In his recent TED talk, Atul Gawande harkens back to the central thesis of his recent book The Checklist Manifesto: How to Get Things Right that medicine has become too complex for physicians to act as cowboys and instead should adopt the paradigm of a pit crew, utilizing teamwork and the humble checklist to solve problems and avert emergencies.

Is this really true though? Can “pit crews” heal medicine? To extend the analogy a bit, can a pit crew win the Indy 500? Try as they might, they would be completely unable to do so without three critical people: the team owner, the driver, and the pit crew boss. Honestly, all analogies fall apart at some point, and this one is already near the breaking point, but bear with me another moment.

The patient in some ways is like the owner: he has the most at stake, yet relies on others to achieve his goal (a win). Similarly, the patient has her health on the line, and relies on medical professionals to get them to the finish line. To do so, they need a driver – someone who is pushing for that result. Ideally, the healthcare “driver” would be the patient’s primary care physician — the doctor who is harnessing the resources of the “pit crew” of professionals to deliver the desired result. Unfortunately, all too often, this does not come to pass.

I suppose Gawande’s true argument is that physicians and healthcare professionals should adopt some of the tactics of a pit crew, not literally become one. While necessary, this does not solve the dilemma from a patient’s perspective. The patient has the most at stake, yet enters the healthcare arena under-informed and under-empowered. In complex cases, even their PCP may become overwhelmed by the complexity of their care. To remedy this, the incentives need to be reassessed. Currently, PCPs like all other providers get paid based on what they do. If it cannot be coded, it cannot be reimbursed. The sad reality is that there is no financial incentive for a PCP to have a thoughtful conversation with a patient, to visit them at home when they are very ill, or to even visit them in the hospital. With that link between patient and primary doctor under siege, the ‘pit crew’ of professionals in the hospital lack a driver, the PCP, the physician who knows the patient best. As our current system shows, our healthcare pit crews can still do amazing things – they just may not be in line with the patient’s wishes.

Ultimately, the changes Atul Gawande advocates are certainly necessary. The concern I have is that they oversimplify the problem. Without working on strengthening the doctor-patient relationship at its core, any improvement to the efficiency of the hospital will not necessarily yield the benefits in patient satisfaction or healthcare outcomes we as a society desire.

“Scrub, MD” is a recent medical graduate and currently a resident physician who blogs at Scrub Notes.

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