Friday, June 3, 2011

"Cowboys and Pit Crews," Atul Gawande

Dr. Gawande's commencement address to Harvard Medical School's 2011 class has been making the rounds. His thesis is that medicine has become so complex that it is beyond the capability of most of its practitioners to keep in their heads everything they must keep in their heads. The solution is to reorient how doctors at all levels think of their jobs: instead of being "cowboys," i.e., people who solve problems on their own, they need to become organized into "pit crews," people who are able to work in teams with the shared goal of giving the patient the best treatment.

Dr. Gawande's diagnosis (ahem) of the problems facing doctors today seems pretty accurate to this non-doctor. I like one of his specific proposals: adopting checklists, a simple but efficient tool adopted by numerous technically challenging fields like aviation and submarining. He neatly and unexpectedly links increased health-care costs to reduced spending on education by mentioning his encounter with the superintendent of his children's school district.
I told him how worried I was to see my kids’ art classes cut and their class sizes rise to almost thirty children in some cases. What was he working on to improve matters? I asked.

“You know what I spend my time working on?” he said. “Health-care costs.” Teachers’ health-benefit expenses were up nine per cent, city tax revenues were flat, and school enrollment was up. A small percentage of teachers with serious illnesses accounted for the majority of the costs, and the only option he’d found was to cut their benefits.
I think Dr. Gawande is quite perceptive when it comes to the challenges of transforming cowboys into pit crews. However, a throwaway remark suggests that he is consciously avoiding a giant obstacle in the road.
I spoke to a hospital executive the day after he’d presented to his board a plan to reorient his system around teams that focus on improving care outcomes, improving the health of the community, and lowering its costs of care. The meeting was contentious. The aims made sense, but hospital finances are not based on achieving them, and the board wasn’t sure about asking payers to change that. The meeting ended unresolved.
[emphasis mine]

The problem is not rooted only in how our doctors are trained. It is embedded in the way our current system of paying for health care allows insurers to dictate how care is provided. The insurers have built their businesses around the way things are done today. It's a lucrative business indeed, and it will require extraordinary measures to induce, or more likely to compel, those insurers to come around to Dr. Gawanda's patient-centric model. That treatment model, after all, would almost certainly affect the insurers' business model, perhaps drastically.

The fact that the unknown hospital board didn't come to a resolution suggests that getting doctors on board with Dr. Gawanda's prescription may be a lot easier than getting the bean counters to go along. Getting doctors to set aside their egos is one thing: getting businessmen to sacrifice their profits is something else.

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