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  • Writer's pictureRuss Powell

Cowboys, Pit Crews, Doctors and Checklists – A Physician's Take on Systems-Thinking

In this TED video, Atul Gawande compares cowboys and pit crews as he discusses solutions to broken medical systems. He also, inadvertently, offers a brilliant summary of one of the things we do here at Russ Powell Consulting every day—we help new and emerging managers learn to analyze problems and develop systems to solve those problems.

We help managers enable the complex, human systems in which they work to function better.

I love that one of Gawande's major points is emphasizing the value of checklists. He reminds us that the systems in which we live and work today are astonishingly complex, and cautions us against going it alone—“We cannot know it all, we cannot do it by ourselves.”

Turns out, these days, even cowboys use checklists.

A few excerpts and key points:

  • “You can’t make a recipe for something as complicated as surgery. But, you CAN make a recipe for how to have a team that’s prepared for the unexpected.”

  • There was a time when we functioned as craftsmen. It used to be that “…what was known you could know, you could hold it all in your head, and you could do it all. [For the physician], if you had a prescription pad, and a nurse, and a hospital… you really could do it all. You set the fracture, you drew the blood, you spun the blood and looked at it under the microscope…. This was a life as a craftsman.”

  • Today, work/life is so complex, “we’ve reached the point where we’ve realized we cannot know it all. We cannot do it all by ourselves.”

  • Like the story of the blind people and the elephant—“We’re all specialists now…. Everyone only has a piece of the [solution].”

  • Rationale for change: “Holding onto the structures we’ve built around daring, independence, and self-sufficiency has become a disaster. We have trained, hired and rewarded [workers] to be cowboys. But what we really need is pit crews.”

  • We need better systems—systems that help us do the following:

    • Recognize success and failure – “When you are a specialist, you can’t see the end result very well. You have to become really interested in data, unsexy as that sounds.”

    • Devise solutions – Sometimes useful solutions include tools as simple as a good checklist.

    • Implement the solution – To get “colleagues across the entire chain to actually do these things." Often this is “…slow to spread. This is not yet our norm… making checklists.” We’re rather resistant to it. We think we can go it alone.

  • On resistance to checklists –

“There’s a deep resistance because using these tools forces us to confront that we’re not a system, it forces us to behave with a different set of values. Just using a checklist requires you to embrace different values from the ones we’ve had like humility, discipline and teamwork. This is the opposite of what we were built on—independence, self-sufficiency, and autonomy.”

  • On adoption of checklists –

"I met an actual cowboy. I asked him, what was it like to herd a thousand cattle across hundreds of miles? How do you do that? He said, ‘We have cowboys stationed at distinct places all around. They communicate electronically, constantly, and they have protocols and checklists for how they handle everything." Turns out even cowboys use checklists.

See the full video here.


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