Moving from “medicine as individual heroism” to “medicine as a team sport”

This topic isn’t directly in our wheelhouse here in the e-patient movement (“empowered, engaged, equipped and enabled”), but as I continue one patient’s odyssey in learning about healthcare, a discussion on Paul Levy’s blog has taught me a lot. So I’m posting it for other interested patients.

It’s on his post What does it take? The original post was about why Boston hospitals aren’t agreeing with Levy’s offer to share knowledge to reduce hospital-acquired infections etc. But it’s shifted to being largely about the use of checklists, which has led to some profound comments about cultural and human issues when change is in the wind.

One comment, from Brent James of Utah’s Intermountain Health Care, is so informative I want to share it here.


Paul, you have put your finger on what I regard as THE core task of the present generation of the healing professions. It is very clear that we are in the midst of a transition. The term of art that is usually used to describe the present state – and which Don Berwick so eloquently explained (at least, at the level that an individual physician would experience it) – is “the craft of medicine.” It’s the idea that every physician (or nurse, or technician, or administrator, etc.) is a personal expert, relying primarily on their personal commitment to excellence. In a very real sense, every physician occupies his/her own universe, with its own reality, truths, physical constants. As a physician I might say to a colleague, “What works for you, works for you. What works for me, works for me. Let’s both stay focused on the patient – our core fiduciary commitment to put the patient first in all things – and that will guarantee the best possible results.”

David Eddy said it most eloquently: This core assumption of the craft of medicine is scientifically untenable.

As a direct result of some solid research around this fact, the healing professions are in the midst of a major sea-change, a once-in-a-century shift: We’re moving from “medicine practiced as individual heroism” to “medicine as a team sport.” The kinds of tools you’re talking about make perfect sense in a team setting, but almost no sense within the craft of medicine.

Don is right in calling it culture change. However, we are well past the tipping point. There is strong evidence that the professions have committed to a new course and are actively moving. It’s the difference between 5% of the profession “getting it” (where we are now), and moving to a point where it is standard, accepted, background business essentially all of the time.

The key change concept was perhaps best expressed by Winston Churchill: “People like to change; they just don’t like to be changed.”

I am also deeply impressed by Roger’s classic text on change: Diffusion of Innovation. He describes bottom-up change, by sharing results (both data and word of mouth) from initial thought leaders (his “early adopters”). That has worked very well for us, and makes the change fun – rather than something that a bunch of external “know nothings” are trying to do to you.


There is an e-patient tie-in, though.

Brent first appeared on Levy’s blog last March. Shortly after, on another post, our Gilles Frydman commented, ending with this:

“It is possible, even probable, that in the end, the only solution to overcome the problems mentioned by Brent James will require a deeper paradigm shift than what can be achieved by the LEAN management philosophy, applying to healthcare entities some of the ideas developped in Eric Von Hippel’s Democratizing Innovation. The sooner you’ll involve the end-users of your system (the engaged and informed patients we call e-patients) to help in the innovation process necessary to solve some of the failures of modern hospitals the faster you’ll be able to produce profound results, IMHO.”

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16 Responses to “Moving from “medicine as individual heroism” to “medicine as a team sport””

  1. Harlan R. Weinberg, MD says:

    Dave,

    Having been a practicing physician since 1981, the focus from all of my training and now private practice, has emphasized the importance of professional and patient communications. The significance of the scientific and personal communications has always been an integral part of the medical world within which I work. Although not perfect, I believe that most physicians want what is professionally best for their patients as well as making sure that their patient discussions are made to be understandable for those individuals and family members under their care.
    We must continue to remember our professional obligations plus the enlarging commitment to all of our patients. It is most unfortunate that difficulties including managed health care, uncontrolled medical malpractice costs, declining reimbursements, algorithm medicine, revolving-door outpatient medicine…all of which have removed the purpose of our profession, critical medical thinking and compassionate patient care. In the end, let us all remember, the purpose of our profession which is centered upon humanitarian care, support and understanding.
    Let us hope that we don’t lose our way.

    Harlan R. Weinberg, MD, FCCP{
    Author, “Dr. Weinberg’s Guide to the Best Health Resources on the Web”
    http://www.drweinbergsguide.com

  2. Hi Harlan – pardon what’s probably a thick-headed question, but what’s the connection between what Brent James said and your comment? (Don’t mean to sound rude – I just don’t see the connection.)

  3. Harlan R. Weinberg, MD says:

    Dave,

    My understanding is that the importance of our craft of medicine is the combination of “communications,” application of scientific concepts to the individual patient and caring. Innovations are wonderful, but even more important, will be those professionals and patients, who will make the whole process work. I like to look at the positive aspects of medicine, fully understanding that there are many difficulties ahead to correct. Yes, I agree, that change can be a very difficult and challenging opponent. We are certainly all smart enough to realize that failure in healthcare is not an option.
    Thanks.
    Harlan

  4. Anybody out there a student of the history of software development?

    This morning I was reflecting on the similarity between this post (medicine as individual heroism, vs team sport) and the same phenomenon in software development. Years ago I worked with developers who were darn proud of how good their code was, and didn’t give a hoot that nobody else could maintain it. And those developers really didn’t like it when things changed so that a good developer was defined as someone who created code that other people could easily test and even a stranger could walk in and debug or improve.

    The analogy to medicine isn’t at all perfect – I don’t know of surgeons who want to do things that others can’t “maintain.” But the angle of hero vs team player certainly does seem relevant.

    What do you know about this?

  5. Carey says:

    Moving medicine from individual heroism to team player is an interesting conversation. But these terms, however, carry much weight and are extremely messy. The posts and comments discuss change, paradigms shifts and enhanced professional and patient communication – but what exactly are these suggestions attempting to change? I’m afraid the “problem” is being suppressed through our preferred solutions – culture change, communication and structural shifts. In no way am I saying the healthcare system is without its complexities and troubled waters but by typologizing and listing the types of problems and how they are initiated (and solved), allows us to deal only with the their effects and sources, not the nature of the problem or change itself. Notwithstanding the challenges that face our healthcare system today, what would happen if we instead started asking questions about what we are doing very well in the healthcare system. What’s working particularly well? Which hospitals are experiencing tremendous results and how are they doing it? And how can we begin with each individuals’ unique contribution and strengths because we all know they are there. Starting with our strengths and knowing all the tremendous talent, creativity and capacity we have now, what then are we hoping to achieve? It is process-based and allows the heros and team players to be in a constant ebb and flow of becoming rather than being a static hero or team player. And this state of becoming might shed light on just what we are trying to do/say/change with moving medicine from individual heroism to team player. We are very good at identifying problems for physicians, patients and medical practitioners and very good at identifying solutions like change in culture and change in structure. What if we ask instead, how the health arena decides what its structures should be, how work should be managed and whose values and voices should guide those decisions. What and who are in need of change? And what will be achieved through such efforts? Looking forward to more conversations!

  6. Okay, Carey, I’m game – this is all an ongoing learning experience for me. What do you suggest? I’m constantly looking for new insights. By all means, illuminate!

  7. Carey says:

    Dave, this is certainly an ongoing learning experience for me too but you’ve started and continued a terrific discussion that I’ve really enjoyed reading! Paul Levy’s original post generated numerous comments which diverted into talk about the checklists and you re-directed the discussion by asking again, what will it take to get hospitals to respond to Paul’s initiative to share knowledge and work together to reduce harm? Checklists may get people talking but for patients, surgeons and medical practitioners to be in harmony, we must think in different terms of collaboration so that our vocabulary for expressing these thoughts grows and so that collaboration becomes the norm and not the exception (or reminder) during surgery. Change is difficult as we all know because it requires people to give up actual parts of themselves and to become something different by using different language, different ways of organizing, and different models of decision making, not to mention consequences for identity and so on. And this can be uncomfortable and problematic for many. What about starting with medical education? Developing a new model of medical training that fosters these very things and notions of collaboration, community, and commitment become the foundation (norm) rather than the exception or intervention. Yes this would disrupt what it means to be a medical practitioner but might shed light on these sets of questions generating exciting conversations. And might help us all set a very different agenda for healthcare and a very different role for ourselves in the new healthcare system (Dr. Ken Cohen had a terrific post about this). Patients too will need to change and adapt to this model by understanding their new role as responsive and responsible players…What do you think?

  8. Sorry for the delay responding, Carey – I’ve been in a frenzy of activity at the day job and now tied up at volunteering at the TEPR conference.

    My career has been in high tech, particularly software, not medicine. There’s a really strong parallel here with the way software was written 20+ years ago, and is sometimes written today.

    Back then black belt programming wizards wrote astounding code that made machines do impossible things. Trouble was, nobody else could maintain the code. Software went through major pains (and many companies went under) as they transitioned from software as heroism to software as a team sport. A brilliant developer came to be defined as someone who could productively add maintainable code to a company’s asset library – not somebody who could make a machine do six impossible things before breakfast.

    Change was indeed difficult because it meant those people had to give up their freakin’ egos in favor of something more important: the end result.

    The analogy isn’t perfect – a brilliant surgeon doesn’t add assets to a hospital’s “library.” The valid aspect is that as processes become more predictable, more repeatable, a person becomes more valuable if they’re able to operate within a framework.

    In an odd way, this parallels Clay Christenson’s later work, beyond his initial thoughts on disruptive technology. Going deeper in that line of thought, he wrote that as a technology matures beyond the “performance at any price” stage, interoperability becomes more valuable: “compatibility at [almost] any price.” Moving from “system component heroism” to “system components as a team sport,” if you will.

    Perhaps medicine is starting to get to the point of having reliable repeatable processes.

  9. [...] back. (Please read the wonderful thoughts from Paul Levy’s blog, copied into our January post Moving from “medicine as individual heroism” to “medicine as a team sport” [...]

  10. ePatientDave says:

    @pfanderson Maybe this is continuation of the shift from "physician as hero" to "team sport" – January post: http://is.gd/51s9P #hcsm

  11. ePatientDave says:

    Medicine as team sport: http://is.gd/51UIH RT @ColetteCote @chrisbrogan [snip] #socmed needs to be a team sport. http://bit.ly/4tMDKk #sm

  12. Pete says:

    In Parkinson’s disease (where I work), it is essentially impossible to get good care without a team approach. People with Parkinson’s (PwP) need medicine, they may need surgery, they need physical, occupational, and speech therapy, they need help from social workers. They and their loved ones may need mental health care and counseling, and they may need “respite care” — where their spouse gets a couple of hours a week rest from having care be their primary occupation. Add to this the fact that the affected organ is their brains and we wind up with a situation that would tax even the most high-functioning individual. My foundation (National Parkinson Foundation) provides grants to centers that specialize in Parkinson’s care to fund a coordinator position, who helps with understanding and explaining PwP needs and scheduling their appointments, etc. We’ve shown, in controlled studies and population surveys, that this team approach gives better outcomes and that it is so complex that few patients can manage it on their own, yet care coordination is not reimbursable.

    The VA does recognize the team model and has Adam Darkins, MD, as the lead person on care coordination. Interestingly, Darkins focus is heavily on coordination through information technology and telemedicine. This is an approach that I’ve been taking (independently) for some time, but we may be as much as a generation away from the time when the majority of the people who need care the most will have the skills to take advantage of technology-enabled care coordination.

    Most physicians (and more specifically, specialists) tacitly acknowledge the need for a team in that they either neglect or refer out aspects of care that are not within their purview — medication for physicians and surgery for surgeons. On a cost-weighted basis, most of the money spent on care is going to specialists who possess quite limited vision. (Any MD who reads this post is almost certainly no so constrained and hopefully will not take offense.) How many obese diabetics are actually put into a care plan that successfully achieves weight loss? In my own field, how many PwP are put in intensive exercise programs that are strongly believed to improve outcomes? (I know the answer to the latter question, and will publish it soon….) Healthcare has to flow downhill, with inexpensive allied providers relying on the expensive physicians and surgeons to build the team. Until we address this using a VA-like model, where a smart, zero marginal cost electronic medical home (health home?) builds the team for you based on a set of standardized, evidence-based rules (and, in such systems that I’ve built, subject to physician approval), patients will fall into two groups: the larger group will get too little care, with touch points only when they are already in crisis, and the smaller group will get too much care, with lots of unproven (and often unprovable) therapies.

    It will take a generation to really, effectively change this, but I think that a lot of the practices that will achieve this change are already established.

  13. RT @ePatientDave: Medicine as team sport: http://is.gd/51UIH RT @ColetteCote @chrisbrogan [snip] #socmed needs to be a team sport. http: …

  14. RT @ePatientDave: Medicine as team sport: http://is.gd/51UIH RT @ColetteCote @chrisbrogan [snip] #socmed needs to be a team sport. http: …

  15. Hi Dave,

    I know I’m jumping into this discussion very late, but I just finished reading Atul Gawande’s The Checklist Manifesto, and when I then found this article, I was flabbergasted by the opening statement:

    “This topic isn’t directly in our wheelhouse here in the e-patient movement (‘empowered, engaged, equipped and enabled’),…”

    The surgical checklist that has been demonstrated to improve the probability of smooth teamwork in surgery, the checklist that will possibly prevent iatrogenic complications from my next surgery–that’s not in the e-Patient’s wheelhouse? I’ve seen numerous instances where you and Trisha Torrey have exhorted patients to ask questions, demand information, insist that your research be considered in diagnoses, and even remind doctors and nurses to wash their hands. But, we shouldn’t be asking our surgeons to use the WHO surgical checklist? I’d think you would want to be at the forefront, telling your readers and tweeting their followers to ask about the checklist before surgery.

    Please, Dave, tell me I was reading too much into that opening clause.

    I had spinal surgery in late 2008, a discectomy that went well in every respect but one: it left behind some scar tissue pressing against the nerves. So, my spine is beautifully fused, but the pain is excrutiating. As I write, I’m wearing a pair of patches that deliver 62 mcg/her of Fentanyl to my bloodstream. In addition, I’m taking hydrocodone and gabapentin, dragging my self through physical therapy, and getting another epidural every three months. What worries me, though, is the other two discs I have that are degenerating. What if they have to be fused.

    I’ve seen the surgeon’s records from my discectomy/arthrodesis. I know I received an antibiotic before the first incision, but I have no idea whether it was in the 60 minute window or even if it was given before the incision. I know my surgeon knew his PA’s name and I know he knew his anaesthetist. I have no idea what their working relationship was with the nurses. My hospital hasn’t signed on to the WHO checklist registry. What if I have to get another disc removed? Will that next fusion be the one that leaves me crippled from a spinal infection?

    I will sure as hell do all I can to prevent any such incident.

    The WHO has a map that shows all the hospitals in the world that have started using the checklist (yellow) and all those who are considering it (red). I strongly urge all my fellow e-patients to ask your doctors about the WHO surgical safety checklist. Urge them to read Atul Gawande’s book. It’s a fascinating read, and it might just scare some sense into a few surgeons. Urge them to adopt the checklist. Urge them to get their administrators interested. Remember, adopting the checklist is free, it only costs a few seconds, but the ROI is astounding.

    This is a matter of patients’ lives, people. We need to do all we can to promote the checklist.

    • Dennis,

      Yes, I’m guessing that you read more into it than most people did. (I just re-read how other people reacted in the comments.) But that’s fine with me.

      I’d mainly point out that this post was written 17 months ago, less than a year into my own e-patient awakening. And as the post itself illlustrates, it occurred at something of a turning point.

      It’s excruciating to read your story.

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