Optimistically, Atul Gawande lays out a case for the future of big, standardized medicine. I think he’s right to be hopeful. His example of The Cheesecake Factory is instructive, and hospitals should be able to serve patients better by adopting some of the restaurant chain’s practices. But I also think that, in the long run, the pendulum of health care will swing away from Big Med and back toward small-scale, personalized relationships.
To explain, let me explore another analogy: to agriculture. What Gawande is really describing, with the tele-I.C.U., menu of services and standardized care, is industrialization.
Agriculture tells a cautionary tale about the promise of industrialization. Some put the blame for the sorry state of the American diet squarely on the shoulders of industrial agriculture. I know it’s more complicated than that, but the conversation – about the perils of trying to achieve quality at scale – is worth our attention.
I’m reminded of the book Oranges by John McPhee, a tireless study of -you guessed it- oranges. It was published in 1967, right around the time that orange juice from concentrate was being touted as the next best thing. “It’s so consistent! All the irregularities are removed! It’s easy to freeze!” … or something like that. It is striking to read such claims about a product that is now widely avoided. In the same way that our tastes tend more toward fresh squeezed these days, what constitutes “quality” health care may prove to be equally subjective.
This is not to advocate against the coming changes in medicine; I think they are an essential step for progress. I only wish to temper any optimism for standardization so that we are not surprised when a patient finds better, happier care outside of the “best practices.”
With this particular iteration of the health care debate, we’re witnessing the pendulum swing in one direction, toward industrialization. As it swings, the pendulum is traveling an arc similar to the one created by the “fundamental tension between the logic of nature and the logic of human industry,” as Michael Pollan puts it in The Omnivore’s Dilemma, his take on the relationship between healthy eating and industrial agriculture.
I predict we will undergo a societal shift in our appreciation of good care and good medicine. How we define “good” will change. I don’t know how exactly, but I would venture a guess that we will do less to extend life at all costs. Maybe we can take a lesson from the industrially produced high fructose corn syrup: the sweetest medicine won’t always be the best for us. After all, as the economists say, in the long run we’re all dead.