For the last several years, I have been using Dr. Atul Gawande’s graduation speech to the Harvard Medical School Class of 2011 (“Cowboys and Pit Crews”) in teaching about the evolution of health care delivery I have witnessed over my years in practice.
When my medical career began (during Reagan’s first presidential term), hierarchical “parallel mono-disciplinary” care was the typical patient’s experience, where a patient was passed between specialists and hospitals until someone (hopefully) took the time to sit down and listen to their journey, piece together the story, mine the available paper records and validate the patient’s concerns with a reasonable differential diagnostic and therapeutic plan. This pattern of care delivery continues in many settings today.
In the closing decades of the last century we moved forward considerably with multidisciplinary (multiple specialties looking at the same patient at the same time, often in the same clinical space) and interdisciplinary teams (multiple specialties looking at the same patient at the same time, including the voice of patient and family, and agreeing on a single patient and family-centered set of treatment goals).
More recently, we have increasingly recognized that health is more than the absence of disease. The true drivers of health are determined by the 8,759 hours a year our patients spend at home in their community rather than the roughly one hour a year the average American spends in a provider’s office. In the future, the individual and population’s health will be addressed by a new model of integrated, community-care teams that include health care professionals but also community navigators and service providers as equal partners who are able to address issues like housing, food security, employment and economics. (But that’s the subject for another post.)
Time has proven that Dr. Gawande was right. The future of health care depends on our ability to function like pit crew teams with broad, horizontal, flexible, situational leadership structures.
But for the past several weeks, I wish we had a cowboy.
Not long ago, a close family member was diagnosed with an aggressive, fatal condition. Unfortunately, we had to derive some of that diagnosis and prognosis from our own research, from combing through the on-line patient portal, using search engine AI and by reaching out to physicians through the “doctor-to-doctor” informal communication system.
The ambulatory provider who had cared for this family member for decades was not a part of the hospital team. The inpatient health care team members were attentive and empathetic. The leader of every team—nursing and physician—met with us. But no one seemed to be willing to address the bigger picture.
I know from my many years practicing pediatric intensive care that there is no joy in delivering terrible news. I recognized in myself long ago the subconscious tendency to avoid this unpleasant, uncomfortable task. I doubt I am alone. And so, we are all at risk to abrogate (“evade a responsibility or duty”) and thus abdicate (“fail to undertake a responsibility or duty”) when it comes to sharing bad news.
This can be compounded by aspects of team-thinking, including a tendency to defer to other specialties when higher-level conversations are needed. The trend towards “super-specialization” may contribute to the practice of leaving some of the tough conversations surrounding death and dying to the palliative or hospice care teams. But they should be invited into the treatment team after these difficult conversations have taken place and not before.
As strangers to the hospital and staff, what we needed was one person.
What we were missing was a cowboy.
We did not need the old-school bluster, swagger, arrogance or patriarchal condescension that occasionally characterized physicians of my era and before. For example, I was told that just before I started my first job in the seventies as a hospital technician in a coronary care unit, the nurses were expected to stand when the senior physician walked onto the unit. That’s not the kind of “cowboy” we were looking for.
We needed a consistent, straight-shooting clinical leader who helped prepare us as a family to make difficult decisions about our loved one’s treatment and outcomes; one voice to whom we knew we could turn over the weeks that this disease took its toll and perhaps even beyond, when the inevitable second guessing becomes an element of grieving. It could have been a person from any specialty. While the hospital inpatient physician and nursing teams justifiably rotated on a daily and weekly basis, we needed someone whom we saw every day, who checked on us and helped us understand the evolving clinical situations in the context of the bigger picture.
Hospitals are infinitely safer, more compassionate, and better organized than when my medical career began in the eighties. The evolution, promulgation and proliferation of healthcare teams has without question been a key driver of these improvements. We would no more go back to the stoic, isolated, aloof physician as sole decision maker than we would give up the electronic medical record to return to paper and pen.
Health care teams are the future of medicine, in clinical settings and in the community.
But sometimes, at specific points across the span of life, we still need consistent, visible leadership.
I think we still need cowboys.
Chuck Callahan Henry V 4.3 – Lead from the Front https://henryv43.com/
Henry V 4.3 