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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Jennifer NsteveG Levin MDMargalit Gur-ArieJames Walker Recent comment authors
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Jennifer N
Guest

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… Read more »

John Ballard
Guest

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… Read more »

Margalit Gur-Arie
Guest

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… Read more »

steve
Guest
steve

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

BobbyG
Guest

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?

Margalit Gur-Arie
Guest

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.

BobbyG
Guest

See “Medicine in Denial”.

G Levin MD
Guest

Oh by the way, Evan, glad to hear your brother is okay. Nice Pitch at Fenway

Evan Falchuk
Guest

Thanks, Dr. Levin, I appreciate that. He is doing great.

Evan

G Levin MD
Guest

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

BobbyG
Guest

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

Rebecca
Guest
Rebecca

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,… Read more »

James Walker
Guest
James Walker

@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… Read more »

Margalit Gur-Arie
Guest

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… Read more »

James Walker
Guest
James Walker

@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… Read more »

Margalit Gur-Arie
Guest

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… Read more »

James Walker
Guest
James Walker

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… Read more »

John Ballard
Guest

This is a good place for this (again)…
http://youtu.be/5J67xJKpB6c

Margalit Gur-Arie
Guest

Pit crews are so….. passé. Here is the future…
http://www.youtube.com/watch?v=pVyS7E8yx_w&feature=player_embedded

John Ballard
Guest

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?

Margalit Gur-Arie
Guest

Probably as good as anybody operating with a “pit crew” mentality of “I only know and care about the top left screw of the rear left tire”

James Walker
Guest
James Walker

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.

Rebecca
Guest
Rebecca

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… Read more »

BobbyG
Guest

See “Medicine in Denial.”

Evan Falchuk
Guest

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.

John Ballard
Guest

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… Read more »