Healthcare Needs Some IHOPs

The New York Times had an article that surprised me: Current Job: Award Winning Chef.  Education: IHOP.   The article, by food writer Priya Krishna, profiled how many high-end chefs credit their training in -- gasp! -- chain restaurants, such as IHOP, as being invaluable for their success.

Credit: Shutterstock/Jonathan Weiss

I immediately thought of Atul Gawande's 2012 article in The New Yorker: What Big Medicine Can Learn From the Cheesecake Factory.

Ms. Krishna mentions several well-known chefs "who prize the lessons they learned — many as teenagers — in the scaled-up, streamlined world of chain restaurants."  In addition to IHOP, chefs mentioned experiences at chains such as Applebee's, California Pizza Kitchen, Chipotle, Hillstone, Houston's, Howard Johnson's, Olive Garden, Panda Express, Pappas, Red Lobster, Waffle House, and Wendy's.  

Some of the lessons learned are instructive.  "It was pretty much that the customer is always right," one chef mentioned.  Another said she learned "how to be quick, have a good memory, and know the timing of everything."  A third spoke to the focus that was drilled into all employees: "Hot food hot. Cold food cold. Money to the bank. Clean restrooms,” 

Oh, gosh, where are the healthcare equivalents of those?

I particularly was struck by three other quotes that could, and should, apply to health

• "There is this understanding that every person is important to making the restaurant run smoothly.  Nobody thought the dishwasher was a lower status than them."
• “You spend a week on the grill, a week waitressing, a week in financials.  You know every aspect of that restaurant.”
• Chain restaurants have a playbook for every position.  There is no guesswork.”

In healthcare., physicians usually get their training in academic medical centers, which is sort of like training chefs in culinary schools or 5 star restaurants.  They learn a lot, see some exotic things, but that experience is similar to what one chef told Ms. Krishna: "a lot of the curriculum in culinary school is not reflective of what is going on in the everyday world."

Physicians are not trained on how the entire system works -- no equivalent of working as a server or in the kitchen first -- and without learning how much things cost.  They tend to develop idiosyncratic approaches that may or may not be based on the latest research/best practices; even if they are, there's no mechanism to ensure that those approaches stay current.  All this while too often tending to see themselves as more important than other healthcare workers.

No wonder Dr. Gawande was impressed by The Cheesecake Factory almost a decade ago.

He marveled at the size of their menu, the quality of the food, and the affordable prices -- all delivered uniformly to tens of millions of customers in two hundred restaurants worldwide.  As he noted:

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.

Some of the things that impressed Dr. Gawande about the kitchens in The Cheesecake Factory:

• "the instructions [recipes] were precise about the ingredients and the objectives...but not about how to get there."
• "a kitchen manager is stationed at the counter where the food comes off the line, and he rates the food on a scale of one to ten."
• The chain-restaurant industry has produced a field of computer analytics known as “guest forecasting.

Dr. Gawande admitted: "As a doctor, I found such control alien—possibly from a hostile planet."  

He went on to discuss the experience his mother had with a knee replacement; he deliberately steered her to a orthopedic surgeon who had led the charge to standardize such operations at Brigham & Women's Hospital: "they studied what the best people were doing, figured out how to standardize it, and then tried to get everyone to follow suit."  Just like at The Cheesecake Factory, it resulted in lower prices and better outcomes.

Credit: The Cheesecake Factory

One of the other Cheesecake Factory practices that Dr. Gawande was impressed was how they adapt to the new; in their case, new recipes.  First they train representatives from the restaurants on the new recipes, then "...also trained the attendees how to teach what they were learning. In medicine, we hardly ever think about how to implement what we’ve learned. We learn what we want to, when we want to."

Most physicians I know recoil at "cookbook medicine."  Most physicians believe their patients are unique.  But, as Dr. Gawande pointed out: "we’re moving from a Jeffersonian ideal of small guilds and independent craftsmen to a Hamiltonian recognition of the advantages that size and centralized control can bring."

Many of the chefs Ms. Krishna talked to reported there is still a stigma in high-end restaurants of having trained in chain restaurants, and that that culinary schools were still sending most of their graduates to independent restaurants, not chains (even though one such graduate complained: "when you graduate and work for that Michelin-star chef, you aren’t going to make enough to be able to pay your loans."  Physicians can empathize).

But "the more casual, business-minded approach of chains is the future of dining," just as the future of healthcare is more patient-centered and business-minded.   Healthcare may be consolidating, but it is far from replicating the business practices that have made chain restaurant successful.  

We are, in essence, training physicians in expensive culinary schools, to work in high-end restaurants.  That may be good for some of them, and for some of us, but it is not good for all of them or for most of us.  The future is going to require that more of them get healthcare's version of a chain restaurant experience.

Healthcare needs its version of "Hot food hot. Cold food cold. Money to the bank. Clean restrooms.”  and training that instills it in everyone working in healthcare.