Dr. Gawande’s Commencement Address: Cowboys or Pit Crews?

Most (all?) of us here did NOT graduate from Harvard Medical School last week. But, we all can read the commencement address that was given by Dr. Atul Gawande, surgeon and author of great books such as Better: A Surgeon’s Notes on Performance and The Checklist Manifesto: How to Get Things Right.

His talk, titled “COWBOYS AND PIT CREWS,” makes for thought-provoking reading.


Gawande recounts some of the history of medicine in the last 100 years and how things have gotten more complex and specialized.
He writes/says:

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“We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.”

And he talks about the need for systems, pointing out:

“…that the places that function most like a system are most successful.

By a system I mean that the diverse people actually work together to direct their specialized capabilities toward common goals for patients. They are coordinated by design. They are pit crews. To function this way, however, you must cultivate certain skills which are uncommon in practice and not often taught.”

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The things are that are generally uncommon and untaught are:

  1. An ability to know when you’ve succeeded or failed for your patients (look at data)
  2. “grow an ability to devise solutions for the system problems that data and experience uncover” (including checklists)
  3. “the ability to implement at scale, the ability to get colleagues along the entire chain of care functioning like pit crews for patients.”

The mindsets and characteristics that Gawande calls for include humility, discipline, teamwork and the belief “that standardization, doing certain things the same way every time, can reduce your failure.”

Gawande points out how this often runs counter to the existing physician mindset:

“These values are the opposite of autonomy, independency, self-sufficiency. Many doctors fear the future will end daring, creativity, and the joys of thinking that medicine has had. But nothing says teams cannot be daring or creative or that your work with others will not require hard thinking and wise judgment. Success under conditions of complexity still demands these qualities.”

Whether it’s checklists or Lean “standardized work” (I’d argue they are philosophically and practically the same), having structure and discipline doesn’t preclude flexibility and they certainly don’t mean that anybody checks their brain at the door.

I won’t give away the punchline here, but please read the whole speech and especially the end, where Gawande talks about his experience meeting a real cowboy…

Read more  http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-gawande-harvard-medical-school-commencement-address.html#ixzz1NzcTVWTu


Thanks for reading! I’d love to hear your thoughts. Please scroll down to post a comment. Click here to be notified about posts via email. Learn more about Mark Graban’s speaking, writing, and consulting.


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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an book titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

9 Comments

  1. Jeromy says

    Its great that a lot if doctors are understand the importance of improving the entire system. Unfortunately some don’t get it. The blogger “Buckeye Surgeon” really misses the entire point of what Atul Gawande is saying. I know who I’d want to operate on me.

    Link –> Blog Post

    1. Mark Graban
      Twitter:
      says

      I’m guessing the surgeon you linked to hasn’t read Gawande’s checklist book, yet alone the shorter New Yorker article from a few years back. The surgeon creates an unfortunate and inaccurate straw man when he says checklists and standardized processes make one an “interchangeable part, a faceless drone who performs menial tasks according to checklists and algorithms that Really Smart People will provide for you.”

      That couldn’t be any further from the truth. Gawande states very clearly that checklists need to be developed by those who do the work, not the “Really Smart People.” Buckeye Surgeon is thinking of Taylorism, which checklists and Lean are very clearly not.

      See also this post on the differences between Taylorism and Lean thinking:

      http://www.leanblog.org/2011/05/time-motion-studies-are-not-discredited-just-the-way-they-are-used/

  2. Anonymous says

    I believe the same holds true for hospital leadership. It takes no discipline to look at the landscape and the hundreds of broken processes all around and decide that it would be funner to open a new specialty clinic that to work on preventing patient harm. And who would blame them when leaders are more likely to be promoted for “growing the business” than reducing avoidable mortality. These “cowboys” bristle at the concept of strategy deployment where they are actually confined to working on the most important things. Forgive me if I come across as more than as a little cynical. I think it must be a burr under my saddle.

  3. Kevin Rutkowski says

    If it makes the doctors feel better, maybe they can see themselves as the race car driver and everyone else at the hospital as the pit crew. The driver gets all the glory and has to be highly skilled, but he or she also have to communicate and coordinate very closely with the rest of the team in order to be successful.

    1. Mark Graban
      Twitter:
      says

      Great idea, Kevin. The hotshot cowboy race car driver still doesn’t get to just pull into the pit area without planning and they don’t get to just stop wherever they want.

  4. Donna says

    I love it. I’ve been using the example of the pit crew for years in my lean trainings. Must be the popularity of Nascar, people seem to really get it when its explained that way.

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