OP-ED

But There Are No Pit Crews

Atul Gawande says that we’re used to doctors working like “cowboys” – rugged individualists who are responsible for making sure your care gets done right.  We don’t need cowboys, he says.  We need “pit crews” – teams of doctors working together toward a common goal, with each playing their own role.

It’s an appealing idea.  Pit crew-like teams work, and work well, in trauma units across the country.

But there’s a problem: if you haven’t just been airlifted to a hospital after a horrible accident, you’re not going to be treated by a pit crew.  You’re going to be on your own, shuffled from one 15-minute specialist visit to the next, likely with no one person in charge of your care.

Dr. Gawande knows this, and he picks a heck of an example of the problem:

“But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to ‘protocol’ the MRI.”

Why is that such a good example?  Because it’s exactly what happened to my brother at one of the leading medical centers in the country.  He had a person directing the work up of his back pain and all the rest, including deciding on the right treatment for the “unexpected cancer found growing in his spine.”  It all worked well….except that he didn’t have cancer at all.  In fact, had he been treated for cancer, he might not be with us today.

The truth is when you get sick, there is no pit crew rushing out to help you make your way through the system.  There are overburdened, time-pressed doctors making decisions based on fragmented and often incomplete information.  Scientific studies showing diagnoses are inaccurate more than 20% of the time are a clear warning sign and a symptom of this public health crisis.

If you’re sick, you don’t have time for the system to change.  And so while we may not want our doctors to be cowboys, as a patient, you better learn how to be one.  Be self-reliant, demand answers, and, above all, know this:  the person with the greatest stake in getting your care right isn’t your doctor – it’s you.

Evan Falchuk is President and Chief Strategy Officer of Best Doctors, Inc. Prior to joining Best Doctors in 1999, he was an attorney at the Washington, DC, office of Fried, Frank, Harris, Shriver and Jacobson, where he worked on SEC enforcement cases. You can follow him at See First Blog where this post first appeared.

 

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26 replies »

  1. Great comment, John.
    I read that book in its entirety and I think it is rather revolutionary in its suggestions and conclusions and I will reserve my comments for a later time, since I am rereading some portions.

    I somehow think that folks in decision making positions ought to put their money where their mouth is. Everybody is advocating for “patient-centered” care and arguing that “less care is indeed better care”, in which case I would suggest that we just concentrate on providing better care and concentrate on engaging patients, and let the money take care of itself as it surely will if those arguments are as genuine as we are told they are.
    We cannot have an honest discussions with folks attempting to sell us a bag of goods.

  2. Being accountable for patient care is something that providers across the country are focusing on. Of course the patient should also be focused on his or her own care…but it’s harder than it sounds. The patient has to ask the right questions and make the right decisions without a background in health care. But ultimately, your life is in your own hands and you have to take responsibility for yourself.I saw a great video on OptumInsight about making sure the patient does the right thing and how to do that when you don’t have a “Pit Crew” team of doctors available. Here is the link to the video: https://ignite.optuminsight.com/archive/patient-accountability-video/

  3. I looked at the “Medicine in Denial” link and as I scanned the summary it was clear that the book is addressed, rightly so I believe, to a professional audience looking for ways to refine further an already good system. That’s a valid conversation and one which should be pursued.

    But this conversation is a mixed up audience which includes a variety of participants. Comments at this blog are left by all kinds of people, from those whose backgrounds include medical devices, pharmaceuticals, HIT, insurance or any variety of medical connections — to lay people like me, an old guy in retirement from the food business, and other non-medical interests as well.

    I was an Army Medic (X-Ray Tech) many years ago and my training was little more than an advanced first aid course. But I can tell you that a medical corpsman in combat is a valued part of any mission, especially if trauma is anticipated. This conversation is clearly not about the theoretical levels of medicine but the mundane work of how best to treat patients at the entry level to a very complicated system.

    I suggest more attention on the infrastructure bridging first aid and specialty care. We need all of it and it must puzzle together quickly and safely with a view of delivering to patients the most effective and affordable care possible.

    ==>EFFECTIVE (Talk about outcomes, the radioactive topic of “comparative effectiveness research” and QALY)

    ==>AFFORDABLE (Talk about how best to deliver care to those with little or no resources including those young, healthy specimens who know that insurance is not necessary but wake up one day with a condition that would financially cripple a banker. Or again, quality of life issues — see QALY above — for patients and their family with a constellation of medical problems. Or “bending the curve” on the spiraling upward path of medical inflation. Keep your attention on the “affordable” ball.)

    ==>POSSIBLE (Talk about what happens when few or no resources are available. Think medical emergency in a plane with only one passenger with whatever kind of training from CNA to neurosurgeon, and no other help. Or think about rural areas, distant from urban centers with no local specialty doctors at all. And no helicopters.)

    This is a good forum to discuss “Second” Aid, family training and preparation, community clinics and the role and participation of places like Walmart, CVS or super markets with mini clinics. And yes, what is the protocol for nights and weekends once a patient gets ALMOST into the system? How many times have we heard that an appointment is not available until Monday?

    One of my children was born on April Fool’s Day because the day before that year was a Jewish holiday and my wife’s dry labor (her water had broken two days earlier) had to wait. And another child was more than half an hour in the birth canal during induced labor because our doctor was tied up elsewhere and had ordered “turn off the petocin”. Had we known then what we know now my wife and I would have told the people in the delivery room to go to Hell.

    Thankfully we are much better informed now than many years ago, but we are the exception. Most people who become patients do not plan their role as informed patients and must rely on whatever “system” is in place to handle them. Those are the issues that need to be discussed here. Not quibbling about how many angels can dance on the head of a pin.

  4. Steve, you are taking this “pit crew” think too literally. I think it means that doctors should view themselves as part of a coordinated effort, carried out by a team of equals, according to well defined and well rehearsed repetitive protocols.
    As opposed to the “cowboy” who supposedly calls his own shots, improvises often, relies on his experience, does his own thing and is not bound by rules and regulations.
    This is why I believe this is a false dichotomy in this context.

  5. I have thought about that for many years. How much should it properly cost for all this stuff to be there on demand for me when I’m in acute, life-threatening circumstances.

    Relatedly: How much should it cost for a military to effectively defend me? Police and fire departments to protect my life and property?

  6. Explain to me how the pit crew concept works at small hospitals. How does it work at nights and on weekends? How do you pay for it? Pit crews stand around waiting for their work to arrive, then swarm it. The rest of the time they wait. How do you pay for that waiting time?

    Steve

  7. Good points, but statistically, I would rather fly coach on the cheapest commercial passenger jet than with any private plane if my priority is safety. There are indeed things that can’t be automated; but it only makes sense to go as far with automation as is proven safe. As the data logarithmically increases (and we are already at that point), advanced automation and standardization will be required even on an individual patient for optimal care. Why I keep gravitating to the airline metaphor is that it is quite literally near perfect in terms of safety, yet complex, and involving hundreds and thousands of variables. We just cannot morally justify not fully exploring that approach – under proper safety analytics during the process, of course – in healthcare delivery. Thus, I for one am answering Dr. Gawande’s call to action in this regard, and I look forward to continuing these helpful discussions with you all along the way.

  8. Six Sigma is a fad, a solution in search of a problem. Mostly just a big marketplace for training seminars, books, swag, consultants, etc.

  9. I agree with Margalit. Why do we always think we have to ‘borrow’ Six-Sigma like analogies from MBAs. We doctors are smart enough to do it our way. In medical school and residency we were organized into teams of experts..the problem is that formerly we were cast out into the world to be on our ‘own’. It should not be hard to carry forward our original excellent training paradigms

  10. Dr. Walker,
    I don’t think we are in too much disagreement. I do believe that HIT can and should aggregate, analyze and exchange clinical information, and I do believe that there are many efficiencies in both cost and quality that can be gained from properly deployed and properly used HIT.
    Standardization of technology, terminology and such, are of course paramount to proper functioning of HIT.

    However, that “personal pilot” you are mentioning above is not available in the airline industry and the “personal mechanic” is not available in the automotive industry, except of course, for the wealthiest of passengers.
    Insisting that we stick with the personal master pilot model in health care, which is what I would prefer, is in no way contradictory to arming said pilot (and his assisting crew) with the best technology has to offer and is in no way suggestive of the patient not being in charge of choosing the destination.

    I am also not opposed to guidelines, but if you insist on using aviation as an example, please remember that manuals and protocols in aviation are largely written per aircraft model. It then follows that in health care we need guidelines and protocols for each person. If you use the manual of a Cessna Citation to fly a Boeing Dreamliner, you will crash the airplane.
    We are approximating now and using all sorts of statistics and magical thinking, but until we can create the “manuals”, on the fly for each patient that walks through the door, and I’m sure someday we will, we need to exercise caution and allow for pilot discretion, which makes pilot education, expertise and resulting judgement imperative at this point in time.

  11. @Margalit – I respectfully disagree. No one is proposing removal of one’s personal physician; and certainly I would not offer a suggestion to let the ‘poor masses’ only have the ‘machine-based’ care, while the well-off have a concierge doctor. There still must be a real-life, personal pilot for every plane flown in our near-perfect safety gold standard industry, the US airline industry. But my thought is we need to re-vamp our research and efforts in healthcare delivery towards standardization of records and process elements to enable computers and human industrialized processes to do the bulk of the data collection and management – enabling a ‘digested dashboard’ view of the ‘doctor-pilot’ or mid-level practitioner to practice much better care than the very best private physician could possibly do for the richest person in the world using today’s approaches. The mounds of data have become just as much a problem as the cost of health insurance. No one – as Gawande infers in his recent Harvard address – has the capability of knowing it or managing it all. From personal experience as a primary care physician dedicated to providing the best possible care, I can also tell you – it is not possible to provide ongoing, prompt, accurate, and standard-of-care management to even a small number of complex patients because of the lack of standardization, and the limits of the human brain. I can’t improve too much on how Gawande eloquently puts it in his address, but I can only say we have an urgent situation that very quickly is going to hit the skids if we don’t deal with it at the highest levels., and with a comprehensive approach. Again, I would ask, though, what is the alternative you would suggest?

  12. Dr. Walker,
    We don’t need to borrow ill-fitting metaphors from other unrelated “industries”. Health care and medicine have enough brain power, ethics and compassion to create their own modus operandi, accounting for the fact that this “industry” is dealing with a different type of “product”.
    All those industrial solutions for cost efficiency, and yes, also for quality assurance, are based on higher specialization of workers and deterministic automation of the smallest possible units of tasks.
    I am not suggesting that in medicine everybody should be shooting from the hip, but higher specialization has not reduced costs so far and while checklists for straightforward technical things (like surgery protocol, central lines, etc.) are possible and welcome, extending this methodology to areas where the science is immature, will adversely impact quality, particularly for those with no means to pay for truly patient-centered care, which includes by definition a “personal physician” (not “provider”) and “whole-person orientation”, whatever that may be.

  13. I believe a point made earlier is that we do well when working in the same room for an acute episode of care, ie a trauma code or surgery. Where we drop the ball is in chronic disease management and care coordination, where the pit crew analogy becomes more tenuous and in fact is partly why we got into this mess in the first place. We have pit crews, with each doctor focused on their own piece of the puzzle. But we don’t have a pit crew leader or coordinator with the 10,000 foot view of the patient’s health.

    Again, I point to the obvious. Primary care has been systematically gutted in this country. We stopped paying, then publicly tarred and feathered our team foreman so that nobody wants that job. Now we throw up our hands and howl about terrible outcomes and a group of people that don’t work well together. Use of technology to integrate systems and improve communication, allied health professionals working at the top of their license especially in complex case management and patient education, and a generalist tracking the entire care plan to ensure the system is being used most efficiently, no medical issues are slipping through the cracks, and treatment plans align, is the best solution.

  14. @Margalit: the pit crew mentality is not so limited as you describe; think about a typical surgery – each person in the room has a respective role that is well-defined, but all are concerned with a favorable outcome. There is leadership, but also bilateral teamwork; there are protocols and checklists, but there is also responding to current conditions and creativity. If we don’t go with the airline industry metaphor, or the pit crew metaphor, in healthcare delivery; then where are we to go from here? There is no other way than a coordinated, systemic approach to driving down costs, increasing quality, and providing care consistently to the increasing insured population – is there?

  15. Cute. I love it.
    And he can probably speak and take instructions in any language as well.
    But how good is he as a facilitator for someone filling out an advance directive?

  16. Gawande’s address and the metaphor of ‘pit crew’ are 100% on-point. This post also is accurate. I agree and the time to do this is right now. It will require not just an incremental set of steps; but rather a complete re-working of the healthcare delivery system.
    Disclaimer: Dr. JS Walker is a physician employee of Scott & White Healthcare, and the opinions and views independently expressed above do not necessarily represent those of Scott & White Healthcare, or its associates.

  17. In a trauma unit there is always somebody in charge, coordinating the efforts of the pit crew towards a shared goal. Its a disaster when this doesn’t happen effectively.

    This person in non-acute medicine, coordinating treatments between specialists and responsible for the initial diagnostic workup (not to mention all of the preventative medicine and lifestyle encouragement thats so hot these days) is the primary care doctor. There is good explanation for outcomes to be better and costs lower in regions with strong primary care networks and good patient access.

    Too bad our country treats primary care doctors like we are either fools or saints, that we are either overtrained for our jobs treating the sniffles (fools view of primary care) or undertrained and must refer everything out (fools view of primary care training). Our medical system reveres and rewards those who have trained the longest in an archaic inefficient education model, is procedure based, or use shiny acute care toys, rather than those that win in comparative effectiveness modeling.

  18. Thanks, John. As ever, the best advice is – don’t get sick. Of course, if you do get sick, it’s on you to make sure you ask questions and get involved in your care. Doctors are better trained, better educated, and have more treatments and technologies than at any time in history…and yet falling through the cracks is as easy as it has ever been.

  19. Bingo!
    Say it again and say it loud.

    I heard yet another report a couple days ago about the looming “doctor” shortage with the retiring baby boom generation, including those in the medical profession, PLUS the additional millions of previously uninsured citizens coming into the system as the result of PPACA.

    In my post-retirement work as a non-medical care-giver I have a chance to see first-hand an array of hospital, assisted living, home health care and long-term care applications of our decimated health care system. It may be the “best health care in the world” but it’s being run like a Rolls Royce being used by a bunch of good ole boys from the woods running moonshine. They know their craft but have no idea that they are treating it like a second-hand Chevy.

    One group of professionals who seem to appreciate the system are the multitudes of immigrant doctors, nurses, technicians, CMAs, and even housekeepers and service personnel who keep it running. I’m sure this is not news to those who work there, but if you want to hear a multitude of languages other than English, just spend a little time riding the elevators or drinking coffee in the dining rooms of any big hospital.

    Another post and comments thread here at The Health Care Blog puzzles about they future of education for doctors. I don’t have the language skills or enough flags to wave to get their attention. But as Dr. Gawande has been saying for some time now the time for improvements is not soon, but NOW. Not all patients will be as blessed as your brother to have you and your colleagues on his case.

    Thanks for this and keep up the good work.

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