I Am Living Proof That Atul Gawande's Cheesecake Factory Missed the Mark When It Comes to Patient-Centered Care

The Checklist Manifesto

The Checklist Manifesto: How to Get Things Right is a 2009 book written by Atul Gawande,¹ a widely known and respected physician, who originally trained as a surgeon and has that special talent of bringing interesting takes to everyday life and work through analogies and storytelling. His central thesis in that book was that we should adopt more protocols (advanced versions of checklists) in health care for more consistency and higher quality care. The key to a better health care system is “applying the knowledge we have consistently and correctly,” Gawande wrote.² To his credit, many protocols and lists came to pass since his manifesto, largely in hospital care, that have no doubt saved many dollars and lives.

The Cheesecake Factory Analysis

In 2012, Gawande published an article in The New Yorker, titled, Big Med,³ which posed the question “Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?” Using the example of a conveyor belt approach to joint replacements and remote monitoring of patients, Gawande doubled down on the notion that solving most of health care’s problems comes from the application of what we already know to be effective care delivery and not deviating from the recipe.

However, in doing so he broached a very sensitive topic among health professionals by analogizing the cook at the Cheesecake Factory to the physician treating patients. Rather than lamenting the de-professionalization of health care, Gawande welcomed it with open arms, “The theory the country is about to test [with health care] is that chains will make us better and more efficient. The question is how … 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.”

The key to it all? Interchangeable parts. At the Cheesecake Factory, everyone follows the formula to the very last detail. Everyone is trained and monitored to play their part. It does not matter who the chef, the line cooks, or the wait staff are. They could be drop shipped from another state in the middle of the night to replace the existing staff and produce the same, consistent, repeatable, menu as are found in all the other stores. “We can bristle at the idea of chains and mass production, with their homogeneity, predictability, and constant genuflection to the value-for-money god … [but 1 bad experience] at the bed and breakfast … and it’s right back to the Hyatt,” Gawande wrote.

So, why do we need professionals or professions at all? Why do we need a chef, when the cook can simply follow the formula? There is no need for deviation, judgment, creativity, or adjusting to preference. And there is certainly no need, whatsoever, to have an interpersonal relationship with the customer.

Leaving the Sport I Loved

I grew up in a sports family in a sports-friendly town in Iowa, with many opportunities to play on any number of teams for the local high school. The nice thing about small towns is that most everyone is good enough to play, and that creates a sense of community. Racing on my own 2 legs won out over all of them, and I was fortunate enough to run for Drake University while attending pharmacy school, compete in the Division I National Championships, and volunteer as an assistant coach for the University of North Carolina during graduate school.

Along the way I ran 60 to 80 miles a week, nowhere near some of my better competitors but enough for my mid-distance oriented genetics. It was enough to scare a 4-minute mile on a few occasions, so I never even contemplated a day when I would not be able to run, even with my kids.

Denial, Rejection, Frustration

“When you say stop running, what exactly do you mean?” I asked my orthopedist. It was not setting in at the age of 38. He said, “You have to stop. You’re bone on bone, and you’ve got a 65-year-old knee. I can go in and do your fourth left-medial partial meniscectomy, but it won’t do you much good.” I dismissed his advice, just as I had before, after 3 prior knee surgeries, just as I did the advice of the physical therapist who told me 12 years earlier to find another sport. Year after year, I hobbled on that leg. I dealt with the pain, and I blew through my health savings account every so often. I would get a brief reprieve and then be back on the operating table. I had been running hours a day, often twice a day, for nearly 3 decades. Wasn’t there some kind of new implant, pill, surgery, or something to fix this?

Turns out, those same genes that allowed me to sprint nearly all out for 4 minutes straight were the same ones that gave me a poor angle on my tibia coming into my knee capsule, putting pressure on my left medial compartment all my life, running or otherwise. No fancy shoes, icing, medications, or surgery, was going to fix that. Discontinuation of running became a necessity, full stop. But I still did not listen, until I met Chris Hirth.

Acceptance and a Human Connection

I begrudgingly walked into the basement of a sports medicine facility to try customized orthotics, a rather simple but artisan-like practice. Hirth molded the material around my feet to tilt the angle of my foot strike inward, thus taking pressure off my medial compartment. “You’ll have to wear these all of the time,” Hirth said. I asked, “By all of the time you mean …” And Hirth said, “All the time, in all of your shoes, whenever you wear shoes.” I was halfway to dismissing him in my mind when his years of experience told him to strike up a conversation with me.

“Troy, I’m telling you man, go get a bike. I know people like you. You’ve got to accept this. No amount of extra work, extra fitness, or extra anything is going to fix this, other than giving up running and taking on something else that doesn’t involve gravity on that leg,” Hirth said. We spent the better part of an hour talking about it, and it all finally started to sink in.

“Here are some exercises, stretches, and your orthotics. I’ll see you in a week” Hirth said. For 3 months I faithfully followed his regimen, because I did not want to let him down.

A New Sport

I bought my first road bike, then another mountain bike, and soon enough my healthy diet of exercise involved mostly biking and swimming. I now run 3.16 miles a year, 2 times a year, once with my oldest daughter at a family fun run on July 4 and the other at the end of a sprint triathlon in September. That is it, not a mile more.

I am perfectly content, my cholesterol is back to being better than average, and I have not had knee pain in more than 3 years. It feels better than it did when I was 19 in front of my first sports medicine physician at Drake complaining of knee pain. Brought about by a patient-centered approach, my relationship with Hirth has given me a heck of a lot more than the three CPT Code 29881: Knee Arthroscopy with Partial Meniscectomy(ies) and hundreds of pounds of acetaminophen and ibuprofen over the years.

The Difference Between Doing Something ‘to’ a Patient and Doing Something ‘With’ a Patient

Not to engage in another TMI (too much information) exercise, but I also had to get a colonoscopy earlier in life than most. I cannot say that I cared much who did the procedure. I would not know him (or was it a her?) from Johnny or Susie at the grocery store.

Gawande has a good point when it comes to doing things “to” a patient. When no relationship is required, when little variation is needed, when life and death have more to do with mechanics, aseptic technique, and increasingly computers and robots, why would relationships matter? Just follow the recipe, and dollars and lives will be saved.

Yet, for me and my knee, I needed somebody who was willing to go off script. I needed a relationship that fit my personality, with my background, with my predispositions and my shortcomings. I needed somebody to take my journey with me, rather than order up another procedure to do to me.

If social media has taught us anything, it is that you cannot manufacture relationships. They must be self-selected, with each person choosing his or her own based on bias, life experience, motivation, and world view. That is a menu far too large for the Cheesecake Factory and too nuanced for a cook.

Chef Gawande’s New Job

If his name sounds familiar, it is because Gawande just took the job of chief executive of a new enterprise that Jeff Bezos of Amazon, Warren Buffett of Berkshire Hathaway, and Jaime Dimon of JPMorgan have formed to transform health care in the United States. Gawande decided to leverage the inevitable headline announcing his hire by extolling the values of the practice of primary care.

Indeed, if you read some of his most recent work, he has come around to understanding the importance of relationships. Gawande’s January 2017 article in The New Yorker⁴ describes the importance of listening and incrementalism and the underappreciation of primary care and the power of human interaction. “’It’s the relationship,’” they would say. “I began to understand [primary care] only after I noticed that the doctors, the nurses, and the front-desk staff knew by name almost every patient who came through the door.”

Gawande wrote about the corollary between how we fail to provide proper maintenance for bridges and roads and a general lack of appreciation for preventive care in our society, and he concludes by offering that incrementalism, with regular follow-up, combined with relationship-oriented care, should be the future of our health care system. Bridges and roads require constant monitoring to identify potential problems early on in their failure lifecycle. We are infatuated with advances in technology and new construction, yet our post-modern health care system needs something far less sexy: a listening ear and individualized plan of care.

Primary Care, Chronic Diseases, and the Role of the Pharmacist in a Post-Modern Health Care System

Fully 70% of the US health care bill is borne by tens of millions of patients with 2 or more chronic illnesses who fill 83.2% of all our prescriptions. Every one of these patients needs a longitudinal approach to care delivery, with frequent care planning and re-planning, with patient goals, health concerns, and a strategy for alerting their care team if something is not quite right. Pharmacists are in an opportune position to monitor for early indications of failure, because they are the most frequent touchpoint in the entire health care system. The question is, will we squander the privilege and defer to the US Postal Service?

On January 1, 2017, the physical therapy profession changed its CPT coding structure. Gone was the 97161, replaced with 97164: Re-evaluation of physical therapy established plan of care. Where is pharmacy’s code for care planning? Will we evolve, too?

Next time you are on the bench, ask yourself, do I provide incremental, patient-centered, relationship-oriented care planning, and follow up for patients in need? If not, you are simply an interchangeable part, yielding your profession to the mailbox at the end of the driveway.

Thank you, Chris Hirth, for changing the trajectory of my health and well-being.

Troy Trygstad, PharmD, PhD, MBA, is vice president of pharmacy programs for Community Care of North Carolina, which works collaboratively with more than 1800 medical practices to serve more than 1.6 million Medicaid, Medicare, commercially insured, and uninsured patients. He received his PharmD and MBA degrees from Drake University in Des Moines, Iowa, and a PhD in pharmaceutical outcomes and policy from the University of North Carolina at Chapel Hill. He also serves on the board of directors for the American Pharmacists Association Foundation and the Pharmacy Quality Alliance.

References

• Gawande A. The Checklist Manifesto: How to Get Things Right. 1st ed. New York, NY: Metropolitan Books. Henry Holt & Co; 2019.
• Jauhar S. One thing after another. The New York Times. nytimes.com/2010/01/24/books/review/Jauhar-t.html. Published Jan. 22, 2010. Accessed June 26, 2018.
• Gawande A. Big med. The New Yorker. newyorker.com/magazine/2012/08/13/big-med. Published August 13, 2012. Accessed June 26, 2018.
• Gawande A. The heroism of incremental care. The New Yorker. hnewyorker.com/magazine/2017/01/23/the-heroism-of-incremental-care. Published January 23, 2017. Accessed June 26, 2018.