Kim Gibbons
Associate Director
Center for Applied Research and Educational Improvement (CAREI)

In his recent New Yorker article “The Heroism of Incremental Care,” Atul Gawande discusses how medicine has a savior complex that rewards heroic intervention while ignoring the value of incremental care. He notes, many physicians are drawn to medicine by the chance to charge in and solve a dangerous problem. In fact, the highest-paid specialties in medicine are orthopedics, cardiology, dermatology, gastroenterology, and radiology. Specialists in these fields receive an average income of $400,00 per year. They are the “interventionists.” Most of their income is generated through defined procedures such as surgeries, conducting and reading MRIs, and other diagnostic procedures. They intervene with a procedure and then move on. On the flip side, the lowest paid specialties in medicine are pediatrics, endocrinology, family medicine, infectious disease, and immunology. Physicians in these fields earn about $200,000 per year. They are the “incrementalists.” These practitioners focus on a person’s health over time – often for months or even years. They collect data, evaluate the impact of various treatments, and continually adjust treatment in response to the data. For incrementalists, success isn’t judged by momentary victories, rather by steps that result in sustained progress. And interestingly enough, there is research that demonstrates the value of primary-care physicians including lower rates of general mortality, infant mortality, and mortality from heart disease and strokes.

Gawande goes on to provide another example of incremental vs. heroic intervention. In 1967, The Silver Bridge that spanned the Ohio River collapsed, killing 46 people and injuring many more. The National Transportation Safety Board investigated the collapse and determined that corrosion along with an outdated design had caused the collapse. Inspection could have caught the issue, but until 1967, officials regarded these catastrophes as random and unavoidable. They found that investments in maintenance and improvement could extend the life of old bridges by decades and at a much lower cost than replacement. So, why do we still have over a hundred thousand problem bridges despite knowing that preservation is cheaper? Gawande argues that we continually raid funds intended for incremental maintenance to pay for new construction.  He says “It is obvious why. Construction produces immediate and viable success; maintenance doesn’t.”

How does all of this relate to education? I would argue that parents, educators, and policymakers often put heroic intervention over an incremental approach. Education has long been known for embracing the fad of the day and then moving on to the newest “intervention” without really giving things time to work. Huge investments are made in curriculum, instruction, and technology without ever evaluating the impact. Most districts now have systems to monitor student progress to evaluate the impact of interventions. When progress monitoring data show a lack of progress, interventions are abandoned and replaced with something else without finding out whether the intervention was being implemented with integrity. Today, many districts examine student data and allocate resources to provide extra help to students without looking at the implementation of universal instruction. If large numbers of students are below grade-level standards, providing extra instruction to large numbers of students is not only economically unfeasible, it also doesn’t fix the underlying issue.

The Center for Applied Research and Educational Improvement (CAREI) is partnering with districts to take an incrementalist approach to system improvement. We are working alongside districts and non-profit organizations to improve programs and practices. Not only do we collect information on whether a program, practice, or framework works, we also collect information to figure out how to make the program better so that it can be maintained over time and enhance student outcomes.  We are also engaged in collaborative partnerships to try to secure legislative funding to support districts in the areas of research, evaluation, and assessment. We want to support school districts to conduct needs assessments to pinpoint areas for improvement, build tools to assist in the needs assessment and monitoring student achievement, engagement, and teacher/leader effectiveness. We also want to support districts to conduct their own program evaluation through templates and protocols. Finally, we hope to provide school districts with resources, professional development, and technical assistance. We are open to your ideas and input! Feel free to e-mail me at!

The Heroism of Incremental Care:

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