Manage the “Cowboys” In Your “Pit Crew”

Cowboys vs. Pit Crews

What we pride ourselves on in medicine — especially as doctors — is in being a great doctor. I remember in my training as a surgeon, the underlying ethic was, “Trust no one.” If you needed your patient to get to X-ray and it had to be urgent, “Well, take them down if you have to. Don’t wait around for transport. Don’t expect the people down there to know they have an allergy to the contrast dye that they’re going to give while doing the imaging. You make sure for yourself.”

Delivering on great care in medicine is no longer about how much you know and how much expertise you have as a clinician, though that’s really important. It’s also about dealing with the fact that no one clinician can do it all or know it all. And so great outcomes depends on the actions of what turns out to be not just a team of people, but often hundreds of people needing to come together consistently, over time and in a reliable way, to deliver great results for people. We have lived in a world of cowboys, but more and more what I’ve realized is it’s the pit crew that we need. A team of people who are able to work in unison, take advantage of the best of what everybody has to offer, work towards a common goal, and deliver on it.

I actually met a cowboy once and got talking to him about what they do. And he described going out across miles and miles with thousands of cattle herding them to a new destination. And he described having a team of people. They each were in communication with one another through mobile devices. They had their checklists for what to do if one of the cattle became sick, for dealing with different constraints. They were a pit crew, even the cowboys.

Wrangling Cowboys

We’re not unfamiliar with cowboys in surgery and the challenges and the opportunities, because some cowboys are innovators and doing important, interesting things that you want to capture. But, you know, one of the reasons you want to be clear about the system that you have is there’s a minimum standard of conduct that you expect from your teams. Ways that you expect people to work together in your culture, in the important processes that you have in your work that things should be able to go. If you have someone who simply will not play by those rules, who undermine a team, who create a toxic atmosphere, who make it harder for people to get great results, then you have to address that directly with expectations about accountability and about change in behavior. Or else: needing to go. That is one version that you see.

A further version is someone who actually does do what’s expected in the culture, does work towards great results, whose got great ideas, but doesn’t necessarily know how to implement them and drive them to scale. What are the insights that they’re having that can be brought more broadly to others? Asking them to capture that and be able to explain it. Asking them to become teachers and part of the culture and having them join with you in solving your problem of, “I love that you’re trying to drive better results and perhaps are one of our outlier performers.” If you are what I call a “positive deviant,” then asking them to figure out, “How do I bring that set of outcomes more broadly to others?” Sometimes they can’t do that, and then you need people who can capture what they’re doing.