Why Pharma can sell to cowboys, not pit crews

Dr. Atul Gawande of the Harvard Medical School has published articles in The New Yorker and other places claiming that medical care would be far more cost-effective if professionals could function the way pit crews do in auto racing.  Members of pit crews act in a tightly choreographed manner, as opposed to the present system where each individual practitioner, more or less, does his/her own thing,

Gawande is an effective publicist for consensus thinking in academic medicine and public policy about ways to improve quality and control the costs of medical care. In most cases, the ideas he expresses have already gained traction in government and private payer circles. Previously, Gawande brought public attention to ideas such as "hot spotting" and using evidence-based protocols to develop customized checklists for each patient. The pharmaceutical industry would do well to monitor his ideas on medical practice because providers are pharma's customers and significant changes to the way they're organized, their goals and their needs, must necessarily change the way pharma does business.

Gawande calls the present method of practicing medicine a "cowboy" approach. He uses that term because medical care functions on the basis of independent professionals, with each maintaining his own focus and no one appreciating the whole picture. As a result, health care delivery is duplicative, too expensive and too slow. By contrast, a pit crew accomplishes in 30 seconds what an auto shop takes half a day to do.

Numerous studies and some compelling evidence support the type of medical delivery that Gawande favors. His approach, however, flies in the face of a stubbornly vestigial element of American culture. One need only look at current phenomena such as the Tea Party and efforts to claim gun ownership as an unalienable right to realize how dearly a large segment of the country clings to the image of the solitary cowboy. Many people in this country still cherish the notion of making their own way on the frontier, asking no quarter and giving none. That means an effort to substantially change any social or professional pattern containing major elements of the cowboy character represents a tall order.  

Medicine developed as a profession with the cowboy mentality at its core. Particular factors of American history supported that process. 

The medical profession in America started taking shape in the late 19th century. At that time, industrial corporations with national and international markets were coming to dominate the U.S. economy and most people stood their best chance of achieving social mobility by working for one of them. The growing corporations, however, presented a major obstacle to some of the most ambitious people within several of this country's population segments because overtly discriminatory policies barred entry into middle and upper management positions. Unless those people had the wherewithal to start their own enterprises, Jews, Blacks, most immigrants, and women faced extremely slim chances of rising up the management ladder. Excluded from those positions, some ambitious people looked to careers in medicine as one way of fulfilling their aspirations. Today, even though that kind of blatant discrimination no longer exists, the cowboy ideal lingers in medicine as a means where the rugged individual can head out to the frontier (i.e., hang out his shingle) and make it on his own. 

A carryover of that legacy in medicine includes a residency training that implants a solid core of machismo for dealing with challenges that, in the contemporary world, would include patients, insurers and other professionals. 

The medical profession considers a well-honed machismo especially relevant for practitioners who offer procedural services such as surgery. For decades, the sociologists who study professional socialization in medicine have shown how a pattern of organized hazing is designed to develop a macho attitude and self-image. Last year a documentary series on ABC television, taped at Mass General and Brigham & Women's hospitals in Boston, made the same point. A chief surgical resident explained that "identity stripping" is an integral part of the way they train surgeons. The process involves tearing down a resident's ego and self-esteem and then allowing the bedraggled trainee to rebuild them only by using the surgical staff's criteria for judging himself/herself.

In this respect, as well as many others, medicine can do a better job of providing the care the U.S. needs by changing into a more feminized profession. The question for pharma consists of what role it will play in such a transformation of medical culture and personality? 

If pharma's initiatives and responses during this currently challenging period are a guide, then don't look for the industry to play a leading role in this transformation of American medicine. That is because efforts to forge a profession based on classically feminine character traits such as supportive cooperation and nurturance will encounter fierce resistance from men who entered their specialties with the same aspirations as people who pursue CEO positions in corporations.  For them medicine is a denatured civil war where rewards such as large incomes and the domination over other egos derive from winning a zero-sum game. 

Over and above any fear of antagonizing medicine's alpha males, drug companies remain wedded to a fee-for-service medical model where practitioners work solo or in small groups of individual prescribers, each of whom was trained to be a cowboy. The macroeconomic factors of health care, however, are pushing medical practice toward consolidating into larger practices. The same forces have also started fusing the payer and provider sectors into unified entities or, alternatively, into performing one another's functions while remaining separate entities.  

Within a few years, pharma's customers will be large institutions instead of individual prescribers. Large organizations predicated on a business model maintain formal objectives and efficient means to achieve them. Checklists and pit crews represent part of that.  

Pharma might do better to view the emergence of a new medical practice culture as an opportunity.  Seizing that opportunity would involve learning to identify the needs and preferences of medical pit crews and determining which products/services can most effectively serve them.   

Of course, that means pharma might have to discover and develop new offerings instead of adamantly insisting on servicing its core, legacy business. But the alternative of clinging to the present system could well see drug companies following their cowboy customers into the sunset or, worse, off a cliff.

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