some of the physicians they saw seemingly having reluctance about further treatment.

But I’m not sure their anecdote speaks to a failure based on bias. I would argue what comes across as a bias in this story is really physicians doing their job. Here is what he says about the ordeal,

Physicians need to be aware of the fact that they both bring pre-existing attitudes and biases to the office visit…and check them at the door. These attitudes and beliefs color the decisions clinicians make.


Lung cancer that presents as a bad cough is like a red flag to a bull. It invokes a whole set of assumptions about…the person’s odds of survival – slim to none.

You have to wonder how many people’s lives are cut short or whose care is not what it should be simply because their doctor jumped to the wrong conclusions.

But physicians are supposed to prognosticate and that’s supposed to help drive the discussion. Advanced, recurrent adeno does have a poor prognosis. It seems to me a thoracic surgeon should seriously question the utility of a risky, painful, invasive procedure and have a discussion on the merits of such. Similarly for an oncologist discussing chemotherapy; even chemotherapy as comparatively well tolerated as erlotinib. These discussions don’t appear to have happened appropriately and that seems to be the failure of the story. Prognostication is imperfect but I don’t think though that represents a bias or something inappropriate in these settings.

Beyond “people’s lives…cut short” by “wrong conclusions” plenty of cancer patients in this country get aggressive treatments that offer extremely poor chances of contributing to their survival or quality of life. These treatments often have side effects and consequences including hastening death if by no other means than by lowering functional status (which is something strongly associated with survival). I would argue in my neurooncology experience probably far more people get unnecessary, overtreatment than don’t get the care they should based on biases.

Monday, September 30th 2013

Cancer Patients Don’t Understand Palliative Therapies

Often times as neurosurgical residents we’re asked by faculty why we would (or wouldn’t) operate on patients. Therapies for cancer can have different goals. You, hopefully, don’t operate just because a brain tumor is there. Often times, surgery for malignant tumors that cannot be “completely” resected – in which a gross total resection cannot be achieved – has limited influence on cure or survival rates. I’m not a big fan of the idea of cytotoxic reduction.

In general then surgery can have any of three goals. It can have an oncological goal – if the tumor can be resected to a degree to influence survival. It can have a palliative goal – if debulking the tumor will relieve symptoms. It can have a diagnostic goal – if getting tissue will identify the tumor so that other treatments can be initiated.

Non-invasive therapies, such as chemotherapy or radiation therapy, can similarly have either an oncological or palliative goal.

All of these therapies can have significant morbidity and side effects and so the decision to undergo therapies merely as a matter of palliation should not be taken lightly. In many cases you can exchange current symptoms for other symptoms or increased risks associated with therapies.

Such makes a study published in the Journal of Clinical Oncology even more discouraging. In the study more than 380 patients with essentially terminal lung cancer with neuro or bony metastasis were surveyed as they underwent radiation therapy. The radiation therapy was solely a palliative therapy to relieve symptoms. And yet,

Seventy-eight percent of patients believed that RT was very or somewhat likely to help them live longer

The therapy was only palliative and had no oncologic goals and no hope of improving survival.

Sad stuff,

Twenty percent of the patients expected radiation treatments were “very likely” to cure their cancer

Its tough to relate these complex ideas to patients when there is such a disparity in information. Often times, in my experience, prognosis is discussed in vague terms. “This is not a curable disease,” or things along those lines without discussion that this is actually going to be fatal or discussion of numbers in terms of survival or what progressive symptoms and quality of life are likely to look like. Difficult discussions no doubt. But without such discussion it seems impossible to fully explain things like palliative therapy.

Monday, May 27th 2013

Does It Matter Where You Die?

Injury to the brain continues to be a unique thing in medicine. These injuries are scary and unfamiliar to many health care providers. There is a finality to them. Their consequences are hidden a little bit; the asystole is easy to figure in the emergency room but the suppression and brain death isn’t something so easily recognized.

They’re what you might imagine, along with polytrauma, as poster child conditions for tertiarization and transfer to a higher level of care.

In truly catastrophic injury to the brain however, I’m not sure that’s a good thing.

My institution has had a small discussion lately on just what ethics and the law requires of us as a place with full neuro specialty coverage.

I’ll make up an example:

A 61 year old man comes into a small community hospital’s emergency room. He was found down at home by his wife and last seen normal four hours previously. He wouldn’t wake up and he was breathing slowly and shallowly. The ambulance crew intubated him. In the emergency room his pupils are large and don’t react to light and he doesn’t do anything when the doctor hurts him. He’s in a very deep coma. If the physician working the emergency room felt comfortable doing a brain death exam, which he doesn’t, the patient might have some very primitive reflexes left but his condition is very serious.

A CT scan of the head is performed and shows a large bleed within the brain.

The bleed was probably caused by high blood pressure. In reality however, the patient’s condition is essentially terminal and the cause of the bleed isn’t important at this point.

The small hospital has an intensive care unit and an open bed. It however has no neurosurgeons, nor indeed even neurologists who round at the hospital. And so the physician in the emergency room starts trying to transfer the patient to a hospital where a neurosurgeon can see the patient.

There are really two issues here. The first is a legal issue concerning a law called EMTALA. EMTALA is a law that dictates transfers for higher care amongst hospitals that accept Medicare (virtually all hospitals). In very broad terms it puts responsibilities and requirements on both the hospital trying to transfer the patient and the hospital that might accept the patient. The former has a responsibility to stabilize a patient. They cannot refuse care in an emergency as a matter of lack of payment or inquire about payment prior to treatment to stabilize. Nor can they transfer a patient after stabilization merely as a matter of lack of ability to pay. The latter has a non-discrimination requirement, that specifically reads,

A participating hospital that has specialized capabilities or facilities (such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers as identified by the secretary in regulation) shall
not refuse to accept an appropriate transfer of an individual who requires such specialized capabilities or facilities if the hospital has the capacity to treat the individual.

Case law on the non-discrimination provision is scarce but in catastrophic injury, where no specialized intervention will alter the course of the patient’s condition, I would argue that the patient doesn’t require specialized care. And not merely cases where the patient is brain dead at the time of the transfer request but also in situations where brain death is inevitable or the condition is otherwise not survivable. The patient and family can proceed to comfort measures at any hospital, there is no specialization about such care.

The second issue is an ethical one. Do hospitals with specialized capabilities owe something to patients and families to transfer as a matter of finality and closure. In that we’re saying, “Watch, we did everything we could…”?

While I’m somewhat empathetic to such an argument I have trouble with it. I think it reflects a problem in both the expectations we have of health care as patients and how physicians are trained to deal with end of life. Really it is a shame for physicians to come out of training without basic palliative and communication skills. Even the physician in the small rural emergency room should have such a skill set. The capability to have an end of life discussion with families, even if the medical issue falls somewhat outside their scope of specialty.

I’m also somewhat disappointed in how some referring physicians appear to place priority in getting the patient off their hands over the patient’s well being. I’ve had cases where even after discussion with the consulting physician at an outside hospital and having seen the films and described in no uncertain terms to the other doc that the injury is not survivable that they continue to press for transfer.

I may be wearing blinders here but, and I think much of this is subconscious, I can only draw a single conclusion from such arguing. The continued pressure to accept the patient in transfer, after I’ve explained there is nothing to do for them, is a condemnation of my analysis of the situation. They’re basically calling into question my competency; my faculty’s compentency.

And I’m okay with that in the sense that I’m not going to take offense. What I have trouble with is they’re now trying to transfer their patient to a consultant who they don’t think is competent.

I don’t know how they can have the patient’s best interests in mind and work to transfer them to another physician they’ve basically said they don’t trust.

The issue gets more complex of course and I could continue writing. What if the patient was 6 months old instead of 61 years but the situation, in terms of the finality of the condition, remained the same? How many physicians on the line at the accepting hospital are literally too lazy to accept the transfer and work for any reason not to?

In general however, in an honest physician-to-physician phone call, with terminal conditions, where nothing will be done at the accepting hospital, no matter the patient’s age, I’m not sure transfer is a good thing. It significantly contributes to costs, provides false hope and contributes to our societal expectations at the end of life.

Monday, May 20th 2013

Financial Toxicity In Cancer Care

I wouldn’t know what to tell patients if they raised the issues of the cost of care. Let me correct that, I don’t know what to tell them. Questions like: “How much will this cost?” or “Are there any resources to help pay for this?” do come up in my patient encounters. I can do little more than shrug ignorantly and suggest a call to the social worker on the floor or in the clinic.

Now some limited research out of Duke looks at how discussions about cost in oncological care impact such,

The people who did talk about financial issues told the researchers it was helpful to do so. “They said it helped decrease their expenses,” Zafar says.


“I treat colon cancer, and I have the option of giving a drug as an IV or an oral pill,” he says. “If I give the pill form, the patient faces a copay even if they have insurance, and that copay goes away if I give the intravenous version.”


“We can’t necessarily give the best care to patients unless we address cost,” Zafar says.

Cost and the taboo about discussing such is obviously an obstacle to care. I wish I was better informed on resources for my patients. I’ve grown better over the course of my training but still feel pretty impotent in pointing them in the right direction.

Monday, May 20th 2013

Your Robotic Surgery Costs More, Doesn’t Get You More

Robotic surgery has been a marketing point for plenty of hospitals across the country. Topping the list is the da Vinci surgical system used primarily in urologic and gynecologic surgeries and some cardiac surgeries. But these systems are expensive, costing nearly 2 million dollars. And the benefits of such, as compared to traditional minimally invasive surgery, such as with laprascopy, is highly questionable.

The surgery is “minimally invasive,” and there is some small evidence, although hardly uniform, that they may be an easier thing to learn than laproscopy. For some procedures, notably prostatectomy, the robot offers the only “minimally invasive” option. But the growth in robotic surgery, and where manufacturer’s are marketing are in procedures with other, cheaper, minimally invasive alternatives.

There is hardly an obstetrician/gynecologist or urologist or general surgeon graduating training in the western world today without extensive laprascopy experience. Heck, after a single year of general surgery, which I’m now well removed from, I almost feel comfortable taking out a gallbladder with a scope. Not that that’s comparative in difficulty to a hysterectomy with a scope (which may be why there hasn’t been a splurge for using the robots from cholecystectomies…yet) but you get the idea. I’m not sure the increased costs associated with robotic surgery can be excused as allowing a subset of older surgeons to easily expand their limited minimally invasive repertoire.

The benefits of robotic surgery have simply not been born out in the literature. See here and here and here.

Robotically assisted and laparoscopic hysterectomy had similar morbidity profiles, but the use of robotic technology resulted in substantially more costs.

The growth in these procedures is being driven largely by marketing. Marketing to providers and directly to consumers. The technology is presented as ideal for “unique” cases. But such obviously is silly. As a patient, my future or your current “unique” case, has been well represented in the studies.

Given my particular health history and current diagnosis, and based on the reading I have done and my consultation with my oncologist, I believe that da Vinci is likely to bring some genuine benefits to my situation. Not only will the surgical incisions be small (minimally invasive), easing my recovery significantly, during the procedure, as this ABC News video shows, the robot’s dexterous mobility and 3D visualization will offer heightened precision. Dr. Irvin has called da Vinci “a quantum leap” forward in treating gynecological malignancies, and that sounds good to me.

Such does little more that contribute to America’s ridiculous health care spending.

I do see a final benefit to this wide adoption. There’s a very legitimate chance that this technology will evolve and improve into systems that truly have benefits. The da vinci may be a precursor to automation or something. Adoption and support obviously make further research and investment possible. But I’m not sure even that’s an adequate excuse for the wide adoption. Maybe skip picking whose going to do your mitral valve replacement based on a billboard for now.

Saturday, January 12th 2013

Culturally Competent Care In A Rush

Providing culturally nuanced medical care is held up, sometimes, as a right of patients and a goal that should be paramount in medical care; even with all else that needs attention. Sometimes the emphasis on culturally component care is stressed to a laughable degree. As if a physician practice, without a significant east African patient population, should have immediate access to an in person female Somali speaker, of the same dialect as the patient,

Though the state requires all medical providers to offer translation, current services fall short. Most rely on special phone lines for translation, which are based out of state and offer little control over the gender (Muslim women prefer female translators) and dialect of the translator.

Even with phone services available, a slapdash approach to translation is the status quo. Providers and patients often rely on neighbors or children, who cannot legally act as interpreters in California.

I’m not saying culturally component care isn’t important. Although the term is broad, it leads to better outcomes through better communication and better patient compliance with therapy. But there is obviously a limit to what can be achieved in most of health care within reason and examples like the above show a naïveté amongst proponents of such care.

Then of course, there are examples of the opposite.

I train in a city where more than half the population speaks Spanish as a first language. Obviously that figure is likely even more impressive for the specific population served by the county hospital. The encatchment area of the hospital extends into territories where the prevalence of Spanish is even more complete. Many of these patients do not speak English in addition. And while translation services are often relatively easy to maintain the established process is haphazard and in more than one instance has failed.

This story has obviously been changed substantially but I think it is in line with some recent experiences which have frustrated me.

I had a patient recent who needed a neurosurgical procedure. He was an inpatient and it was my first time meeting him and his first time meeting a neurosurgeon; their was no established repoire or understanding about what we were about to discuss. He was a Spanish speaking only gentleman with no family. He had had extensive, destructive sinus surgery which had made him nearly unintelligible in speech at times. While the surgery wasn’t urgent, there was an opportunity it done the same day and move the patient’s care along. That obviously depended on, most importantly, discussing such with the patient.

So, after my halting introduction of myself in Spanish, knowing I was over my head I went to his nurse, who did not speak Spanish, and asked if he could help me find someone to translate. He rather unhelpfully, but not rudely, merely offered up a name of a tech who was on the floor who could translate. So I went to the front desk and inquired for the tech with the clerk, who not having seen him recently paged him overhead to the patient’s room. I went back and waited awkwardly with the patient. No one showed. Back to the clerk I went and inquired again. This time I asked for the charge nurse who the clerk promised to find and in the meantime she suggested I use the translation phone that exists on every ward and unit. While trying to explain that the patient’s speech was garbled, I still took the phone while I waited. I set up the phone and dialed in and the translator on the other end did his best but essentially could not comprehend the great majority of the patient’s responses. At the end of my discussion and introduction of what I thought we needed to do next for the patient, with surgery, he offered up questions which were useless and devolved into me trying to read his Spanish writing over the phone to the translator. The patient merely shook his head finally, shrugged and said, I think, in English, “Is okay.”

During the conversation over the translation phone the nurse popped in again and left, on a journey he said to find a translator. He didn’t return with any haste.

The entire ordeal took perhaps twenty or thirty minutes. No doubt the institution failed. I’m not sure, serving a majority Spanish speaking population, that organized, readily available, in person Spanish translation can even be called something like cultural competency under such circumstances. It seems even better practice than that; a necessity. And yet here we are.

To be fair I could’ve done better. A surgical intervention is a major life altering point and thirty minutes looking for the appropriate translator was worse than my patient deserved. I should called up the line of command in my pursuit. But in house, with sixty patients under care and consults stacking up in the emergency room, real time pressure exists. Not that I got, say, four consults while I was talking to the patient, only that there are other pressing things that require attention. A reason; not an excuse.

Sunday, November 4th 2012

What Healthcare Can Take From Other Industries

As with everything Dr. Atul Gawande writes nowadays, his recent piece in The New Yorker has drawn some attention. In it Dr. Gawande asks what medicine can take from the efficiency and mass produced quality of chain restaurants, specifically The Cheesecake Factory restaurant.

Big chains thrive because they provide goods and services of greater variety, better quality, and lower cost than would otherwise be available. Size is the key. It gives them buying power, lets them centralize common functions, and allows them to adopt and diffuse innovations faster than they could if they were a bunch of small, independent operations. Such advantages have made Walmart the most successful retailer on earth. Pizza Hut alone runs one in eight pizza restaurants in the country. The Cheesecake Factory’s major competitor, Darden, owns Olive Garden, LongHorn Steakhouse, Red Lobster, and the Capital Grille; it has more than two thousand restaurants across the country and employs more than a hundred and eighty thousand people. We can bristle at the idea of chains and mass production, with their homogeneity, predictability, and constant genuflection to the value-for-money god. Then you spend a bad night in a “quaint” “one of a kind” bed-and-breakfast that turns out to have a manic, halitoxic innkeeper who can’t keep the hot water running, and it’s right back to the Hyatt.

Medicine, though, had held out against the trend. Physicians were always predominantly self-employed, working alone or in small private-practice groups. American hospitals tended to be community-based.


Historically, doctors have been paid for services, not results. In the eighteenth century B.C., Hammurabi’s code instructed that a surgeon be paid ten shekels of silver every time he performed a procedure for a patrician—opening an abscess or treating a cataract with his bronze lancet. It also instructed that if the patient should die or lose an eye, the surgeon’s hands be cut off. Apparently, the Mesopotamian surgeons’ lobby got this results clause dropped. Since then, we’ve generally been paid for what we do, whatever happens. 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.


To most of us who work in health care, throwing a bunch of administrators and accountants into the mix seems unlikely to help. Good medicine can’t be reduced to a recipe.

Then again neither can good food: every dish involves attention to detail and individual adjustments that require human judgment. Yet, some chains manage to achieve good, consistent results thousands of times a day across the entire country.

In likewise fashion Sully Sullenberger, the US Airways captain who landed flight 1549 in the Hudson, has been making the rounds talking about how ideas from the airline industry can improve patient safety. Here is the proposal he has signed on in full (PDF).

The homogeneity and economies of scale improving health care efficiency and safety. And there’s something to that, so I feel bad knocking it but I doubt about the ability to standardize health care. There’s much to some of the examples Dr. Gawande gives, including standardizing operations; I’ll make only sarcastic mention, and ignore otherwise, that standardizing implants to reduce costs has the potential to reduce new entrants and innovations within that sphere of biotechnology. But other suggestions in Dr. Gawande’s work raise more eyebrows. We’re already seeing how little patients choose to use quality data readily available to them. THe vast majority of patients simply use just as much data, and the same type of data, in choosing a physician or a hospital as they do choosing a restaurant.

And as an op/ed in The Boston Globe notes, the efficiency of The Cheesecake Factory has some costs.

While the Cheesecake Factory may have developed a highly efficient and thus profitable business model, it seems to be one based on punitive labor practices. In California, Cheesecake Factory workers won a $4.5 million settlement with the chain for its widespread wage and hour law violations. It appears that the chain has not learned its lesson: A law firm in Tennesee is pursuing litigation on behalf of current and former servers at the chain. The complaint alleges that all across the country Cheesecake Factory servers have worked hours for which they have not been compensated or for which they have been paid “at rates less than one-and-one-half times their normal hourly rates, and/or for which they were paid below the minimum wage.”

Because of its continuing deficiencies in this area, the Restaurant Opportunities Centers (ROC), a nationwide restaurant workers group, gave the chain a very low rating in its 2012 “Diners’ Guide” to ethical eating. The guide named the Cheesecake Factory as one of the worst employers in the industry.


It is hard to consider the Cheesecake Factory’s record of process innovation while divorcing it from its product. Dr. Gawande, who has written about the costs of obesity-linked cardiac problems in some of his other writings, does acknowledge that the food at the Cheesecake Factory, ” was sweeter, fatter and bigger than it had to be.” At the same time, he lauds the chain for providing “goods and services of greater variety, better quality, and lower cost than would otherwise be available.”

There’s something to be said for checklists and standardizing processes but medicine isn’t the airline industry and it isn’t The Cheesecake Factory and changes towards making it more like such aren’t necessarily for the best, or more importantly, even in the best interests of patients.