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Gawande on Cowboys and Pit Crews

Philip Betbeze, for HealthLeaders Media, July 19, 2011

Teamwork, by and large, is hardly ingrained in healthcare, an autocratic system if there ever was one.

And the system is costly. "Healthcare costs are the fundamental issue of our generation," he said. Gawande used a historical analogy to illustrate the seriousness of the problem.  

In the 1900's, it was food. Forty percent of income was spent on food and 50% of the population depended on agriculture for employment. Governments rose and fell over this issue. It was responsible for tens of millions of deaths. The market couldn't solve it. Food was largely produced by tenants and sharecroppers. It didn't pay to invest in mechanization.

Food shortage was one of the reasons Communism developed. It failed too. The incentives were all wrong. But through a combination of government and private solutions, the food problem was largely solved in the developed world. It was solved by providing farmers with knowledge and power. It used comparative effectiveness and financed incentives. The government funded agricultural extension services, the National Weather Service, and other programs. Financial incentives helped develop a nation of farmers who owned their land. In one generation, outlays for food went from 40% of income to 20% and only 20% of employment depended on farms.

The most difficult skill in this transition attempt is leadership, Gawande contends. "The hardest thing to do is lead institutions -- to make those necessary changes.

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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.