via The New Yorker

Last week I tweeted out the arrival of Atul Gawande’s recent New Yorker article about what the medical industry could learn from the restaurant chain called the Cheesecake Factory, suggesting that maybe there were things that the education industry could learn from the article as well:

“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.”

If you’re anything like me you’ll experience recognition, rage, and some sense of what the education debate is missing.

First and foremost, Gawande’s description of the struggles the health profession has had in improving and equalizing outcomes – and the slow pace of change — will ring familiar in the ears of anyone who’s been around the education issue for more than a few days.  Even in an environnment in which there are conclusive studies and centralized recommendations for best practices (around preventing migraine headaches, for example), doctors and hospitals still don’t do what they would, ideally, do — or at least not for a long time afterwards.

“Physicians were always predominantly self-employed, working alone or in small private-practice groups. American hospitals tended to be community-based…The consequence is the system we have, with plenty of individual transactions—procedures, tests, specialist consultations—and uncertain attention to how the patient ultimately fares.”

Nearly as familiar will be the stories of resistance, active and otherwise, from practitioners who consider themselves to be autonomous (and indeed worked independently for many decades) and don’t want to be supervised, managed, or even tracked — and the resulting inefficiencies, enraging bureucracies, and lack of care that can result.

Says one of the characters whose mother has just gone through an infuriating hospital visit” “It is unbelievable to me that they would not manage this better,” Luz said. “I’d study what the best people are doing, figure out how to standardize it, and then bring it to everyone to execute.”

“Customization should be five per cent, not ninety-five per cent, of what we do,” says another of the characters in Gawande’s story.

It can seem almost childish, the “don’t tell me what to do” mentality that’s seen in medecine and education, given the vulnerabilities of children and patients and the ostensible goal of service to others, but it’s real and has to be addressed.

The political issues aren’t all that different, either:

“For the changes to live up to our hopes—lower costs and better care for everyone—liberals will have to accept the growth of Big Medicine, and conservatives will have to accept the growth of strong public oversight.”

But not all is hopeless, at least in health care reform.  A handful of group practices and networks have revamped their treatment protocols with great results in terms of costs and outcomes — setting clear standards for results but leaving practitioners some wiggle room.

“To prevent revolt, he learned, he had to let them deviate at times from the default option. Surgeons could still order a passive-motion machine or a preferred prosthesis. “But I didn’t make it easy,” Wright said. The surgeons had to enter the treatment orders in the computer themselves. To change or add an implant, a surgeon had to show that the performance was superior or the price at least as low… About half of the surgeons appreciate what he’s doing. The other half tolerate it at best. One or two have been outright hostile. But he has persevered, because he’s gratified by the results.”

Ditto for the Cheesecake Factory:

“The instructions were precise about the ingredients and the objectives… but not about how to get there… There might be recipes, but there was also a substantial amount of what’s called “tacit knowledge”—knowledge that has not been reduced to instructions.”

What makes this all have any chance of working, according to Gawande, is the presence of a knowledgeable supervisor — a former practitioner now tasked with watching his or her former colleagues and praising and prompting them throughout the day. Both the hospitals and the restaurants have them. (There’s also some high-tech remote supervision being tried .)

Of course, closer supervision of practitioners is a delicate business, as Gawande makes clear, and neither restaurants nor hospitals have (most of them) wholly unionized workforces. But shared efforts, and group responsibility, seem necessary.  It makes me sad there’s so little of it we read about in schools, or that it’s so occasional rather than common.

Cross-posted from TWIE.