Wednesday, August 29, 2012

In Defense of the American Cowboy

Atul Gawande, MD is a brilliant writer, no-doubt an excellent surgeon, and many would say a physician-visionary for all that ails America’s health care system.  He speaks first-hand of the changes that have occurred in American health care and recently offered his perspective for fixing our health care system to the fertile minds of Harvard’s recent graduating class of 2011.  In his graduation speech, published front and center (yet again) in the New Yorker magazine, he compares a “pit crew” model of health care delivery to an earlier day of individualized health care delivered by those he calls “cowboys.” In his piece, he dismisses the attributes of the independent-thinking physician “cowboy” because he claims, quite correctly, that no one doctor can possibly comprehend every aspect of medicine these days.  He implies that people who work in a larger, bureaucratic centralized locales in specialized and coordinated "pit crews" implicitly save costs and improves efficiencies.   He posits that by dividing the vast medical knowledge base amongst individuals that refine and practice a multitude of specilized skills on an individual that health care for the masses will succeed. 

So what could possibly be the problem with such a vision? After all, this vision seems so comfortable and reassuring given our health care system's need to save money while extending coverage to a larger portion of our populace.

To answer this question, perhaps Mr. Gawande should have delved into his “pit crew” metaphor a bit further.

Pit crews, by their definition, are highly trained, highly selected individuals that work on a specially formulated race car that would be the envy of any race car enthusiast. These professionals understand the very real value of working as a team: so their particular race car can complete a certain number of laps around a single racetrack in the shortest amount of time. Pit crew members, then, are highly committed to working faster and faster while streamlining their processes.  They have an intimate working knowledge of their highly specialized race car; they know each lug nut, each brake pad, each tiny screw down to its finest detail. In that sense, there are only a limited number of permutations of possible variables that are available for tweaking pit times. So they hone their efforts and as they gain confidence, their driver gains confidence in them, too.  He sees their speed, he sees their safety checks, so his confidence builds, too. Hour after tireless hour, the car, the training, the track, is the same.

But what happens when there is not one car or one track, but an infinite variety of cars entering the pit from all directions?

Suddenly, the pit crew is thrown into disarray. The benefits and safety aspects of the predicable “pit crew” model quickly dissolves. Suddenly, the pit crew isn’t sure which wheel or lug nut or brake pad to apply to each new-model car since their available supplies are limited to only their model of race car. Speed, however, remains of the essence.  Consequently, the whole mentality for car care shifts from a specialized "pit crew" to that of an assembly line approach: grab what you can, slap it on, and hope it works. Throughput, you see, is the real goal. No longer is there an allegiance to the car or the driver.  The pit crew becomes disenchanted and before you take the first lap, the Indy 500 “pit crew” morphs into the old failed Chrysler production line crisis of 2009. Pit crew members’ judgment is quickly superseded by a Pit Boss or car owner who has no clue of the frontline challenges. Just get 'em in and get 'em out as cheaply as you can.  It’s all about winning, remember?

Contrast this to the American cowboy.

Cowboys are free to roam, to place themselves wherever they are needed, even if it’s in the most remote region of the land. They are not bound to a single track or the big city. They certainly don’t need a multi-billion dollar roof over their head when a tent will do.  They prefer the stars rather than a big screen TV. In this respect, they are highly cost-efficient.  They don't need bureaucrats to tell them how to ride, how to rope, or how to bring the cattle home. They are free to lead their herd from harm’s way, even if it means crossing a fenceline or two. They are the also the ones who slow their herd’s migration to deliver a calf because it’s the right thing to do, not because its efficient. They are the innovators and skilled improvisers who may not have every expensive widget at their disposal, but have learned the skills to do things far safer, cheaper, and faster nonetheless. Sure, they use new data and technology when it comes their way (or maybe a specialized vet if needed), but the cattle are the priority rather than the marketing team. Perhaps most important, cowboys are humble, realizing that no real cowboy has ever known everything there is to know about ranching nor has pretended they ever will.  The cowboy understands that the learning never ends.

I am convinced that Americans want their doctor to be cowboys and not pit crews. They look for someone who’s a leader, autonomous, brave, empathic, and isn’t afraid to take a risky trail if their life depended on it. They trust their cowboys. They know their cowboy would seek out professional resources unavailable to his local ranch if it was the right thing to do. They'd even let the cowboy care for their kids because they know him or her.

Our task is to train and inspire more cowboys so they can be with us when we receive the diagnosis.  No one wants an assembly line worker at such a moment. This is common-sense. Re-direct the money. In their hearts, the medical students of today want to be on their horse, not standing with power tool  in  hand waiting for the next roll-out.

One of the telltale signs of Progressive thinking is that these thought leaders would not implement their beliefs on their own personal lives. Would Dr. Gawande want his mother cared for a pit crew or a cowboy?

I wonder.

And you?



Anonymous said...

Atul has the greatest analogies except the driver keeps crashing into the walls because he is texting, smoking, drinking. And there are no spare parts. Of course, the pit crew is blamed when the driver destroys the car and comes back to the pits to often. The crew mistakenly changes the tires too often (waste) rather than waiting for them to blow out on the track. The crew must wait 90 days to install a starter/distributer even if the old ones are shot. A clogged fuel line must result in engine failure to require unplugging. Besides this and numerous other missteps, he is right on. Go Atul.

Dennis said...

Thank the gods for the 'cowboys' in our war zones...

Anonymous said...

Race Car Pit Crew or the corner Jiffy Lube?

At the race track, each crew member is a top performer. There are only a handful of them, for good reason. The team works so well that changing a team member throws everything off. Getting top tier results from a team doesn't just happen because they're scheduled on the same shift.

At the Jiffy Lube, everyone does the most complicated job they qualify for. Someone who makes less does the cheaper stuff. Think 'The Peter Principle'. Things get forgotten and key steps are skipped. They even have a checklist :)

Anonymous said...

I vote for the cowboy.

Jay said...


You wonder at the end of your post:

"Would Dr. Gawande want his mother cared for a pit crew or a cowboy?"

As it so happens, in his recent New Yorker piece on "Cheesecake Factory" medicine ( ), Gawande spends some time discussing how he found a doctor to do his mother's knee replacement

On page 5 he writes about selecting an innovative surgeon, Dr. John Wright, who has worked hard against the grain at implementing innovations within his department. His findings suggested that standardization of orthopedic surgical procedure can improve efficiencies and outcomes.

It's an interesting vignette to parse. While Gawande clearly picked a individualistic, "cowboy" style doctor, his innovations play directly into pit crew style medicine.

I guess if you have Gawande's clout, you can go after the Pit Boss, as it were.


Anonymous said...

I guess that, in addition to the cowboy, Dr. G wants to get rid of the racecar driver also?

Anonymous said...

Some of the newer docs will actually tell you, "No. I don't do that part. I only do such and such a part" hands in pockets backing out of the room. This for things that ARE in that particular doc's realm. Things that the patient needs now rather than later (pit crew mentality). This infuriates me. It's what happens when nobody even knows what a cowboy/cowgirl is anymore.

And Wes, I saw my IM the other day and we gossiped a bit. The door to the room was open and the medical group office administrator was passing by the room, and suddenly my doc hushed to a whisper like the scared little employee he now is. That's what corporate owned medical groups have turned into - worrying what your practice admin is going to pass on to corporate.


Anonymous said...

tough call
cowboys have big ego's, hold onto beliefs in the face of evidence to the contrary.. some are right, some are wrong. the ones that are right are remembered as cowboys, the others as fools. But they act by the same principle. The same of course can be said of some pit crews. Innovation involves making mistakes... Sounds like for his mother he wants the cowboy who knows many cowboys are misguided and is willing to use his lasso... Who do you want managing your money?