Atul Gawande, MD, a surgeon, public health researcher and a writer for The New Yorker, advocates a mindset switch from docs as cowboys to docs as pit crews. Gawande also urges the smart use of data and a well-designed checklist for better and safer care.
Physicians have long operated as independent problem solvers, he says, but the complexity of healthcare has become more than what individual physicians can handle. That autonomy has also contributed to higher costs.
“We have trained, hired and rewarded physicians to be cowboys and what we want are pit crews for patients," he said at a recent conference in the nation's capital. "It’s a dramatic change in our culture and our way of doing things."
Gawande, who is affiliated with Brigham and Women's Hospital in Boston and serves as associate professor at Harvard Medical School, noted that physicians now have in their compendium 13,600 diagnoses, 4,000 medical and surgical procedures, 6,000 medications that can be prescribed.
Through most of the 1900s, physicians were paid to provide a service and to solve a problem they did mostly on their own with the help of a nurse and a prescription pad. In the 1970s, it took two doctors to take care of a patient in a hospital; in the 1990s, 15 physicians, each with built-in autonomy and little communication, were involved in a patient’s care.
In his research, Gawande has found that many of the healthcare organizations with the best results are among the least expensive, and the most successful behave like systems, for example like the parts that make up a car.
Changing from cowboys to pit crews will take three key skills that don’t exist right now except in small pockets:
- Recognize success and failure through the use of data. Current data can’t supply how many people had a heart attack last year or last month and what their survival rates are. If it could, physicians could pinpoint where the problems are.
- Devise solutions by thinking like other fields that are high risk and high failure. A well-designed checklist is the simplest way to get teams to work together. For example, a Boeing engineer helped develop a flight-deck type checklist for surgery, which Gawande tested in eight locations, with an average 35 percent reduction in complications and 47 percent reduction in death. Since then, VA has adopted it and has reduced deaths by 18 percent.
- Overcome the culture of resistance among physicians by making solutions simple enough to be implemented and accelerated.
Working as a well-tuned pit crew includes values of humility, recognizing that physicians can make mistakes; discipline to repeat every time what works to avoid mistakes; and teamwork that recognizes the need for skills of groups of people, Gawande said.
A century ago the nation faced another seemingly intractable problem. Food absorbed 40 percent of the family budget of Americans, half of whom were rural farmers.
What bent that cost curve, after many experiments, was a mix of public and private solutions. Government played a fundamental role by providing data. It created the National Weather Service to support farmers and supplied crop reports so farmers could see where they were failing and succeeding. Farmers’ cooperative banks enabled tenant farmers and sharecroppers to own their land and invest in it over the long term. Land grant colleges did comparative effectiveness research to compare which pesticide and which seed types offered the most value.
It took 20 years to knock prices down so food was 20 percent of family budgets.
In the clinical world, “I’d say we have eight to 10 years to make sure we drive it down," Gawande said. "But we need to bend the curve in the next few years.”
