The Incongruous Cheesecake Factory Metaphor in Atul Gawande's "Big Medicine" Piece

Surgeon, author and medical error expert Atul Gawande has a new piece in this month's New Yorker focusing on best practice in medical care. Another of Gawande's articles prompted an Oval Office strategy meeting that helped formulate major cost controls in Obamacare. In other words, while we may not agree with everything Gawande has to say, we should read him because he has the President's ear and we are interested in future policy actions.

The current New Yorker piece essentially argues for standardization and quality control while focusing on improving patient outcomes. He spends a great deal of time discussing food at the Cheesecake Factory, where, in a fit of slurpishness he revels:

"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. The chain serves more than eighty million people per year."

Let's just say that quality control is not exactly unique to the restaurant industry or politically controversial. In other words, who gives a shit whether the Cheesecake Factory can cut down on cost?

To tie it back to the health care industry where (unsurprisingly) there are plenty of people engaged in patient-outcome and cost-control research, he summarizes work by his colleague John Wright, an orthopedic surgeon who relies on comparative outcome data to find out what knee implants work best. If implants cost more while not improving outcomes, his surgical team is basically forbidden from using them. And data used by Knight came from Australia's single-payer, national health care system? OK, Atul, this all makes sense. What's the point of spending half your time talking about the Cheesecake Factory?

Atul has a gift for language and metaphor. As a single-payer advocate (a system that in all other countries leads to much less cost and much better patient outcomes), Gawande is undoubtedly aware of the communications constraints (socialism!) faced by advocating single-payer health care.

Talking about the Cheesecake Factory is just a way to sell the idea. It's a way to talk about Australia and national data-collecting through the back door. Although there's certainly better or pithier ways to phrase it for public consumption, the public doesn't read the New Yorker. The Cheesecake Factory is a Trojan Horse: it's a way to talk about single-payer while attempting to ensure the reader doesn't think about Big Government and consequently dismiss the idea.

So, serious readers, forget about how chefs make that perfect veggie burger. There's already plenty of research about quality control in health care settings. Health policy folks know what works better than the American system. When we read Gawande, we just have to keep in mind what he's trying to sell.

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