Cowboys and Pit Crews

June 1, 2011 5:01 PM

The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people. We train, hire, and pay doctors to be cowboys. But it’s pit crews people need. - Atul Gawande’s commencement address at Harvard Medical School.
posted by AceRock (18 comments total)

We have amazing and intuitive fighter pilots. We give them checklists, because statistically it produces better outcomes and we avoid sticking hundreds of millions of dollars of hardware and pilots in the ground. Medicine isn't that different, it's just that the risk is borne by the patient rather than the practitioner.
posted by jaduncan at 5:27 PM on June 1, 2011

The best way to learn any skill is to make mistakes; unfortunately in medicine, the cost may be a human life.
posted by Renoroc at 5:44 PM on June 1, 2011

A big part of what I do for a living is supporting efforts to get doctors to start looking at medicine in this way. It is shockingly and depressingly difficult to do for many of them.
posted by middleclasstool at 6:38 PM on June 1, 2011

I suppose I should emphasize there that I'm speaking for myself, not my employer.
posted by middleclasstool at 6:40 PM on June 1, 2011

Seems like a lousy analogy to me. I, for one, have only the haziest idea of what a pit crew does -- maybe the average Harvard Med student is a bigger NASCAR buff than I -- but at least as far as pit stops go it seems like a highly practiced and mechanical activity. AFAIC he might as well have said that doctors need to be more like assembly line workers. It seems both uninspiring and inaccurate.

The air crew analogy works, IMO, not only because the history behind those practices is obviously analogous to the way medicine is progressing, but also because it's more obviously pointing out that "you do it this way because it's mind-bogglingly difficult." You don't think of pilot checklists as useful not because it makes flying simple but because it leaves the pilot free to concentrate on the actual, difficult work.

I guess what I'm saying is, if he wants people to accept his ideas, he could try to sell them a bit better.
posted by bjrubble at 6:48 PM on June 1, 2011

Gawande on hospital practice: It’s like no one’s in charge—because no one is.

QFT.
posted by Apropos of Something at 8:14 PM on June 1, 2011

AFAIC he might as well have said that doctors need to be more like assembly line workers. It seems both uninspiring and inaccurate.

This is exactly correct: by applying a consistent process you get more consistent results and you spend less time and money fixing errors. With knowledge workers the emphasis is on making sure they don't jump to conclusions in the middle of the process and start working on a solution to the wrong problem. Doing a particular thing the same way has a bit more overhead and is a bit more tedious than just winging it, but doing something over again because you did it wrong the first time can be pretty tedious as well.

Your objections have been brought up in every industry that has ever tried to adopt this approach. Generally the only way people buy into it is by being backed into a corner and having no choice left but to give it a try. It takes a counter-intuitive way of thinking to work this way, but it has been shown time and again to be more efficient in the long run when fully implemented.
posted by cardboard at 8:19 PM on June 1, 2011 [2 favorites]

I strongly recommend checking out Gawande's book Better if you're interested in this conversation.
posted by hepta at 10:27 PM on June 1, 2011

The best way to learn any skill is to make mistakes; unfortunately in medicine, the cost may be a human life.
posted by Renoroc at 8:44 PM on June 1

laciretsynope
posted by aws17576 at 11:27 PM on June 1, 2011 [1 favorite]

he might as well have said that doctors need to be more like assembly line workers

Gawande's three points are: create accountability, use checklists, and orchestrate your teams.

Here in the UK this excellent advice is increasingly being implemented by private firms that run public services and they're leading to better patient experiences (mostly shorter waiting times). most patients wont even realize its an NHS service with NHS staff that isnt being run by the NHS....

in a private-run public health service the doctors are members of the technical staff (who happen to get paid well).
posted by dongolier at 12:37 AM on June 2, 2011

This is exactly correct: by applying a consistent process you get more consistent results and you spend less time and money fixing errors.

It's also a very hard sell. A lot of doctors sneer at what they call "cookbook medicine" because they view themselves more as practitioners of an art and guardians of arcane knowledge than scientists. Getting them involved in collecting and studying patient population data, applying evidence-based medicine principles and using clinical decision support systems -- hell, just getting them to use checklists for patient safety is often an uphill battle, because many take it personally, as if those raising the point are demeaning their importance or questioning their skill.

The NASCAR analogy actually might get some traction with a lot of doctors, because doctors tend to be a conservative bunch, but it could also backfire. Everybody wants to drive the car; nobody wants to be the guy who changes the tires.
posted by middleclasstool at 5:03 AM on June 2, 2011 [3 favorites]

Here in the UK this excellent advice is increasingly being implemented by private firms that run public services and they're leading to better patient experiences (mostly shorter waiting times). most patients wont even realize its an NHS service with NHS staff that isnt being run by the NHS....


This style of medicine is probably much more acceptable in the UK given the significant underqualification of doctors here. It takes laughably little education to be a doctor in UK compared to the rest of the developed world.

Checklist based medical systems explain why outcomes are not worse. I still got the correct treatment for Shingles from my local GP even though he had no clue that Shingles is a secondary infection from Chicken Pox (never mind that he practically hid in the corner of his office!). He didn't need to have a clue about the disease to enter the symptoms in the software and read the diagnosis and treatment off the screen. That said he couldn't answer my question as to whether I was contagious for Chicken Pox and should avoid contact with people who could catch it.
posted by srboisvert at 6:52 AM on June 2, 2011 [1 favorite]

As a doctor in training and someone who as worked in the healthcare field the last few years is that most people don't need a doctor. They need better health education, access to good food, spare time to cook said food, and time to walk around/excercise.
When they do need a doctor usually the problem(diabetes, heart disease,etc) is complicated enough that several staff are required to take care of them. Even in primary care they are moving towards having case managers to coordiante the care between nursing, PCP, specialist, patient educators, and therapists.
Most of this is a function of living in a modern society with specialized domains of knowledge.
posted by roguewraith at 8:47 AM on June 2, 2011 [1 favorite]

A friend of mine is sick and in pain most of the time. It isn't as if she hasn't been to doctors, many. It isn't as if tests have not been performed, often. It isn't as if she hasn't had operations, plural. She is, however, still sick and still in pain and still has zero idea of what is causing it. Just having a diagnosis would make her life easier.

I realize that mistakes get made and nobody is perfect. That is fine. Somewhere along the line, though, stuff like this needs to be Dealt With in a Reasonable Fashion.
posted by adipocere at 9:04 AM on June 2, 2011

It takes laughably little education to be a doctor in UK

the emerging role for GPs is to diagnose illness at a very basic level: they write referals to specialists for things they cannot treat.

a secondary role is to fast-track refer cancer-like lesions and there are enough sad, horror stories to really mandate shorter wait times---although the current administration is rolling-back the two-week rule to save money---which it wont.

i personally dont mind when my GP sits there with google and prints out some stuff from patient.co.uk to answer my questions----there's simply too much medical information now to expect the "G" in "GP" to mean anything more than "Google".

better than google is my personal favorite: the free full text NIH site PubMed Central

-------
adipocere: is you friend in america? the american system doesn't own people's problems, there is a moral hazard to continue (expensive) investigation without really eliminating illnesses one-by-one. while plenty of people in the UK suffer with undiagnosible pain, its only after an exhaustive, comprehensive analysis---and its illegal to prescribe treatment that is not clinical proven.
posted by dongolier at 9:23 AM on June 2, 2011

I'm a big fan of Gawande's work, and I think about it quite often when I'm working at the hospital as an RN.

Gawande talks about how physicians must be specialists these days, even the GPs, but we also know that the increasing specialization in medicine is a contributing factor to rising healthcare costs. As much as I love the idea of an integrated team working together like a pit crew, the process of getting to that system is really filled with landmines. Consulting a wide variety of specialists to work on a case is vastly different from working together as a team, and I can only imagine that it's vastly more expensive. Unfortunately that seems to be the tentative first step that is being made toward this "pit crew" approach he's advocating, and I worry that it will backfire.

As an RN in a hospital, I see some attempts to get the doctors working as teams. Different specialties are consulted, and sometimes a care coordinator plays phone tag to get them all on the same page with a patient. It's better than one doctor trying to pretend he or she knows enough independently to handle a complex case. But do these doctors ever get together in a room to hash out what's going on with the patient and what the plan of care should be? No. It's a good day when they write a decent note in the computer and read the other specialists' notes too.

They walk into a patient's room, maybe give their name or say that they're a doctor (maybe not), listen to the heart and lungs, nod a few times, and then head out. Patients are always asking me, "Who was that guy?" "That was Dr. So-and-So." "Oh, right... Now which specialty is he again?" Patients have people ducking in and out of their rooms all day and night, and they have very little chance of keeping them all straight. Even the patients who are really awake and not troubled by pain or delirium, even the patients whose families are present 24x7 and taking notes each time a doctor visits, even these lucky few have trouble keeping track of the "team."

So yeah, it's great that more specialists are being called in to help treat a patient. But it breeds a lot of confusion, not only for patients and families but also for everyone on the "team." As a nurse I spend a fair amount of time trying to resolve confusion or conflict between various physicians' orders. I know that pharmacists and imaging techs and respiratory therapists and all the other people who work in health care do the same. I would be able to provide better, direct, hands-on care to my patients if I wasn't spending that time on the phone trying to sort things out, so I know without a doubt that the confusion leads to lower-quality, more expensive care.

If I have one quarrel with this speech, it's that Gawande doesn't give any concrete ideas about how to form the teams he envisions. It's not a simple matter of getting more doctors involved in a case, but that seems to be the way the industry is heading. To use his analogy, a bunch of lone cowboys does not make a team.
posted by vytae at 10:37 AM on June 2, 2011 [1 favorite]

The NASCAR analogy actually might get some traction with a lot of doctors, because doctors tend to be a conservative bunch,

Doctors have become less politically conservative as small practice medicine has become less economical, and those who remain conservative, are not of the NASCAR sort.
posted by blargerz at 11:31 AM on June 2, 2011

But do these doctors ever get together in a room to hash out what's going on with the patient and what the plan of care should be? No.

Not the hospital setting, but we're slowly seeing some progress made in the physician office setting with those doctors who are setting up their practices to be a patient-centered medical home.

Often the implementation involves having PAs or APNs to handle the physicals and colds and quick-hit stuff like that, and leave the doctors for the difficult and chronic cases, organized into care teams. One practice I know of physically built their facility around this principle. The rooms are all arranged in a ring with two doors each: one on the outer wall to the hallway, the other on the inner wall to a central hub room where nurses, doctors and Pharm.Ds can consult on patients together. For those practices that have figured out how to do it well, PCMH has been a positive transformation for their practice and patients. But they're still a minority.

Once we get enough doctors meaningfully exchanging patient data through health information exchanges, that has the potential to really help things along too. There's way too much duplication of effort going on, and not near enough communication between PCPs and specialists.
posted by middleclasstool at 12:17 PM on June 2, 2011