What My Dog's Neutering Taught Me About US Healthcare – Forbes

As a doctor, I never expected my 60-lb. Samoyed to teach me something new about healthcare.
His name is Powder, though some friends and family prefer “Powpow.” He’s a 60-lb. Samoyed, white as snow and full of fluff. He came into my life last year, one of roughly 900,000 “pandemic pets” adopted in 2020.
I’d been a dog dad twice before, once with a stray spaniel named Tasha who sat shotgun on a cross-country trip from Yale’s campus to Stanford’s, where I began my surgical internship. When Tasha died eight years later, I rescued Bandit, a tireless terrier who helped me train for a dozen marathons. He passed away just before I started my 18-year tenure as CEO of Kaiser Permanente. By that point, I didn’t have the time to be a dog’s best friend.
Now there’s Powder, the perfect work companion for today’s virtual world. He lays at my feet and listens whenever I record healthcare podcasts. He trots across the background of my keynote presentations with his poufy, corkscrew tail held high. He’s gregarious, has his own Instagram page and recently required a trip to the vet’s office to “help control the pet population.”
Powder’s neutering, much to my surprise, taught me several lessons about U.S. healthcare that I’d never considered as a physician or medical group CEO.
He was only six months old when we adopted him from a military veteran. The man had just entered a lengthy rehab program and needed to rehome his dog. We promised to take good care of his boy and made an appointment that same week for Powder’s first exam. The veterinarian recommended we wait another year to neuter him, so his bones and joints could grow fully.  
When the time came, I asked how much the procedure would cost. The vet’s quote of $800 left me with sticker shock. I know a thing or two about medical pricing, so I ran the numbers in my head for the IV, anesthesia, sterile field, a short procedure and the post-operative recovery. Factoring in the lowered risk of operating on a dog vs. a human, the vet’s total was double my expectation.
I Googled “dog neutering,” along with my location, and was surprised with how easy it was to find dozens of options, each with an exact price. One animal hospital nearby, which specializes in spay/neuter procedures, charged a flat fee of $350—much closer to my calculation.
I booked an appointment online, paid a nonrefundable deposit and then, almost instantly, felt a wave of guilt wash over me.
Perhaps every pet parent feels a tinge of remorse about “fixing” an animal, even though it’s the socially responsible thing to do. And even though death rates from spay/neuter are less than 0.1% of all cases, I nevertheless worried about the risk of anesthesia, the pain following surgery and the possibility of complications, however minor.
But it wasn’t until we pulled up to the animal hospital on the day of surgery that I realized what was really at the root of my guilty conscience.  
Fifteen minutes before the doors opened, the parking lot outside the clinic was a cacophony of cars, dogs and humans. Inside, the lobby looked clean but the flooring was made of cheap linoleum and the chairs looked slightly worn. A single receptionist slowly checked in over a dozen dogs.
This was nothing like Powder’s regular vet. There, a greeter stands outside to welcome pet owners upon arrival. Three receptionists in uniforms sit behind a U-shaped partition, all with friendly faces. The tiled floors sparkle and the waiting area smells of fresh sage. Display cases feature gourmet snacks and hand-sewn toys.
One place more closely resembles the lobby of a Four Seasons hotel. The other place, the site of Powder’s surgery, looks more like the lobby of a budget hotel chain.
Suddenly, a voice inside me asked, accusingly, “What are you doing? Why are you compromising the health of your loyal and loving companion to save a few hundred bucks?”
I almost turned to leave. Seconds later, I laughed out loud, drawing strange looks from everyone in earshot. It was in that moment I realized how greatly emotions can influence our healthcare choices. Though the contrast in atmosphere between the spay/neuter hospital and Powder’s usual vet was striking, it was also totally irrelevant.
A man and his dog out on the water, sharing a paddle board
Judging by the packed parking lot and the hospital’s primary focus on spay/neuter, it was clear the vets here did a high volume of procedures. These people were pros with well-honed surgical skills and all the necessary equipment to get the job done right.
The cheap linoleum and lack of a greeter had no bearing on the quality of care. I realized I had subconsciously mistaken style for substance.
At Stanford University, I teach graduate business-school students about high-volume surgical facilities around the world: the Aravind eyecare system in Tamil Nadu, the Shouldice hernia hospital in Ontario and the Narayana cardiac hospital in Bangalore. Each facility focuses on a single procedure and nothing else. Inside, teams of highly trained surgeons spend their days repeating the same operative steps, over and over, achieving near-perfection.
You would expect outstanding quality from such frequent repetition. After all, professional golfers practice their swings and dancers rehearse their routines until the movements become muscle memory—that seamless and unconscious flow between the brain and the body. Surgery works the same way. Repetition leads to mastery, which leads to superior results.
That’s precisely what these world-renowned surgical centers deliver: consistently great results with fewer complications (from medical errors or infections). And when you combine hyper-specialization with high volume, you also attain economies of scale, which leads to dramatically lower costs. These hospitals don’t feature marble flooring or crystal chandeliers like their global competitors, but their clinical results match or exceed the quality of even the best hospitals in the United States—all at a fraction of the price.
Nevertheless, both doctors and patients harbor biases against these places. In the United States, patients wrongly equate the dull façades and spartan interiors of high-volume surgical centers with poor quality. Meanwhile, many doctors dismiss these facilities as inferior. In their minds, medicine isn’t some assembly-line product. It’s a craft, a creative skill, an art form. And they believe this in spite of overwhelming data that link high-volume and standardization to superior quality outcomes.
As the vet assistant took my furry friend through the back door for his procedure, I knew I had made a wise decision. Of course, Powder might have experienced an equally quick and complication-free recovery had his regular vet done the operation. But there was no reason to think the results would have been better—regardless of the fancier atmosphere and higher price.
My new book “Uncaring: How the Culture of Medicine Kills Doctors & Patients” is all about helping patients understand their doctors and the way medical culture shapes the world of healthcare—for better and worse.  
In one of the final chapters, I spell out nine questions everyone should ask their physician. Two of them apply to surgery, either for dogs or people: (a) How many of these procedures did you do last year and (b) What was your complication rate?
While there’s no guarantee a surgeon who did 35 operations last year is better than a surgeon who did 30, both are likely to achieve better outcomes than a surgeon who did fewer than 10.
Despite my research and acquired expertise, I’d fallen into the same psychological trap as many patients, relying on surrogate measures for quality: a posh waiting room, friendly receptionists and “premium” prices. It’s one thing to know the facts, intellectually. In fact, I’ve spent the past six years teaching about high-volume centers of excellence. But I’d never fully appreciated the intense emotional pull that higher prices and luxury trappings have on our perceptions of quality as patients and family members. The latter serves as a powerful force, resulting in irrational choices.
As consumers, we usually get more when we pay more. Although a $60,000 car isn’t necessarily three times better than one priced at $20,000, it will likely have more of the bells and whistles you desire.
That’s not the case in healthcare. Back in 2008, the Pacific Business Group on Health looked at the cost of hip replacement surgery and found that prices varied from $30,000 to over $100,000 without any measurable difference in outcomes.
In healthcare, choosing the more expensive option is common because insurance usually insulates patient from the full costs. After all, who wouldn’t select the more expensive car if someone else was going to pay the extra $40,000?
But there is no correlation between higher prices and better outcomes in medicine. Expensive brand-name drugs are identical to generics. Heart hospitals in India achieve identical results to cardiovascular surgeons in the U.S. at a fraction of the cost. And, of course, vets with extensive experience in spay/neuter procedures are just as good as the vets who charge double for the same service.
In healthcare, the old adage about getting what you pay for is accurate, but only once you realize what you’re buying is the illusion of better medical care, not the real thing.

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