In 2012, the noted Harvard surgeon and New Yorker staff writer Atul Gawande wrote an article that drove many doctors and nurses crazy. In the article, titled “Big Med,” Gawande argued that health care could learn a lot about efficiency from another industrialized service sector: Big Food. Specifically, the Cheesecake Factory, a chain of nearly 200 restaurants with a menu that is more than 400 items long, all made from scratch in each restaurant. Cheesecake Factory kitchens are model Henry Ford–style production lines. Food comes in the back door; gets prepped, cooked, and plated; and winds up in front of eight million diners a year, each dish identical to the one prepared at every other location and none costing the diner much more than $20. Managers use algorithms to predict the amount of food they need each night, and they operate their restaurants with less than 2.5 percent waste. “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,” Gawande observed. “Unlike the Cheesecake Factory, we haven’t figured out how.”
Indeed, health care, unlike the Cheesecake Factory, is massively, monstrously, colossally wasteful. Hospitals routinely throw out unconscionable amounts of expensive supplies that have never been taken out of their packaging. Home Depot tracks a box of nails more effectively than many hospitals track supplies, labor, and even patients. A few years ago a friend’s intensely suicidal wife went missing from a secure ward at a Washington, D.C., hospital. He found her several hours later at home.
A now-famous article published in the Journal of the American Medical Association about six months before Gawande’s story created categories of waste in health care and provided a dollar estimate for each. Those categories included fraud, of course, but also things like unnecessary treatment, excessive overhead, and “pricing failure,” which is a euphemism for profiteering by drug companies, pharmacy benefit managers, medical device manufacturers, insurers, and hospitals. Estimates for how much this waste costs the U.S. each year range from 20 percent to nearly half of total spending. That’s $600 billion to $1.5 trillion.
So why are comparisons to industrialized food—or to the commercial airline industry, another business model sometimes held up for health care to emulate—so deeply offensive to many frontline doctors and nurses, even those who understand the need to make health care safer and less wasteful? Having read Victor Montori’s elegant collection of essays, Why We Revolt, I think I know the answer.
Montori is an endocrinologist, meaning that most of his patients are people with diabetes, a disease that usually cannot be cured but often can be managed to avoid its devastating effects. Born and trained in Peru, Montori came to the Mayo Clinic for his residency and has spent the bulk of his career there. His experiences treating poor patients in Peruvian hospitals, and providing rudimentary care to copper miners as a medical student, have marked him as a humanist first and a man of medicine second. He wrote his slim and moving book to “see things as they are,” as George Orwell put it, and what he sees is the ways in which the industrialization of health care, rather than making it more efficient, has instead corrupted the mission of medicine. It has turned doctors and nurses into tools of a profit-seeking machine, “care” into a means to fulfill corporate ends. Montori sees a system filled with “unintentional cruelty” where “care happens almost by mistake.”
Many readers will undoubtedly have little experience with health care’s cruelest side. Most of us are denizens of the kingdom of the well. It is people who are chronically ill, aging, and frail, those who are most in need of good care, who are most likely to be repeatedly exposed to the system’s petty rules, rushed visits, bullying accounting departments, and impersonal or overwhelmed clinicians.It is possible to increase the efficiency of health care without turning clinical encounters into transactions focused on the exchange of a service for money. But that won’t happen as long as we see the delivery of care as just another profit-driven business.
This includes people like Montori’s patient with diabetes, who must refill a potentially life-saving prescription but whose pharmacy will only fill prescriptions within ten days of the end of the patient’s current supply. When the patient calls to renew the prescription on day t-minus-11, the pharmacist says her request cannot be saved; she’ll have to call tomorrow. She forgets and runs out of the medication. When Montori sees her a few weeks later, her condition seems out of control.
The many small cruelties of industrialized medicine manifest in the language we use in health care reform circles. Patients are supposed to be “engaged” and act more like “consumers” in order to get “high-value care.” The system wants “productivity” from doctors, and will “pay for performance,” as measured by “quality metrics.” All this market-speak translates into shorter and shorter visits, during which doctors and nurses spend more and more time entering data into electronic medical records in order for the doctor to get paid for her “performance.”
In the exam room, the doctor faces a computer screen, not the patient, and then interrupts after the patient has been speaking for an average of less than thirty seconds. She fails to listen carefully to the signals that the patient’s inability to control his blood sugar is not because he is “noncompliant,” or “nonadherent” to his drug regimen—terms that carry a whiff of moral judgment—but because his life is spiraling downward.
Montori writes about just such a patient. “John” is fifty-five years old, overweight, and diabetic. He has nerve damage in his feet, a bad back, insomnia, and depression. He takes two pills a day to control his blood sugar, another for high cholesterol, and another for his blood pressure. Recently his primary care doctor prescribed yet another medication because John was not hitting his “target” blood pressure. The new drug makes him dizzy when he stands up, but the doctor never seems to hear that. He’s told to cut carbs and exercise more, despite his painful back and feet. His daughter has moved back home with her two children, seeking refuge from an abusive relationship. Layoffs at work keep him up at night. Now, he’s the last accountant left at his firm, and he’s been finding irregularities in the books.
John has to take time off to go the doctor, and at every visit, his doctor admonishes him for his inability to control his cholesterol, blood pressure, blood sugar, and weight. There’s never a word, writes Montori, “about John’s difficulties with pain, insomnia, and despair.” One day, slumped on his living room sofa, John opens an envelope. It’s a letter from his doctor. “It was terse. He was not meeting his disease control targets. He should look for another primary care clinician.”
Getting “fired” by one’s physician is increasingly common, and understandable once you know they are paid in part based on performance metrics, like John’s blood pressure “target.” These targets often leave doctors in a quandary, because short visits make it difficult to sort through the various struggles facing a patient like John—which is essential to helping him change his lifestyle enough to control his weight and his blood pressure. A doctor can’t afford to have too many patients like John, because they will hurt her performance. Eventually insurers might cut that doctor from their list.
“John is an archetype,” writes Montori, “a patient living in a complicated medical and personal situation that industrialized healthcare seems unable to help, yet is ready to shame and blame.” Patients like John are legion. When Montori presents his story at medical conferences and other events, clinicians tell him, “You just described a large part of my practice”—patients who have multiple conditions that demand more time than allotted in the average fifteen-minute primary care visit. Patients approach Montori, saying, “I am John.”
The drive to make medicine more productive has succeeded in making it more like the airline industry—just not in the way reformers intended. Instead, writes Montori, “impossibly busy appointment schedules and heavy patient loads force clinicians, even the kindest, to see patients as a blur.” Patients are almost as indistinguishable to their primary care doctors or hospital nurses as airline passengers are to the pilot who stands outside the cockpit after the flight has landed.
What is too often missing for both clinicians and patients is the human interaction that forms the ineffable “art” of medicine. On one side of the stethoscope stands a person in a white coat, name embroidered in cursive over her breast pocket. On the other side is a person in a state of a greater or lesser degree of vulnerability. The sicker we are as patients, the more we need to be acknowledged as individual persons, not just the passenger in seat 14B or the diner at table 12. We need our doctors to have the time to ask enough questions—and actually listen to the
answers—in order to reach a correct diagnosis. We want to feel like a person who is cared about, rather than a mere vessel for a disease that requires treatment, or a bag of hormones and biochemicals that must be adjusted with drugs.
Montori knows this through his extensive research filming interactions between doctors and patients. In one case, a ninety-two-year-old man with diabetes is discussing different drug options with his doctor. At first, the doctor slumps in front of his computer, seeming to be barely present. Then the patient says he wants to try the drug that is best at controlling weight gain. The doctor perks up and asks why, at ninety-two, the patient is worried about his weight. The patient replies that his wife died a few months before and he has moved into an assisted living facility. Then the camera catches the patient in a micro-smile, almost coquettish, and the doctor encourages him to go on:
“Yes,” whispered the clinician . . .
“Doc . . .”
They both now leaned towards each other, as if in sharing a secret.
“That place is filled with women!”
Patient and clinician laughed, making eye contact. After a decade of knowing each other, they had started to cover new ground.
These subtle connections between clinician and patient open a doorway to a “sacred space,” in Montori’s words, that is essential to good doctoring. In fact, research has shown that caring—as opposed to just treatment—eases suffering and pain, and may lead to better health and longer life. Patients who feel cared for are more likely to follow their treatment regimens and engage with their doctors in making decisions. Montori goes so far as to say that the sacred space permits patient and clinician to love one another, however briefly, and for healing to take place.
That momentary love, what clinicians call the “privilege of the bedside,” also feeds their souls. The vast majority of people who go through the expense and hard work of medical or nursing school do so out of an idealistic desire to help others. If your doctors seem rushed or uncaring, it’s partly because the ideals they once had are routinely extinguished by a system hell-bent on squeezing every last dollar of “productivity” out of them. A young nurse I know recounts her first, exciting day on the job, when an older nurse said, “This job will wipe that smile off your face.” A medical student reports that the CEO of the prestigious academic medical center where he is training has quietly told the supervising physicians to prioritize the care of patients with private insurance and to send patients on Medicaid and Medicare, which pay less, to other hospitals.
There’s a certain amount of unpleasantness involved in being a clinician. You must put your fingers into other people’s orifices. You put up with bodily fluids, bad smells, and the sounds of wrenching pain. What sustains the best clinicians through their training and the rigors of practicing is the momentary connection they forge with another human being, who can be helped by the clinician’s expertise and caring. Reduce those opportunities, and you get what we have today: epidemic rates of bad diagnoses and burned-out clinicians who are themselves vulnerable to epidemic rates of drug abuse, suicide, divorce, and greed.
How can the health system begin to address the problem of waste without destroying whatever vestiges are left of real human caring? First, by recognizing the need to preserve the sacred space. It is possible to increase the efficiency of the background machinery of health care without turning every clinical encounter into a transaction focused on the exchange of a service for money. But that won’t happen as long as we continue to see the delivery of care as just another profit-driven business.
The solution? Montori argues that patients must rise up and begin to demand better. But unlike proponents of the so-called consumer revolution in health care, where each patient is supposed to comparison-shop, vote with his feet, and go only to hospitals and doctors that offer the best value, Montori believes patients must begin making these demands as citizens and voters. That process will start with conversations: between doctor and patient, patient and family, citizen and citizen. We must not only “see things as they are,” in Orwell’s words, but also imagine something better. In calling for this clarity of perception and vision, Montori echoes the words of the founder of my organization, world-renowned cardiologist Bernard Lown, who at ninety-six is calling on doctors to revolt against the industrialization of their profession.
Despite all I know about the failings of our broken system after years as a health care journalist and now head of a health care think tank, I keep asking my now twenty-two-year-old son if he wants to be a doctor. Each time, he gives some variation of the same answer: “Not a chance. I live with you. I know too much about medicine.” His answer means I have failed to convey the privilege medicine offers for a deeply meaningful and powerfully felt life, a privilege that arises from having a front-row seat at the most intimate, sorrowful, harrowing, and joyful moments in the lives of others, as Montori describes so eloquently. Read this book to regain your sense of hope for the future of medicine and nursing. Or read it to understand how we can integrate the need for clinics and hospitals that are as safe as airliners and as efficient as Cheesecake Factories with the need to build a sacred space for healing and our healers. There are many more reasons to pick up this slim and beautiful book. Just read it.