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Atul Gawande: Patients Need Pit Crews, Not Cowboys


Teams of medical specialists working toward a clear patient-stated goal, while being reimbursed for value, is the direction healthcare needs to go.

Healthcare providers must work collaboratively and pull in the same direction with the patient's expectations and goals in mind, and ultimately, they should be rewarded for better outcomes.

That was the crux of Atul Gawande's message during his keynote presentation at the Medical Group Management Association's (MGMA) Annual Conference, held this year in Nashville, Tenn. Gawande, a surgeon, public health speaker, and bestselling author, spoke in front of a packed house at the Gaylord Resort and Convention Center's Delta Ballroom.

During an approximately 45-minute speech, Gawande surmised that most failures in medicine happen because parts of the system - clinicians, drugs, devices - are not coming together and working toward one goal. As a result, patients are slipping through the cracks, Gawande said, using the example of a 34-year-old grocery store manager from East Texas who lost his toes, fingers, and nose because he wasn't vaccinated properly, while being hospitalized for a car accident.

Gawande compared this kind of thinking in healthcare to building a car with all of the best parts. "You have a car with the best parts, a Porsche engine, Ferrari brakes, BMW chassis, and a Volvo body, put it all together and what do you have? You have a pile of junk that won't get you where you need to go … and an expensive one at that," he said.

Citing leading healthcare organizations, like the Mayo Clinic and Kaiser Permanente, Gawande said that teams of healthcare specialists working toward one goal deliver better results than autonomous specialists. "We've trained, hired, and rewarded [clinicians] for being cowboys, when pit crews is what we need for our patients," he said.

Some groups, like the World Health Organization (WHO), have implemented this philosophy to a great deal of success. The WHO created a surgical safety checklist, to be completed before the operation, to get everyone in a "collective mind to go in one direction." The checklist was implemented in both the poorest and richest places in the world, and was successful across the board. Researchers saw an average of 35 percent reduction in surgical complications across 2,500 operations.

"If everyone is pulling in the same direction, the team can achieve extraordinary results … if not, it's painful for the patient," Gawande said.

It isn't just enough, though, to get everyone on the care team moving in the same direction, said Gawande. Provider teams need the goal of the patient to be clearly stated, he said. Too often, patients are not being asked about what their goals are and what they understand of their condition. "The most logical way to confirm what those priorities are is a highly technical procedure: You ask them," he said.

When the patients are asked about what quality-of-life measures are important to them, the goal becomes clearer for the healthcare team and the patients do better.

The third and final part of Gawande's healthcare equation was the necessary move providers must make from volume to value-based reimbursement, to empower the patient-centered, team-based model of care.

"We've had the landlord-tenant model in healthcare. You as a clinician get pulled into a health system … and they might look over you before you become tenant, but after that, what you do is none of their business," Gawande said. This attitude won't work when it comes to rewarding healthcare providers on value - healthcare teams must be transparent and work collectively to achieve the patient's goals.

In terms of value-based care models, Gawande sees a tipping point occurring, with younger physician residents joining more forward-thinking organizations. "They don't want to go to a place where you are rewarded for volume, where the game is figuring out how to run that hamster wheel faster. They want to be in a place where they can innovate and think about how they get that best possible outcome," he said.

Gawande closed out his speech challenging attendees to think about how they can create a team with a clear expectation of the patient's goals, while driving toward a system where they are rewarded for better outcomes.

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