Big (Box) Medicine?

Nov 6, 2014, 4:55 PM, Posted by

Items are mass produced in factory in China. Photo courtesy Cory M. Grenier, Creative Commons

Let’s see a show of hands. Who among us, doctor, nurse, patient, family member, wants to give or get health care inspired by a factory—Cheesecake or any other?


I didn’t think so.

True confession: I have never actually eaten at a Cheesecake Factory (hereinafter referred to as the Factory). My wife, Mary, and I did enter one once. We were returning from a summer driving vacation. Dinnertime arrived, and we found ourselves at a mall walking into a busy Factory.

It seemed popular. The wait was long—really long. We got our light-up-wait-for-your-table device. We perused the menu. There was a lot there. Portions seemed gigantic. We looked at each other and, almost without speaking, walked back to the hostess, returned our waiting device and left.

You got me—I cannot say 100 percent that I wouldn’t love Factory food. We were so close that one time!

A young woman in our small New Jersey town recently opened a new restaurant here. We tried it the other night. She and her business partner tended us and all the other patrons with such attention and care. We waited some, true, but she seated us near the bar while we waited and brought over pieces of cheese (no light-up device) for us to enjoy. The menu was ample and varied—not enormous. It’s also true that two items on the menu—including my first choice—were no longer available that evening. The chef, however, crafted the dishes that we did select with flare and pride. Dinner was a delicious, wonderful, relaxing experience, made better because of the human touch.

It’s probably not fair to contrast my one near-Factory dining experience with this other. Big chain restaurants have clearly figured out a way to provide a consistent meal for millions of satisfied customers. But the Factory way is not for everyone. People, I think, crave customized, attention-to-detail service experiences in their dining choices. And—I’ll go out on a limb—in their health care too.

Urban Institute fellow and renowned health care expert Robert Berenson MD recently interviewed Atul Gawande MD, The New Yorker writer, for an Urban Institute/RWJF brief, “Is Bigger Better? The Implications of Health Care Provider Consolidation.”Atul is an enthusiastic soothsayer for what he sees as the coming era of big medicine. In his popular New Yorker article published two years ago, “Big Med,” Atul cast his bright light on the virtues of the Factory as a model for health care. In this latest interview, Atul continues to carry the Factory flag. He observes that two years hence, we now have about 90 super-regional medical centers across the nation. These centers bristle, he says, with advantages like information systems and access to standardized measurement and improvement approaches—not bad things, of course. In the interview he also notes that “[w]e’re in the process of shifting from what I call ‘cowboys’ to ‘pit crews’ in medicine ...”

Hard to disagree that a shift to smart team-based care is a strong positive. The lone, isolated, unconnected physician working on his or her own providing care based on what he or she learned years prior, in school or in residency, is, thankfully, rapidly becoming a thing of the past.

Still, these are our choices? Lone, isolated, ill-informed cowboy-on-the-range care versus Factory care? I think there’s almost certainly another way.

I definitely get it. The Factory ideal is enticing. It’s a successful vision imported from the Industrial Age—i.e., the 20th century. But—brace yourselves—we are no longer in that century or age. We’re in a new one—a new machine age.

Think, for instance, about the waves disrupting or wiping away industries—cloud computing, disintermediation (e.g., video), unbundling of services (e.g., music, newspapers), the sharing economy (e.g., Uber, airbnb), new networking organizational approaches, democratization of knowledge (e.g., Khan Academy).

Consider the potential for customized care with predictive analytics, the range of new -omics data and the proliferation of health data from ever more sophisticated devices—not to mention the emerging power of DIY care from those same devices. Don’t forget the coming cognitive agents and artificial intelligence, robotics, and 3D printing. Incidentally, we’re just starting up the Moore’s Law-driven escalation.

The opportunities of our new age open novel ways, I believe, to improve care. We can create vibrant, joyful, human care relationships in small, intimate, connected settings, that also deliver informed, smart cutting-edge treatment when, where, and how people want it. One key aspect of our new age tools: They proliferate and get cheaper and better, year after year. That means that most of the exotic soon becomes commonplace. It may be ironic, but our new machine age is going to free us to reclaim our humanity. I fervently believe that.

At RWJF we are working on a range of projects exploring this sort of vision. Perhaps the most obvious is Flip the Clinic—essentially the anti-Factory. There, we’re inviting human beings to come together and explore what it might be like to co-create new caring relationships (not factories) fitting for the new age.

I understand. Many may find the Factory approach suitable, even desirable. That’s OK—the door for that is swinging wide open over there. If, however, you hunger for another way, you are not alone! Granted, the door this way is still a little hidden—you have to look for it a bit—but trust me, it’s there, and it’s big.