Elizabeth Loder: Why can’t a headache clinic be more like a Cheesecake Factory restaurant?

Elizabeth Loder I hate to think of myself as prejudiced, but a night out at a Cheesecake Factory chain restaurant is not my idea of fine dining. I’ll go there if I have to, of course, and in the end I did. Once a month, the doctors from the Graham Headache Center (where I work when not toiling for the BMJ) gather for a journal club meeting in a local restaurant. We spend a few team-building hours discussing a recently published medical article, usually from the journals Headache or Cephalalgia. This time we chose a Cheesecake Factory restaurant in the Boston suburbs as the obvious place to discuss Atul Gawande’s recent panegyric to Big Medicine in The New Yorker magazine. “Restaurant chains have managed to combine quality control, cost control, and innovation. Can healthcare?”, asks the article’s teasing subtitle.

As you might have guessed, the thesis of the article is that the methods of big restaurant chains—exemplified by Gawande’s case study of a Boston Cheesecake Factory restaurant—hold promise as a way to fix the wasteful, second-rate system that is modern medicine. A Boston orthopedic surgeon’s standardised approach to joint replacement surgery—it worked on Gawande’s own mother—is presented as a model, along with the algorithmic approach to intensive care unit treatment that is used by a for-profit chain of hospitals. Gawande describes the movement towards large group practices that incorporate the efficiency and quality control principles of chain restaurants, and refers to this as “Big Medicine.” He acknowledges some problems, but on the whole seems to approve of this phenomenon—and to see it as inevitable.

Applying the standardised routines of big restaurant chains to medicine will, Gawande suggests, get good ideas into practice faster. Here we were entirely with him, because the example he offered of a good idea that has taken “an appallingly long time to trickle down” was none other than using drugs to prevent migraine attacks in people who have frequent headaches. He even mentioned the recent migraine prevention guidelines released by the American Academy of Neurology and the American Headache Society. Talk about coals to Newcastle!

It so happens that recently we have been pondering whether we should standardise our approach to headache treatment. We like to think that the practice patterns of doctors at our clinic are very similar. Still, there is no getting around the fact that when discussing specific clinical situations the six of us often find that we would recommend six different treatment approaches. Usually the differences are slight, but sometimes they are more substantial. From a quality control perspective, this is the medical equivalent of the mashed potato tower that is perfectly fluffed up on one plate and overly molded on another. It is also an example of the dreaded “unexplained variability” that is often invoked as an explanation for the high cost and poor quality of medical care. Would our patients be better off if we tried to run the headache clinic more like a chain restaurant?

We pondered this question as we ate our food, which was indeed nicely plated and uniform in presentation. As the evening drew to a close we had not reached agreement about whether it is desirable or even possible to achieve a Cheesecake Factory level of standardisation in specialty headache practice. Our patients are complex and, like the unhappy families of Tolstoy, all of them seem to be so in their own way. But we did agree to try: our first effort over the next few months will be to hammer out a common approach to preventive treatment for patients with uncomplicated but frequent migraine.

And how was our experience? Did the Cheesecake Factory set a standard for “quality control, cost control, and innovation” that we at the headache clinic would do well to emulate? Well, no one raved about the food, but then again no one complained. When the bill came we agreed that the cost was indeed reasonable. And that herbed salmon from the Skinnylicious® menu was innovative if not exactly life-changing. On a 0-10 scale I would give the whole experience a 7. In the words of John Prine: “Pretty good, not bad, I can’t complain.” As Big Medicine bears down upon us, here’s hoping our patients will say the same.

Elizabeth Loder is US research editor, BMJ