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Gawande on Cowboys and Pit Crews

Philip Betbeze, for HealthLeaders Media, July 19, 2011

"This is playing out in the political realm, and it makes it difficult to have a successful conversation about it. It descends into a yelling match," Gawande said. "There's not even agreement about the source of the problems. Is it government, for-profit medicine? I don't think these are the factors. Regulations and insurance hassles make our jobs more difficult. But they are not the root of the problem, they're the symptom."

Man's most ambitious endeavor is how to provide optimal capability without wasting resources. We have 13,600 diagnoses on how the human body can fail, we have 6,000 drugs and 4,000 possible medical and surgical procedures. While other industries have succeeded in driving down costs and improving quality, no single industry has to deliver on that many service lines, let alone do it every single time, he said.


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In fact, healthcare has become so complex, that no single physician can hope to do it alone. Part of the problem with healthcare costs and complexity is that we've built our system on the belief that the physician is the ultimate arbiter and that he or she should have autonomy.

"Five percent of the population accounts for 50% of healthcare costs. That's no surprise. They're sick," he said. "We've built our system on a structure that was built 50 years ago. This has forced us into a very difficult situation."

Gawande argues that the system should be built instead on the analogy of race team pit crews, which must function as a team, not as cowboys, who make all their own decisions. Part of this teamwork ethic can be applied in surgical checklists, a safety innovation borrowed from other industries based on the fact that no single person can keep track of all the processes that must be employed to provide optimum care.

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3 comments on "Gawande on Cowboys and Pit Crews"


Dean White (8/2/2011 at 4:04 PM)
Dr Gawande is a star and his books have been insightful and relevant. I agree with his premise about most Cowboys but I would argue that Michael DeBakey, Denton Cooley, Sir William Osler, Ignaz Semmelweis (to name just a few) were all "Cowboys". Where would we be with the innovation and forethought of these pioneers.

Joseph Momia (7/21/2011 at 3:42 PM)
While I agree with Dr. Gawande on many things I believe he left out a crucial reason why health care costs are so high, it's the for-profit nature of the 'business'...if we adopted a Medicare for all system like Canada or any number of systems that work very well in other countries like Japan, Denmark, Switzerland, Germany, etc. all of whom provide better care for 40-50% of the cost in US. But of course in the uS we don't have a health care 'system', instead we have the health care-industrial complex where everybody tries to wring out as many $$$$ for themselves with no regard to the consequences! But the political debate won't allow this because all of our politicians are owned by the corporate whores who run this country, and they just won't use things like 'reason' and 'common sense' to solve the problems! The VA works very well for veterans and Medicare works great for most seniors and we can cover ALL Americans for much lower costs!

Phyllis Kritek, RN, PhD (7/19/2011 at 9:45 AM)
Kudos to Dr. Gawande! He is a bright light in what often appears to be a gathering darkness. I agree that checklists are invaluable. If you read his book, you learn that he discovered checklists from RNs. We understand his message. I look forward to his next tough message: the need for physicians to understand their relationship to pit crews. I have worked for over forty years with the cowboys and I know how they can destroy the good faith efforts of those in the pit crew. He is going to eventually have to tackle this challenge more directly and precisely. When he mentions an "autocratic" system, he is eventually going to have to mention who the autocrats are.