There is in fact a consensus out there. The consensus is that health care costs are too high, and rising too rapidly. But the consensus evaporates with the question of how to fix it.
One man who has thought a lot about this is Atul Gawande. Dr. Gawande is a surgeon, he teaches surgery at Harvard Medical School, he led the Surgical Task Force for the World Health Organization (he developed the surgeon’s check list), he is a regular contributor to the New Yorker, and he is a Macarthur Fellow (commonly called the “Genius Grant.”) So, he has hefty credentials. (I presented my synopsis of his terrific book The Checklist Manifesto at the First Friday Book Synopsis back in April, 2010).
He writes important long-form pieces about health care regularly. Among his best was a look at why McAllen, TX has the most expensive health care in the country: The Cost Conundrum: What a Texas town can teach us about health care. And he has this must-read piece on the Supreme Court Decision regarding the Affordable Care Act (“Obamacare”). It includes this really insightful section:
In 1973, two social scientists, Horst Rittel and Melvin Webber, defined a class of problems they called “wicked problems.” Wicked problems are messy, ill-defined, more complex than we fully grasp, and open to multiple interpretations based on one’s point of view. They are problems such as poverty, obesity, where to put a new highway—or how to make sure that people have adequate health care.
They are the opposite of “tame problems,” which can be crisply defined, completely understood, and fixed through technical solutions. Tame problems are not necessarily simple—they include putting a man on the moon or devising a cure for diabetes. They are, however, solvable. Solutions to tame problems either work or they don’t.
And he ends this piece this way:
Beneath the intricacies of the Affordable Care Act lies a simple truth. We are all born frail and mortal—and, in the course of our lives, we all need health care. Americans are on our way to recognizing this.
One reason he is such a helpful and important author is that he learns from everywhere. We live in an “everything is connected, learn from everywhere” world, and yet so few of us actually learn from outside our own narrow slices of the world. Dr. Gawande learns from a much broader swath of the world than most of the rest of us.
Dr. Gawande is observant, curious, and determined. I suspect that he walks up to people (as he did to the manager of the Cheesecake Factory where he ate a meal), and says, “look, you may not have time for me, but I think a bigger world needs to learn from what you do. Will you show me? Will you teach me?” In The Checklist Manifesto, he described successful checklists from surgeons, and pilots, and chefs, and construction project supervisors, and…. He learns from everywhere!
And, right now, our health care system needs to learn from anywhere and everywhere. This article reminded me of an example/story in Practically Radical: Not-So-Crazy Ways to Transform Your Company, Shake Up Your Industry, and Challenge Yourself by William C. Taylor, where he describes how a health care company in the Pacific Northwest takes a group of executives and team leaders to a Toyota plant in Japan to watch the way they make cars.
So Dr. Gawande’s latest is: Big Med: Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care? This short blog post will not be enough. I urge you to read his article, and think not only about our health care challenges, but about this question: “what can I learn from somewhere outside my narrow circle?”
Here are some excerpts of this wonderful essay. First, his description of the Cheesecake Factory:
The place is huge, but it’s invariably packed, and you can see why. The typical entrée is under fifteen dollars. The décor is fancy, in an accessible, Disney-cruise-ship sort of way: faux Egyptian columns, earth-tone murals, vaulted ceilings. The waiters are efficient and friendly. They wear all white (crisp white oxford shirt, pants, apron, sneakers) and try to make you feel as if it were a special night out. As for the food—can I say this without losing forever my chance of getting a reservation at Per Se?—it was delicious.
Now his curiosity and inquisitiveness kicks in:
I wondered how they pulled it off. I asked one of the Cheesecake Factory line cooks how much of the food was premade.
And then, the problem he seeks to answer:
I’d come from the hospital that day. In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how. 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.
I’m thinking a lot about problems these days. I have a few myself… I just presented my synopsis of The Goal by Goldblatt, and the book pretty much says one thing:
figure out what your problem is, then fix it.
Goldblatt labels the “big” problem the bottleneck, and offers a path to follow to fix your problems. And, by the way, he seems to argue that many (most?) problems are not equipment or software problems, but process problems. That seems to be Gawande’s discovery also.
The successful people in the world do not attain their success because they never have problems and challenges. They have them. They just know how to identify them, and then fix them – and then, to find the next one and fix that one too.
So, I encourage you to read this Gawande article to learn about our health care challenges. But also, to learn how to find, and face, and tackle, and solve your own problems and challenges.
He ends his essay with this:
The critical question is how soon that sort of quality and cost control will be available to patients everywhere across the country. We’ve let health-care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous. The Cheesecake Factory model represents our best prospect for change. Some will see danger in this. Many will see hope. And that’s probably the way it should be.
We’ve all got problems to find, problems to solve. Let’s get to it.
First Friday Book Synopsis 