Cowboy or Pit Crew?

Posted by VISTA Staffing on Oct 7, 2014 12:55:00 PM


In a recent TEDTalk*, Atul Gawande set out his prescription for healing medicine. Gawande is a general and endocrine surgeon at Brigham and Women’s Hospital in Boston, and a staff writer for The New Yorker. His talk included a little history, a little psychology, and, in my opinion, good news for locum tenens physicians.

Gawande explains that the structure of current-day medicine was established in the late 1930s. He quotes Lewis Thomas, author of The Youngest Science, who said that in those pre-penicillin days a hospital patient probably benefited more from the warmth, food, shelter, and caring attention of a nurse than from a doctor’s care. Doctors had a handful of treatments for a handful of recognized conditions and if they didn’t kill you with one of those treatments (i.e., mercury and arsenic to treat syphilis), you would likely get better.

“You could keep what was known in your head,” he says. “You could do it all.”

This reality led to a “craftsman” structure for health care that attracted daring, courageous, independent, self-sufficient practitioners. Autonomy held the highest value.

Fast forward a couple of generations, Gawande says, and healthcare practitioners have access to treatments for tens of thousands of conditions, 4,000 medical and surgical procedures, and 6,000 drugs. We have reached a point where one person can no longer keep it all in his or her head. And it’s a wrong to try. Every provider is now a specialist to some extent. For example, he says, in 1970 a hospitalized patient was cared for by two people, usually a doctor and a nurse. In 2000, a hospitalized patient was care for by the equivalent of 15 clinicians. The complexity can only have increased in the 12 years since, leading Gawande to this conclusion:  “[In medicine,] we have trained, hired and rewarded people to be cowboys, but it's pit crews that we need.”

What a perfect image. If you think about a pit crew in action you think “communication,” you think “distinct roles,” you think “system.” Gawande’s team at Harvard was asked by the World Health Organization to find a way to reduce deaths during surgery. Instead of simply recommending more training or better technology, the team looked at other high-risk occupations—skyscraper building and aviation. They found systems.

Systems, he explains, have to have these skills:

  1. The ability to recognize success and failure through data.
  2. The ability to devise solutions.
  3. The ability to implement despite deep-seated resistance, which requires a willingness to embrace a different set of values, namely humility, discipline, and teamwork.

While exploring successful systems, they discovered checklists. Not as tools to help the weakest link, but as tools to make the experts better. Tools to provide the best care at the lowest cost.  Reminders of key things that are often forgotten. “Pause points” when it is possible to identify problems before the problems become disasters, “pre-flight” if you will. Their 19-item, two-minute checklist for surgical teams includes the mundane—Was antibiotic administered?—to the intriguing—Has everyone in the OR introduced him or herself at the start of a shift? The checklist has been introduced in eight hospitals from rural Tanzania to the University of Washington in Seattle, and has resulted in a 35% decrease in complications and a 47% drop in death rates.

This shift in thinking creates a tremendous opportunity for locum tenens physicians who, by nature and circumstance, are more pit crew than cowboy. You have the ability to be daring, courageous, and self-sufficient, but you have the insight to know that you will better serve your patients and yourself by collaborating with your new colleagues. Based on decades of conversations with locum tenens doctors before and after assignments, I believe having standard protocols and checklists that get everybody on the same page will help you settle in quicker and ramp up faster. I think it will make your experience in multiple systems across the country and the globe even more highly valued.

Atul Gawande closed his TED Talk by explaining how the same insights have reached cowboys. “I know because I met a cowboy,” he says. “And I asked him what it’s like to herd thousands of cattle over hundreds of miles. ‘Well, ‘ he said, ‘we have cowboys stationed across the range and we communicate electronically constantly. And we have protocols and checklists for how we handle everything from bad weather to emergencies or inoculations for the cattle.”  Well I’ll be danged. Cowboys in pit crews. Who knew?

* TED is a nonprofit organization devoted to Ideas Worth Spreading. It started out (in 1984) as a conference bringing together people from three worlds: Technology, Entertainment, Design. Since then its scope has become ever broader. Along with two annual conferences -- the TED Conference in Long Beach, Ca., and Palm Springs, Ca., each spring, and the TEDGlobal conference in Edinburgh, UK each summer -- TED includes the award-winning TEDTalks video site, the Open Translation Project and TED Conversations, the inspiring TED Fellows and TEDx programs, and the annual TED Prize.

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About VISTA Staffing Solutions

Founded in 1990, VISTA Staffing Solutions helps hospitals, medical practices, and government agencies in the US optimize their physician staffing, ensure quality and continuity of care for patients, and maintain financial stability. A leading provider of US Locum Tenens and Permanent Physician Search Services, VISTA has over 28 years of experience providing award-winning service in the locum tenens industry.

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