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.
“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.”
The things are that are generally uncommon and untaught are:
- An ability to know when you've succeeded or failed for your patients (look at data)
- “grow an ability to devise solutions for the system problems that data and experience uncover” (including checklists)
- “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…