It's Time to Stop Oversimplifying Healthcare If We Hope to Fix It

September 16, 2013

Atul Gawande and others tend to speak about healthcare as if it is simple and straightforward. But those of us on the front lines know it is multi-layered and diverse.

Last summer, noted author and surgeon Atul Gawande famously compared the American healthcare system to the Cheesecake Factory in an article for The New Yorker. It’s been over a year, and still this single article bugs me! For the record, I am a tremendous Gawande fan. If you haven't watched his inspirational TED Talk, I highly recommend it. I also have made his "Checklist Manifesto" required reading for my entire staff.

Think about this: What if the Cheesecake Factory had to serve more customers than they could find staff for (our physician shortage)? What if a large percentage of the customers paid a reduced rate (via the U.S. government) or didn't pay at all? And don't even get me started on the vast difference between an Ahi salad and the real issue we deal with every day when we advocate for life-saving vaccinations amidst protests from parents who subscribe to Internet-based fear mongers. (I’m feeling a little emotional about this one as we are currently seeing a whooping cough epidemic in our community). In his article, Gawande had forgotten that more than half of all Americans could never afford to eat at the Cheesecake Factory; and there certainly isn't the political will to tax wealthier Americans so that poorer American's can enjoy that great Ahi salad (it really is good; I’ve ordered it a few times).

I think, though, the real reason the article bothered me is that Gawande, like so many of our healthcare thought leaders, feel the need to oversimplify our industry. Is there, truly, an industry that is as vast and complex as healthcare? While there might be some aspects that are like high-end restaurant chains, say private hospitals for elective surgery or cosmetic dermatology, most Americans never encounter that kind of care.

Healthcare is multi-layered and diverse. For me, primary care is more like public schools. Benjamin Franklin said, "An investment in knowledge pays the best interest." Study after study shows that good basic primary care improves health and cuts costs in the long run. I’ll take the analogy one step further to point out that good public education seemingly benefits the individual, but really it is society that benefits from a well-educated workforce by increasing the tax base and reducing poverty. Similarly, primary care might focus on the individual, but really it’s the whole community that benefits when we reduce communicable diseases and the complex public cost of patients in health crisis. Still, this analogy is only good for one aspect of healthcare, namely primary care.

Contrast to primary care, the wide variety of specialty care each has its own analogy. Emergency care, like the amazing healthcare workers at the Boston Marathon bombing, is like national defense (something you hope you never need, but pay for just in case). In contrast to that, gynecology only serves half the population, but its close specialty obstetrics serves us all at birth and, since birth centers are such major money makers for most American hospitals, are most like $66 billion baby-product industry. And I haven’t even touched upon controversial and very expensive end-of-life care issues, a topic truly too large and too complex for me to address adequately in this one blog post.

For me, the most interesting and the least talked about segment of healthcare, though, is public health. According to the CDC, since the turn of the last century, the average American lifespan and increased by 30 years; 25 of those years can be attributed to public health initiatives. Government-led programs to increase safer workplaces, assure safe and healthier foods, and provider better family planning are the reason we all live significantly longer than our grandparents did.

Healthcare with the most impact on our lives is a public good. Meanwhile, the Cheesecake Factory is a luxury good; a luxury, I might add, that most people can’t afford! While it might be easier to talk about healthcare as if it’s simple and straightforward, all of us in the industry owe it to ourselves and our communities to not let leaders oversimplify the complex and layered reality of the healthcare industry.