From cowboys to pit crews: Patient-focused care starts with a team approach

Atul A. Gawande, MD, MPH, FACS
Atul A. Gawande, MD, MPH, FACS

“The invitation to give this lecture was a chance for me to think about systems improvement in historical terms,” said Atul A. Gawande, MD, MPH, FACS, who presented the Charles G. Drake History of Surgery Lecture, Slow Ideas: Scaling Surgery, Monday afternoon at Clinical Congress.

“When I think about the challenge of trying to be good at what we do, I think about why some good ideas seem to spread faster than others,” said Dr. Gawande, a general and endocrine surgeon at Brigham and Women’s Hospital, Boston, MA, in front of a capacity crowd.

Dr. Gawande asked attendees to consider two notable surgical innovations from the 19th century—anesthesia and antiseptics. Within weeks of its discovery, surgeons were administering ether to patients, and it was absorbed into the profession six years later. However, the concept of using antiseptics to fight infection by destroying germs entering the operating field did not become a popular practice until an entire generation later.

“You would have thought the antiseptic method would have spread as rapidly as anesthesia,” Dr. Gawande said. “So, what is the difference between them? Anesthesia solved an immediate, visible problem—patients in pain. The other combatted an invisible problem. Germs aren’t something we can see and infection doesn’t happen right away, so it is a delayed response. But a second reason antiseptics didn’t catch on—both are great for the patient, but only one is also good for the doctor. Anesthesia was greeted by pure joy from surgeons because it made life better for them.”

“For innovation [to be successful], there are two customers: the patient and the provider,” Dr. Gawande said before describing three stages of performance improvement: teaching, which has a widely variable performance rate; mandates/regulations, which results in a modest level of performance improvement; and systematization including data feedback loops, coaching, and checklists, which result in high reliability.

Through Ariadne Labs, the center he founded at Brigham and Women’s Hospital and Harvard, Dr. Gawande and colleagues have organized a global effort to standardize safety measures in operating rooms (OR) through the promotion of the Surgical Safety Checklist, which was originally developed by Dr. Gawande and adopted by the World Health Organization in 2008. He emphasized three critical pause points for surgery as identified by the checklist: before the induction of anesthesia, before the incision in the skin, and before the patient leaves the OR.

Dr. Gawande said Ariadne Labs has added other tools to help standardize safety measures, including an OR crisis checklist—a compendium of 12 checklists to assist OR staff during life-threatening situations.

According to Dr. Gawande, meaningful implementation of these safety measures occurs when there is a shift in the surgeon’s mindset, a perspective he called “going from cowboys to pit crews.”

“When I was in my training, if you made the surgeon happy, you made the patient happy. The value we prized above all was our autonomy and our ability to make the call for the best thing to do for the patient, and that works incredibly well until you have multiple team members,” he said, noting that moving to a pit crew approach in the OR involves humility, discipline, and teamwork.

Another area of focus for Ariadne Labs, according to Dr. Gawande, is the Serious Illness Care Program, which is a system-level intervention built around the Serious Illness Conversation Guide. The guide is a series of structured questions drawn from best practices in palliative care and is intended to help clinicians assess patients’ understanding of their illness, determine their preferences for future care, and document the conversation.

Less than a third of patients with end-stage medical diagnoses discuss their goals and preferences with their surgeons, said Dr. Gawande, and when those conversations do occur, they tend to focus on medical treatments rather than the patient’s values and priorities.

Dr. Gawande revealed that his father, also a physician, was diagnosed with a slow-growing spinal cancer several years ago, and at one point during his treatment, Dr. Gawande encouraged his father to undergo radiation based on the prognosis of his father’s physician.

“We didn’t ask what he most valued in life, which was getting to the table and eating and talking with friends and family. He lost six weeks being in treatment, and he lost his ability to taste food,” said Dr. Gawande, noting the radiation didn’t shrink the tumor. In fact, the treatment caused the tumor to grow slightly. “A technician can talk about the pros and cons of treatment and a counselor can determine what the patient’s goals are and then make a recommendation, and I think that is what my father needed.”

Determining a patient’s preferences and values is not only necessary at the end of life, but also for the other diseases managed by clinicians, he said. “It’s our ability to elicit people’s priorities that ultimately matters. We are shifting from solo practitioners to teams that can meet these priorities. This is our job,” said Dr. Gawande.

In July 2018, Dr. Gawande became chief executive officer of the Amazon, Berkshire Hathaway, and JPMorgan Chase health care organization. In this role, he is working to improve health care delivery for the companies’ employees and their families in ways that will create better models of care for all.

The Charles G. Drake History of Surgery Lecture is sponsored by the Advisory Council for Neurological Surgery. The lecture was established in 1992 to explore the historical development of surgery and to honor Dr. Drake, a leader in neurosurgery.