I recently re-read the article “Big Med,” by Atul Gawande, in which he examines the future of medical care from kitchen of the Cheesecake Factory. He marvels at the efficiency achieved by Cheesecake Factory in everything from ordering the correct amount of chicken to processing orders to teaching new recipes and dishes. They have maximized the cost-effectiveness of their business, but it was not without significant consumer research, vigilant oversight, and continued modification. What is preventing medical care from achieving similar efficiency?

The increasing importance of guidelines, protocols and algorithms in directing care is pushing medicine in a direction similar to the Cheesecake Factory. When a patient presents with a specific set of complaints, there are now measures in place that dictate the tests and studies that will yield the most likely diagnosis. A 66-year old female with burning on urination gets urine dipstick and culture, and is treated with Bactrim for a likely UTI. Similarly, a 34-year old male with Chrons disease who is 5 days post-op with fever and hypotension will be treated according to Surviving Sepsis guidelines with fluid resuscitation, blood cultures, a specific set of labs and empiric antibiotics. Both of these measures, used in drastically different situations, have been shown to reduce unnecessary testing, costs, and all while improving outcomes. 
 
Still, physicians are hesitant to implement new protocols without seeing sufficient evidence with controlled trials. And for good reason, a patient is a person not a dish leaving the kitchen of the Cheesecake Factory. At the restaurant, we expect today’s crab cake to be the same one that we loved a week ago; patients are each different and we must consider comorbidities, insurance status, medications and allergies, and acute and past medical history. Significant increases in outcomes research to drive the development of protocols is beneficial in identifying significant steps that will maximize treatment with the impetus on improving outcomes and reducing cost, but we must remember that medicine is not a box that patients fit neatly in. We must maintain a sense of autonomy and humanism, taking each patient at face value, and not perform as robots confined to a set of tests and diagnoses. 
 
Guidelines are just that—guides, roadmaps to improve the efficiency of care with regards to outcomes and cost. There is a time and place for the use of guidelines, but not every patient falls neatly within the circumstances in which these guidelines are meant to be implemented. For students being taught in the world or Up-to-Date, MDConsult, and AccessMedicine, we must remember that guidelines and protocols are merely starter recipes for success, but also ones that must be tailored to each patient’s taste.

The envelope felt heavy in my hands, heavier than a few pieces of paper should. The name on front was printed in crisp black ink and while it was my own, it looked foreign. It seemed only days ago that I first slipped into a short, white coat. I was young and eager, bright-eyed and bushy-tailed with 170 other new physicians in training. Over four years of medical school, our aspirations lead us down a multitude of diverging paths, yet today our paths merged once again for a champagne toast and the opening of these envelopes. Inside, the beginnings to our futures were laid out in a few lines, new paths for each of us to follow. My fingers stuck to the edges, unwilling to slide under the seal and make real the inevitable. I could feel my heart beating, a sensation we learned about years ago; I forget the mechanism now. Around me, the sounds of excitement began to grow, confining me even more. What name lay inside, what did I hope for? In moments I would know, and then what? My mind raced ahead to all of the things that will happen in the next two weeks- signing paperwork, fixing financials, securing housing; packing up the life I had built over four years in Ann Arbor and starting anew.

A squeeze on my thigh brought me back to reality and I looked past the envelope to the barren left hand that was turning white with tension. Abagail. After six years, that finger deserved to be adorned. As a career-driven person, I could never back her into a corner with an engagement. But she has been there, through the highest highs and lowest lows of medical school and life. Our tale is one I don’t want to end. I am reminded that the contents of this envelope affect her life every bit as much as my own. I wished we could stop time, enjoy life together without the anxiety and tension that has been building a wall between us. Hoping for the best, we prepared for the worst. I looked up and our eyes met, her soft smile nudged me along, as if to say, "there’s nothing left now, just do it."

More people have discovered their future. They begin to rise from their chairs, family members clapping, and hug or high-five each other. Laughter abound. My hands begin to wake up and feel the sharp corners of the envelope. I begin to slide my finger under the flap and peel away the glue. I cannot help but wonder if I made the right decision, if I chose the best career path, if my rank order was correct. Would I be truly happy with whatever name was written on the piece of paper I was about to read? This was supposed to be the most exciting day of medical school, but it left my stomach in knots. I quickly took a sip of champagne, liquid courage? My hand returned to the envelope and began to rip across the top. I could not be the only one feeling this kind of pressure. I half-admired my classmates who chose to do this in front of everyone and half-wondered if they secretly knew their destination. They all seemed happy to place their pins on the map. Where was my pin going to go?

I pulled out the piece of paper. My hands had new life, though they seemed not my own. I could not control them now. I wanted to stop them, to keep them from revealing my future. I tried to avert my eyes but they were stuck on the unfolding edges. “Dear Justin Steggerda.” There was my name again. This was not a mistake, just a few more lines and I would know. “Congratulations.” My breath caught in my throat. I closed my eyes, the next line carried my future. There is no stopping now. I forced my eyes back open. I read on. I smiled. My future was here.