June 17, 2020 0 By admin

The model of the “cowboy” researcher has its roots in the world of basic As Atul Gawande writes: Gawande A. Cowboys and pit crews. “The invitation to give this lecture was a chance for me to think about systems improvement in historical terms,” said Atul A. Gawande, MD, MPH, FACS, who. GAWANDE: We have trained, hired and rewarded people to be cowboys. But it’s pit crews that we need, pit crews for patients. There’s evidence.

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And on the show today, ideas about Rethinking Medicine.

Pioneers and pit crews

We are trained, rewarded and hired to be cowboys. And what the individual clinician says is what goes. Atul’s a surgeon at Brigham and Women’s Hospital in Boston. He’s also a researcher and writer.

You might have read his work in The New Yorker. And Atul says medicine’s cowboy culture just isn’t working. My mother had a straightforward knee replacement that she needed. I hung out with her for the three days she’s in the hospital and then the few days afterwards while she was in rehab.

And I’m pretty bored. And so I just decided to count the number of nametags that came into the room, someone who either made a decision about her care or physically touched her and executed on her care. And in the course of that short period of time, it was 66 different people Eight different physical therapist, for example. And if they were not on the same page, it could be infuriating. A physical therapist comes in the morning and says, what are you doing in bed?

You should be out of bed. And then the afternoon, the physical therapist – a different one comes in. And they could end up saying, what are you doing out of bed?

You should be in bed. In a world of 66 different clinicians – smart, great hardworking people – having autonomy be their highest value, it’s a cacophony of everybody saying, listen to me, listen to me. And you want to scream, who’s in charge? But the thing is – medicine wasn’t always like this. It wasn’t always so complicated. There was a time when one doctor could know and do everything.

Atul Gawande tells a story of how that came to be from the TED stage. And he wrote this book at the Boston City Hospital in the pre-penicillin year of This was when the core structure of medicine was created.

It was at a time when what was known, you could know. You could hold it all in your head. And you could do it all. If you had a prescription pad, a nurse, a hospital that would give you a place to convalesce – maybe some basic tools – you really could do it all. You set the fracture. You drew the blood. You spun the blood and looked at it under the microscope.


You plated the culture. You injected the anti-serum.

Pioneers and pit crews

This was a life as a craftsman. As a result, we built crsws around a culture and set of values that said what you were good at was being daring, courageous, independent and self-sufficient.

And that changed and evolved as knowledge exploded.

We suddenly came into a world where we had not only enumerated all the different kinds of conditions that human beings could have to, now, a number more than 60, different ways our human body can fail. But we had generated thousands of drugs. And then we designed 4, medical and surgical procedures.

And atup trying to deploy that capability town by town to every person alive. And none of us can grasp the entirety of it. We have trained, hired and rewarded people to be cowboys. But it’s pit crews that we need, pit crews for patients.

There’s evidence all around us. Forty percent of our coronary artery disease patients in cfews communities receive incomplete or inappropriate care. Sixty percent of our asthma, stroke patients receive incomplete or inappropriate care.

Two million people come into hospitals and pick up an infection they didn’t have because someone failed to follow the basic practices of hygiene. There’s another sign that we need pit crews. And that’s the unmanageable cost of our care. Now, we in medicine, I think, are baffled by this question of cost. We want to say, this is just the way it is.

But as we’ve looked at the data, we found that the most expensive care is not necessarily the best care. And crdws best care often turns out to be the least expensive. And what that means is there’s hope. When we look at the ones who are getting the best results at the lowest costs, we find the ones that look most like systems are the most successful. That is to say, they found ways to get all of the different components to come together into a piy. I got interested in this when the World Health Organization came to my team, asking if we could help with a project to reduce deaths in surgery.

The volume of surgery had spread around the world. But the safety of surgery had not. You know, so I became fascinated with the question of, you know, medicine is not the only field in which the knowledge and the skill has exploded in ways that have exceeded the ability of the individual.

And now you’re having to have teams of people come together. One example is construction, right? You know, I visited a skyscraper construction site.


And on the day I came to visit, there were people on site from 60 different subcontractors. I was like, how do they do this? It’s like a patient who has 60 different specialists who are all supposedly there to help them out.

How in the world did they make this happen? The answer was that it wasn’t an architect. It wasn’t an engineer. It wasn’t a contractor. In the middle of it was someone they called the project manager who sat in a room with the checklists of the day.

Spread across the wall was a checklist. The police had to come and shut down the road in order for these giant girders to get delivered. There had to be a receiving team – you know, the electrical people had to be told not to show up until later in the day.

And it was all a system that treated it as a project with many moving parts coming together for the sake of their client. So the starting place began with just saying, let’s create a checklist for surgery. Part of what the checklist did was it forces you to name and prioritize – what are the most critical, key elements that we can miss?

So we did this. We created a item, two-minute checklist for surgical teams. We implemented this checklist in eight hospitals around the world deliberately in places from rural Tanzania to the University of Washington in Seattle. We found that after they adopted it, the complication rates fell 35 percent.

It fell in every hospital it went into. The death rates fell 47 percent. This was bigger than a drug. And it’s been slow to spread. There’s a deep resistance because using these tools forces us to confront that we’re not a system, forces us to behave with a different set of values. Just using a checklist requires you to embrace different values from ones we’ve had, like humility, discipline, teamwork. This is the opposite of what we were built on – independence, self-sufficiency, autonomy.

Gawande on Cowboys and Pit Crews | HealthLeaders Media

I met an actual cowboy, by the way. I asked him, what was it like to actually, you know, herd a thousand cattle across hundreds of miles? How did you do that? And he said we have the cowboys stationed at distinct places all cowboyys. They communicate electronically constantly. And they have protocols and checklists for how they handle everything from Bad weather to emergencies or inoculations for the cattle.

Even the cowboys are pit crews now.