Magazines: If Doctors Can Do It, So Can Teachers

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: 

"In medicine, too, we are trying to deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality. Unlike the Cheesecake Factory, we haven’t figured out how. 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."

My goal is to make you see education everywhere, like I do, and to learn to ignore the events and coverage that are ostensibly about education but really offer little new or helpful. However, knowing that you are perhaps as lazy or even lazier than I am, I thought I'd lay out just what I learned from the article now that I finally had a chance to read through it.  If you're anything like me you'll experience recognition, rage, and some sense of what the education debate is missing.

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

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.”

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.

Comments

[Matthew]

Alexander,

When I read this article I had the same reaction and talked about it (ad naseum) with my teacher wife and teacher friends. (Me, I'm just a parent, so I know nothing, right?)

As ever, Gawande raises great questions and explores the answers in his engaging manner.

One distinction that I suppose teachers who feel defensive about this analogy might raise, is that unlike the Cheesecake Factory, they exercise little control over which customers they get.

Now I think the analogy is weak, as municipal hospitals face the same issue, especially with respect to poorer or less well educated patients who treat the ER like a doctor's office. And Gawande's point is those ERs can do better through standardization and sharing of best practices.

So why not schools? My wife says she'll now consider dining at the Cheesecake Factory, who knows what else we all might learn.

I look forward to the responses.

[Bea]

Been at this nexus for awhile myself. I serve as an advisor to physicians and to our local school district. Instead of former practitioners, we train patients to observe and advise doctors. Our schools superintendent and the medical director leading the advisor program have had several fruitful discussions about bringing the model to our schools.

[Alexander Russo]

thanks for the comments -- tell us more, bea -- would love to hear or read about what you've been doing -- post something more here or email me at thisweekineducation at gmail. / ar

[Seth]

The NY Times magazine had a great story a few years ago about an effort by a few doctors to implement standards of practice, which had been demonstrated to improve patient outcomes. The whole story could have been reproduced replacing "medicine" with "education". In both cases, the whole debate boils down to how much practitioners should be guided by intuition and how much they should be guided by empiricism.

http://www.nytimes.com/2009/11/08/magazine/08Healthcare-t.html

[Sarah]

It’s a nice ideal as a thought, but as Matthew pointed out, teachers can’t control the students they get. Not to mention, you can’t teach one student following a method that worked for another and the same result as a guarantee. I've always been a better student if I'm handed the material and left to research and come up with my own method. My sister needs to see a teacher work out a problem physically step-by-step because she simply can't understand the material from a book alone.

[ipsol@mcitp certification]

The combination of doctors and teachers is interesting.will like to read more about this.