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Why pregnant women need ‘pit crew’ Ob/Gyns, not ‘cowboys’

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Pregnancy requires a team approach to care, not “cowboy values.”

At the 2019 American Congress of Obstetricians and Gynecologists (ACOG) National Meeting in Nashville, surgeon, author, and public health researcher Atul Gawande, M.D., discussed two studies that approached (from different perspectives) the idea of “cowboy values” vs. “pit crew values” in patient care – and how transitioning from the former to the latter can save patient lives.

Let’s discuss why starting with the first study, which features an old medical standby – the checklist. 

The first study: Cowboy values and checklists

The first paper, a landmark study published in 2009, was launched to potentially help doctors provide better patient outcomes in the traditional health care model: a lone doctor is the leader of the medical team and his or her decisions are final.

Taking a cue from the airline industry’s preflight procedures, researchers created a 19-point checklist that surgeons could follow before operating. And, similar to airline findings, the data suggested checklists were the way to go. After the pre-op checklist was implemented, researchers noted a decrease in rate of death from 1.5% to 0.8%, as well as a decrease in inpatient complications from 11% to 7%.

But there was one problem. Hospitals outside the study couldn’t replicate these results. Over the next 10 years, it became clear the “cowboy values” model puts a lot of pressure on medical teams to “know their role” and feed the ego (or perceived ego) of the doctor. Not only that, but doctors themselves felt substantial pressure to be infallible.

“In the airline industry, the first officer can question the pilot if something isn’t right. In health care, the same mentality should be true. In a ‘pit crew values’ or team model, nurses, surgical technicians, residents, and other members of the medical team should be empowered to question each other and the doctor, as well as offer suggestions and innovations.”

Shivani Patel, M.D.

As Dr. Gawande noted at the ACOG meeting, the last century produced more advancements in medical knowledge, innovation, and technology than ever before. In 2019, there are approximately 50,000 procedures, 40,000 available medications, and 70,000 medical billing (ICD) codes.

It is not humanly possible for one doctor to know about, let alone recommend, the perfect combination for every patient every time. Researchers began to wonder whether the “cowboy” way was outdated, and if a new approach emphasizing a team culture could improve patient outcomes. This question was the basis of the second study by Dr. Gawande.

Shifting from cowboy values to “pit crew values” in patient care

In the airline industry, the first officer can question the pilot if something doesn’t seem right. In health care, the same principle should hold true. In a “pit crew values” or team model, nurses, surgical technicians, residents, and other members of the medical team should be empowered to question each other and the doctor, as well as offer suggestions and innovations.

Likewise, these team members should be respected and treated as equals with equal responsibility for patient care and outcomes. Dr. Gawande and his research colleagues discovered in the second study, published in 2017, that this shift in medical culture can save patient lives.

In a survey of nearly 1,800 hospital surgical personnel, researchers found that for every 1-point increase in certain cultural factors among providers, patient outcomes dramatically improved. A one-point increase in respect was associated with a 22% decrease in 30-day postoperative death rates. The same trend followed for clinical leadership (14% decrease in post-op death rate) and assertiveness for patient safety (a whopping 29% decrease in postoperative deaths).

Clearly, the respectful team approach we talk about so often on this blog is in the patients’ best interest. Particularly in caring for women with high-risk pregnancies, there are simply too many factors for one provider to manage on his or her own.

And in that same vein, doctors and other providers must recognize that, as humans, we all have inherent biases unique to our upbringing, culture, and personal experiences. Patients deserve a care team that has a firm grasp on the importance of cultural competency

A few closing thoughts

The realization that doctors and surgeons shouldn’t work in a vacuum has made many of us take a step back over the past few years, acknowledging our limitations and relying on our colleagues to work as a team and provide the best care.

But even the best programs can do better for our patients. We must continually challenge each other – nurses, residents, and patients – to break down political and cultural barriers that can hinder care.  

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