In a recent New Yorker article , Atul Gawande compares medical—especially surgical—care to the service at the Cheesecake Factory chain of restaurants. While the analogy seems somewhat absurd at first—no doubt Gawande's point—we are soon sucked in to his comparison. The cooks and servers at Cheesecake Factory master hundreds of recipes, serving thousands of customers exactly what they ask for, night after night. Why, he asks, can't medical care work the same way? Why can't doctors deliver a measurable standard of care on a routine basis?
Gawande offers some cheering examples, including a tale of his mother's knee surgery that includes shortened recovery time and a better outcome because the surgeon in charge of her care had made a study of both the entire procedure, from the choice of prosthesis to the anesthesia to the timing and type of rehabilitative care. See, Gawande's article seems to say, standardized care is better care!
It's a tempting thought. As I read the article I found myself wondering if we could do something similar with teaching, in fact—study best practices (people like Ken Bain and John Bean, among others, have already made a start at this), figure out how best to engage students and then work with faculty to ensure that they follow the standard protocols. Surely by this time we have some good research on exactly what engages students so that they best learn the material—we have both general principles and some discipline-specific case studies that are documented in books like John Bean’s Engaging Ideas, Dee Fink’s Creating Significant Learning Experiences, and Ken Bain’s What the Best College Teachers Do, among others. Teaching centers at large and small institutions work with faculty to review their teaching practices and implement small and large changes that can lead to revitalized teaching and learning experiences.
But. Eating dinner at the Cheesecake Factory is, of course, voluntary. No one has to go there—indeed, I haven't since the early 1980s, and I seem to be doing fine. If no one wants to eat the wasabi-crusted ahi tuna, it can simply disappear from the menu, to be replaced by something else.
But no one chooses to need a knee replacement—or, to make the point more clearly, to suffer any one of a number of rarer diseases and conditions that may not be quite as easy to diagnose as a failed knee. (I say this not knowing how hard that may be to diagnose—in Gawande's story, though, it is obvious that his mother needs a new knee. He sees it on the x-rays.) So if my disease or condition isn't on the menu, as it were, what kind of care do I get? Needing medical care is very different, in other words, from choosing to eat at a chain restaurant. Can we really make analogies, then, between the training of doctors and the training of kitchen staff in a large chain restaurant? Even the extensive menu that the restaurant offers—Gawande counts three hundred and eight dinner items—pales in comparison to the number of different diseases and conditions doctors face, even when they specialize.
In a throwaway line Gawande hints at another problem with the chain restaurant approach to medicine—he notes that the food he had at the restaurant was delicious, though "no doubt everything we ordered was sweeter, fattier, and bigger than it had to be." One wonders, then, if the restaurant itself is helping to create the patients Gawande will later see? Is giving customers what they want the same as treating patients as they should be treated? To take it back to teaching—students are not customers, and they are not (perhaps like Cheesecake Factory diners) always the best judges of what they need.
Nonetheless the article made me wonder if we teachers sometimes ignore best practices at our peril. If Big Medicine is coming to standardize care, for better or worse, Gawande wants to make sure it does it for the better, so he looks at the ways it really can improve patient care rather than simply cutting costs. Teaching, too, is becoming more standardized in many arenas. I once heard a standardized curriculum for elementary-school students referred to as "teacher proof"—the idea being that any teacher could "deliver" it to any group of students. As a professor in a liberal arts college that values teaching I usually feel relatively immune to the kinds of "innovations" that have been creeping in to K-12 and online education, especially, but perhaps I should be paying closer attention. Have we, like doctors, become too protective of our independence to pay attention to real innovations that could increase efficiency and improve our outcomes? Will we lose the thing we most value if we ignore the calls for improvement?
For Gawande, always working his Cheesecake Factory metaphor, increased efficiency is the same as improved care, at least in the important examples he provides. But it's here that I get really concerned. The research on teaching suggests, for example, that while the lecture is a reasonably efficient way to convey information (second only to reading), students who memorize information that they learn in lectures may not actually be able to apply the information or to use it critically in settings beyond the lecture and examination halls. Engaging students by having them write, teach each other, express the information in other formats, and a myriad other practices, may help them learn, remember, and use the material they are learning—but shifting away from the lecture requires an investment of time by the professor beyond simply refreshing one's knowledge of the material.
I left the article feeling both enlightened and confused. It is good, indeed, to know that smart people are looking at these issues and trying hard to take the best of standardization and best practices with the focus on improving care, not just increasing efficiency. I hope that we as teachers take heed—if we don’t make our own changes, I fear they may be imposed upon us.