Gawande on Cowboys and Pit Crews

Philip Betbeze, for HealthLeaders Media , July 19, 2011

Although hospitals have introduced technology to cut down on mortality, the death rate from surgery has remained high. About 150,000 deaths a year are attributed to surgical complications, but about half are avoidable, Gawande says.

Part of the frustration stems from the fact that although checklists in surgical situations have been proven to reduce complications and costs, hospitals, health systems and physicians, with many notable exceptions, continue to resist them.

"I spend half my time as a surgeon building checklists," he says. "Many industries that grapple with high risk and high failure depend on them, like skyscraper construction or airlines." Boeing, whose top safety engineer is helping on this project, says a good checklist undergoes as many as 50 revisions before it is incorporated into practice.

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But the results are undeniable.

"Through use of this successful two-minute checklist, patients had a 47% lower death rate and complications dropped by one third," he says. "VHA has tried it across 74 hospitals; results show an 80% drop in mortality."

So why is adoption so slow?

"If we had a drug that could cut complications by this much, everyone would implement it, we would have ads all over TV, and lots of people would become rich from it. But it's free, and ironically, that's part of the problem," he said. "Contained in checklists are values very different from what we have in many cases. It requires humility, discipline,  and teamwork."

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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.




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