American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Atul Gawande: Don’t let your surgeons grow up to be cowboys

OCTOBER 22, 2018
Clinical Congress Daily Highlights, Monday First Edition

Surgical innovations that spread quickly have certain traits, argues Atul A. Gawande, MD, MPH, FACS, Brigham and Women’s Hospital, Boston, MA. Practices that catch on right away tend to have an immediate and visible effect, and they are good for both patient AND doctor.

Two life-saving developments — anesthesia and antisepsis practices — provide contrasting cases in point. Within six years of the first reported use of anesthesia in 1846, every hospital in the United States was using it. Antiseptic practices took more than a generation to take hold, despite the fact that infection was the biggest killer in surgery.

In the Charles G. Drake History of Surgery Lecture, Dr. Gawande noted that anesthesia provided an immediate benefit for a highly visible problem: a patient in pain. Antiseptic procedures, however, offered a delayed benefit for an invisible problem: germs that took about a week to do their damage. But just as important, anesthesia immediately benefited the surgeon, who could take more time and care to do a procedure. Antisepsis on the other hand “was a pain in our butt,” said Dr. Gawande. “At the end of the day, for good ideas, there are two customers: the patient and the provider.”

When faced with the task of spreading such “slow ideas,” what is the surgical community’s best hope? History and research tell us that the answer lies in making doing the right thing easier, Dr. Gawande said. This was true with antiseptic practices more than 100 years ago: a conversation on a train between antisepsis pioneer Joseph Lister and Robert Wood Johnson purportedly led to Johnson & Johnson’s development of prepackaged gauzes and other sterile surgical sundries. And making things easier works today: studies of hospitals that consistently outperform their peers find that these positive outliers have several key practices in place, which including prioritizing communication and teamwork.

The recognition that a team is more powerful than a lone actor has been key to introducing practices that improve patient outcomes, Dr. Gawande said. It requires a huge shift in thinking from the long-standing belief that if you make the surgeon happy, the patient will be happy.

“The value we prized above all was our autonomy,” Dr. Gawande said. But evidence suggests that shifting from “cowboy values” to “pit crew values” can save patient lives. Research at several hospitals has found that a cultural shift toward team values actually predicts a decrease in patient mortality. “When you realize it’s a culture change,” Dr. Gawande said, “you realize how long it takes.”

Additional Information

The Named Lecture, Charles G. Drake History of Surgery Lecture, was held October 22 at the 2018 Clinical Congress of the American College of Surgeons in Boston, MA. Program, webcast, and audio information is available online at

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