Atul Gawande and The Cheesecake Factory

Let Them Eat Cheesecake

By Suzanne Gordon

The other day, at the suggestion of Boston surgeon and New Yorker writer Atul Gawande, my husband and I made a lunchtime visit to The Cheesecake Factory.  In his latest New Yorker article, “Big Med,’ Dr. Gawande touted the national chain restaurant as a model of the kind of standardization and quality that have been so lacking in healthcare.  The Cheesecake Factory, he argues, delivers “delicious’ meals that represent just the kind of affordable, reliable product that would better fit the budgets of cost-conscious health care providers–and meet the needs of their “customers”–in the competitive new world of medicine. The chain’s highly profitable and efficient “model represents our best prospect for change” in health care, he argues.

This Rx from a well-respected and generally insightful physician who has become a leading health policy observer surprised me.  Is this the same local physician/author who, in his book “The Checklist Manifesto: How To Get Things Right,” waxed poetic, about the creative, collaborative, non-hierarchical kitchen culture of Jody Adams, the renowned chef and owner of Rialto in Cambridge?

Inspired three years ago, by the “level of skill and craft” Adams and her staff displayed, he contrasted their “ever evolving, refined, and individual[ized]” menu with the “Taylorized, assembly line” methods of popular fast food chains. The key to quality chez Adams was information sharing and cooperation among co-workers, and the disciplined use of “communication checklists” to “ensure that people recognized and dealt with unexpected problems as a team.”  How could the Cheesecake Factory have suddenly eclipsed Rialto in the area of institutional quality, innovation, and every-day excellence?  What was more, how could a healthcare observer like Gawande, who has written about the need for greater attention to disease prevention, enhanced patient safety and curbing escalating healthcare costs, tout a chain like The Cheesecake Factory, which has earned a reputation as a proverbial production line of obesity.

Maybe something had changed at the chain and I should go to my nearest Cheesecake Factory to see if it had.

It hadn’t.  On my subsequent visits to the chain restaurant in several locations I found enormous portions of food that was larded with fat, swimming in sugar and drowned in salt.

Of the 50 people in the restaurant when I  went my husband for lunch several weeks agoat at least 15 were overweight.  Four of the customers were morbidly obese.  One woman was so huge, she had to use  a walker.  Her husband was also grossly overweight and her son, who was tucking into a monster plate of ravioli was well on his way to joining them in tipping the scales.

`           My husband and I ordered from the small plates menu.  My “small” kale salad was enough for four.  The salad dressing was a combo of fat and sugar that was distinctly undelicious.   At the table next to us, a young man was eating a Chinese salad.  The plate it arrived on had to be 12 inches in diameter and the hillock of salad was at least 6 inches high.  The waiter told us that this was just a luncheon portion — the dinner portion was twice as much and came on a plate the size of a tray.  An overweight African American woman nearby was eating what looked like the meal Dr. Gawande had ordered – salmon with mashed potatoes.  The salmon looked to me like over half a pound and there was at least a cup and a half of  mashed potatoes (made with plenty of butter and cream, the waiter cheerfully explained).  After downing all the salmon, she lost her valiant struggle to clean her plate  and asked to take the potatoes home.  Other folks were digging into similarly over the top portions –a burrito the size of a mini football field and a portion of meatloaf that was, again to use the waiter’s description, “gigantic.”

We finished the meal off with a piece of Reese’s peanut butter cup chocolate cheesecake, which we took home not to eat but to weigh.  One slice for one person came in at six ounces and was accompanied by a third of a cup of highly sweetened whipped cream.

In our society we are coping with record levels of obesity as well as diabetes – even in young children.  Obesity leads to all kinds of dreadful health problems – diabetes being only one, whose effects Dr. Gawande surely sees in his practice.  Not only does obesity lead to terrible human suffering, it leads to sky rocketing healthcare costs.  A 2008 article in Health Affairs estimated that the cost of caring for the obese with their complex chronic illnesses was $147 billion in that year alone.  In 1998, dealing with the health consequences of obesity took up 6.5% of healthcare spending.  By 2008, it had jumped to 9.1%.

In 2011, Science and the Public Interest gave the cheesecake factory one of its Extreme Eating awards for its Farmhouse Cheeseburger which has “1,530 calories and 36 grams of saturated fat topped with 3,210 milligrams of sodium. That’s assuming you just eat the burger: French fries bring an additional 460 calories and 1,460 mg of sodium. “ Of restaurants like The Cheesecake Factory, The Center’s nutrition director Bonnie Liebman says, “It’s as if the restaurants were targeting the remaining one out of three Americans who are still normal weight in order to boost their risk of obesity, diabetes, heart attacks, and cancer.”

In his book, The End of Overeating: Taking Control of the Insatiable American Appetite, physician and former head of the Food and Drug Administration David A. Kessler, singles out The Cheesecake Factory for its deliberate decision to overuse sugar, fat, and salt to encourage over-consumption.  Like the tobacco industry manipulated its product to encourage addiction, restaurant chains like The Cheesecake Factory are, as Gawande argues, innovative.  They use scientific innovation to make sure that their product encourages the kind of overeating that

In perhaps the understatement of the new century Dr. Gawande allows that the restaurant chain may serve portions that are a bit too big and fatty.  But he says, The Cheesecake Factory “knows its customers.”  So do doctors.  Does this mean they should continue to give us anti-biotics we don’t need and order MRIs an CTs which , patients , in our ignorance, too often demand? Which is why touting a model like the  to a chain like The Cheesecake Factory only throws fat – as well as salt and sugar – onto an out of control fire.



Showing 16 comments
  • Bindu

    Good work Suzanne, you are too kind to him!

    • Suzanne

      Thank you for writing. I am sorry to disagree. I have not misrepresented Dr. Gawande. I have instead engaged with his fundamental argument and disagree with his conclusion that The Cheesecake Factory, as he argues, produces a better product. Because this is his argument, it is simply not possible to divorce product from method. Dr. Gawande is a very respected health care writer and I admire much of his work. He has made many contributions to the debate. I think, however, that a careful reading of his article, will show that he says the Cheesecake Factory produces a quality product — a better one he says. He also talks about the innovations of the company. Sadly, the major innovation of the company, as Dr. David Kessler has documented so well, is huge portions and the manipulation of the fat, sugar and salt content of the food so that their food overrides the brains satiety signals. If Dr. Gawande had wanted to write about standardization, he could have many other companies that produce less problematic products and have better labor practices. Had Dr. Gawande done a little more digging and talked to more front line workers and as well as to line managers and company executives, he might have discovered the sorry history of the company’s relationships to its workers, which is also relevant to healthcare.

  • Cyclamen

    Suzanne Gordon totally misrepresented Atul Gawande’s recent New Yorker article. In that piece he analyzed and praised the chain’s methodology, not its product! As I recall it, the article talked about idea development, sharing, testing, testing and more testing, and then sharing the results of a successful (not healthy) product throughout the system. Not a medical person myself, I can still see where the Cheesecake Factory’s METHODS, not its products, are consistent with Gawande’s otherwise excellent ‘checklist” contribution to medicine.
    As a side (no pun intended), let me just mention also that it was Guwande’s gut-wrenching article in The New Yorker many years ago that first focused my mind on the health system catastrophe we still live with. The article opened with the story of a woman who had no teeth, and it showed how lack of basic dental care can and does lead to misery, poverty and yes, death. If this country’s leadership class really cared about the public’s health, they would stand up for an expansion and improvement of the Medicare program, such that it would cover everybody, from pre-birth to death; cut the blood-sucking insurance industry out of healthcare decision-making; free US businesses from the gigantic burden of paying for their employees’ health; and relieve the threat of bankruptcy from tens of thousands of people! We’re worth that, aren’t we?

    • Suzanne

      The comments you make are very apt as are all your criticisms. I do not in anyway approve of the unlimited discretion physicians currently have, their lack of accountability as Marty Makary has called it in his book Unaccountable, or their freedom to harm patients if they do not follow guidelines. I think, however, that Atul Gawande has compromised his own argument by choosing the wrong model to emulate. The Cheesecake Factory is not about standardization, it’s about Taylorization, something very different. And I do not believe you can abstract its production processes from its product and the harm that product does to millions of people everyday. In his article, Gawande points to a perfect example of standardization with the surgeon he describes. But that was not what got picked up by the media. Nor was that what he himself promoted in his discussions with the media. In fact, the two for-profit companies he uses as examples, the Cheesecake Factory and Cerebrus, which is now buying troubled community hospitals in New England are perfect examples of the trends you site above. Doctors who are tainted by corporate connections, who are unaccountable, etc act, in miniature, like the companies who are the models for this behavior. The Cheesecake Factory is one of the responsible and reprehensible partners in the obesity crisis, and until it divested itself of its gun manufacturing arm after the Newtown shooting,Cerberus Capital Management,owned the largest manufacturer of firearms in the world. If someone is truly interested in healthcare and public health, should he not be choosing models to emulate that are not responsible for such serious health and public health problems? In your comments, you suggest that I am throwing out the proverbial baby with the bathwater. While I believe that Gawande has written some excellent articles in the New Yorker, I and many others are disturbed by the current path this excellent writer seems to be on as he increasingly promotes the very for-profit healthcare models that are responsible for our nation’s failure to create a safe, equitable, and sustainable healthcare system.

  • Carrie

    I found this piece disgustingly ableist and fat-phobic (with a side of problematic/stereotypical racial characterizations… the only person who’s race gets described is the overweight black woman “downing” food, no out-of-context racial descriptions necessary for anyone else).

    You say “One woman was so huge, she had to use a walker.” You have NO idea why this woman needed the walker.* No clue. And you feel entitled to look at her mobility device and decide you knows exactly what it is about. No regard for this woman’s probably long story with her body and disability and maybe pain. You can have a disability and be fat too (just like most people in the U.S.). In fact, often mobility difficulty can make it hard to exercise and adds to or causes weight gain. But even if this woman’s fatness predated her need for a walker, assuming she does not have a disability (which is common – a lot of people have disabilities – about 1 in 5 in the U.S. by CDC estimates) and just needs it because of her size is a really overstepping, inappropriate, messed up, and probably inaccurate assumption.

    I think saying obesity singularly leads to those healthcare problems is not accurate – obviously it is complex, and there is a lot of debate on this issue and the medical and corporate-funded research has a fatphobic lean – but this conclusion has been challenged by some major studies.

    And if 19 people (15 overweight + 4 “morbidly obese”) of 50 were overweight or obese, this would actually be a much lower proportion than the general population. People are fat. It’s not that shocking.

    And other than that, I found this piece without much real substantial critique of Gawande’s arguments about market force healthcare – a critique that is so desperately needed.

    Carrie (a nurse with invisible disabilities, a bachelors’ in sociology of health/illness/medicine, and experience working with people with type 2 diabetes)

    *I assume you would have included it if you had an actual conversation with the woman instead of just looking at her and deciding you knew all about her body.

    • Suzanne

      I am sorry you were offended by this article. I am very concerned with the pain and suffering of those whom the food industry — like the tobacco industry — has turned into victims of practices that encourage literal addiction to high fat, salt, and sugar products that circumvent the brain’s ability to signal satiation and that create addiction to certain foods. I am sorry I disgree with your comments. I do not think serves the interests of either the nation or individuals to deny that there is an obesity crisis and that people are not served by the priorities of the American fast/processed/chain food industry.

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  • Taylor

    Suz wrote:
    Does this mean they should continue to give us anti-biotics we don’t need and order MRIs an CTs which , patients , in our ignorance, too often demand?

    and this is why hospitals ARE exactly like cheesecake factory.
    Are we really in the health promotion business or are we in the make-a profit-fast-health business?
    Take a drug, have a surgery…these are great for life-threatening emergencies but not for health promotion and long before hospitals serve cheesecake factory cheesecake to their patients in return for a payment from the chain? How many children’s hosptials house a McDonald’s? Gawande is articulating exactly how healthcare has sold out to profit

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