Cowboys and Pit Crews

… or what’s wrong with medicine today

Copyright 2008. United States National Guard Bureau.

I came across a speech in the New Yorker given to a graduating class of medical students by Dr. Atul Gawande that I wish I had seen in person, but if I had I wouldn’t have this awesome transcript to refer back to.

Dr. Atul Gawande is a staff writer for the New Yorker but also a surgeon with a current practice. He deals mostly with military surgical research and research dealing with medical errors. He also is a director for the World Health Organization and was a senior health policy adviser for President Clinton.

In the speech, he talks about how the older generation of physicians lament getting into medicine and how if they were given the option today they would not do it. This is mainly because of insurance hassles, regulations, litigation, but also that medicine has becoming exceedingly complex, even beyond the capabilities of the most capable physician.

This strain, he continues as I paraphrase, is based on how medicine is structured and practiced. In the days of old doctors were the sole source of information and skill in the hospital. There were no lab technicians, legions of other specialists, and armies of nurses involved in the care. As he says:

One needed only an ethic of hard work, a prescription pad, a secretary, and a hospital willing to serve as one’s workshop, loaning a bed and nurses for a patient’s convalescence, maybe an operating room with a few basic tools. We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly.

Now, all the information needed to create a diagnosis can not be done by the individual physicians because either a case is so complex that it requires more than the individual to diagnose and fix it or that the protocol created by years of litigation (hence to avoid further litigation) demands it. The number of required hands in medicine has grown from 2.5 in 1970 to more than 15 today. He states that most hospital based infections and surgical mistakes could be avoided with anti-septic techniques and current knowledge. With so many hands, control is lost, and a loss of control equals mistakes. Every physician is supposed to be a cowboy, but medicine requires pit crews. A team approach to create a continuum of care (a buzz phrase my wife uses a lot) makes sure that everyone is on the same page.

“Another sign this is the case,” he continues, “is the unsustainable growth in the cost of health care. Medical performance tends to follow a bell curve, with a wide gap between the best and the worst results for a given condition, depending on where people go for care. The costs follow a bell curve, as well, varying for similar patients by thirty to fifty per cent.” He notes, however, that the best care usually comes from a cheaper source, and those sources are usually those best organized like a system.

The system has to be coordinated and have a common interest, and requires skills and knowledge not commonly taught to today’s doctors. I summarize the main points:

  1. You must recognize when you’ve succeeded, and when you’ve failed.
  2. You must be able to devise solutions for system problems that data and experience reveal.
  3. Leadership that gets everyone organized under the same banner, being a cohesive system that works for patients.

So what does he champion? The results may shock you.


Yes, checklists.

Properly designed checklists can reduce errors, as they have shown in all industries that combine high complexity and high risk. Sound familiar?

Leadership must be strong. As Dr. Gawande notes:

There is resistance, sometimes vehement resistance, to the efforts that make it possible. Partly, it is because the work is rooted in different values than the ones we’ve had. They include humility, an understanding that no matter who you are, how experienced or smart, you will fail. They include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures. And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy.

This is already rooted in the basics of Six Sigma, and how process standardization has created a system with so many successes that they far outweigh the failures by lowering costs associated with mistakes. As the mistakes go, so do the costs associated with mistakes. Those costs are spread out all through society. We have seen recent attacks on governmental employees and professionals, one of the many benefits being attacked is health care because of rising costs. Medicine, it seems, really does lead to an impact on quality of life. How we define that quality, in either healthy individuals or dollar signs, seems to be inversely proportional to each other. The fewer healthy individuals the more the cost. Are we a sick nation?

Medicine must come together as a system, and that involves EMS as well. Around me I see much of the “Us vs. Them” mentality. EMS vs the ED staff, hospital vs hospital, and the list goes on. I came from a system with no such barriers, where there were open lines of communication between hospitals, and many times I was sent in a big ambulance bearing the name of one hospital to a supposed “rival” hospital to pick up a patient that that hospital couldn’t treat. It wasn’t because they didn’t have the equipment, it was because the experts were elsewhere. Transfers based on the needs of the patient and not that of the hospital’s profit margin. Novel idea.

Dr. Gawande finishes the speech best, and I’ll close with his words:

Recently, you might be interested to know, I met an actual cowboy. He described to me how cowboys do their job today, herding thousands of cattle. They have tightly organized teams, with everyone assigned specific positions and communicating with each other constantly. They have protocols and checklists for bad weather, emergencies, the inoculations they must dispense. Even the cowboys, it turns out, function like pit crews now. It may be time for us to join them.

You can read the speech in it’s entirety here:

  • Dr. Gawande’s book the Checklist Manifesto is on my “to-read” list. Perhaps we should have a book club to read the book and then discuss it on an episode of the EMSEduCast podcast. Who is interested?

    • Bill Toon

      I have read all three of Dr. Atul Gawande books.  All are very good and I think a good read for all EMS providers.

  • Dr. Gawande’s book the Checklist Manifesto is on my “to-read” list. Perhaps we should have a book club to read the book and then discuss it on an episode of the EMSEduCast podcast. Who is interested?

    • Bill Toon

      I have read all three of Dr. Atul Gawande books.  All are very good and I think a good read for all EMS providers.