Teaming Up
A young girl with a ruptured appendix; a middle-aged man with a massive heart attack; a mother of three with a scary lump in her breast. Or perhaps it's your mother who fell on the pavement and broke her hip. Or your son who just attempted suicide at college. Or your husband, whose spleen began leaking after an automobile accident. These are everyday events in the world of medicine, but they are all personal crises that quickly make most other everyday things seem trivial.
At those moments of treacherous illness, what matters most is that the patient is in the trusted hands of expert, caring doctors. Ones who explain what's going on, who are there with round-the-clock ministrations if need be, and who secure the best possible outcome. This is the expected way, honoring no clock or self-interest. And this is the stuff of medicine that makes nice people want to be doctors.
There is no greater thrill than seeing a sick patient heal. No greater joy than knowing hard-earned human efforts made a difference. But to achieve that in today's world, doctors can't fly solo anymore. For one thing, by today's rules no docs should be working around the clock; they need to be spelled by rested colleagues. Beyond that, however, medical advances have led to an ever finer carving of medical disciplines into specialties and sub-specialties, driven by scientific discovery, which has brought good results in the curing or quelling of human disease.
Uberdocs. But this is recent history. Surgery was medicine's first one-on-one therapeutic specialty, flowering over the past 100 years. It was enabled not only by understanding infection and its prevention through clean hands, masks, rubber gloves, and sterilized instruments but also by the discovery of anesthesia. Without anesthesia, doctors dared not penetrate the belly or chest or drill into the skull. But with it, and accompanied by postoperative teams specialized in intensive care, surgeons began to cure many diseases that, left to their natural course, were killers. The surgeon became the uberdoctor, the center of hospital life, and the ultimate healing hands.
Further medical advances ushered in other disciplines to rival surgery, using less blunt instruments. The internist, for example, started as the learned diagnostician who grasped the disease, pontificated on its outcome, and called in surgeons as needed. In those good old days of the solo doctor making house visits late into the night, his signature black bag was actually pretty empty--and what was there often did more bad than good. It was Oliver Wendell Holmes Sr., the renowned Boston physician and father of the famous Supreme Court justice, who summed it up in a speech before the Massachusetts Medical Society in 1860. After deriding the use of emetics, cathartics, blistering agents, and opium, he told his colleagues that if the whole existing formulary of drugs and potions available to them were sunk to the bottom of the sea, it would be all the better for mankind--and all the worse for the fish.
Drug therapy was mostly quackery back then. Since, research breakthroughs have turned medicinals into rational, safe, and dose-specific therapies. Bearing veritable nanoscalpels in the form of drugs that zero in on a disease pathway invisible to the eye or even the microscope, internists rose alongside surgeons as healers. Much of the diagnostic work was turned over to newer specialties. For example, CT scans and MRI s give physicians the X-ray vision to peer inside a troubled body; and sonograms turn the noises of the stethoscope into images of a beating heart or a growing fetus. Diagnosis got better and much easier on the patient--but high-tech and expensive. This pattern has been replicated in virtually every domain of medicine. At the same time, the general field of nursing spawned nurse practitioners, allied health therapists, and physician assistants to complement medical expertise in the vastly more complex care of both the healthy and the sick.
Through necessity and opportunity, medicine has become a huge group effort. The titans of yesterday fought hard for their autonomy and happily polished their individual pedestals of near godliness. Yet, the wisest of them set the stage for their own toppling by embracing the endless frontier of medical science, which ultimately transformed the way we give care. But, solo or group, yesterday or today, on the frontier or in the midst of today's fast-paced clinic, the practice of medicine by all its participants has never been easy. It comes with long and continued study, hard physical and mental work, and heavy responsibility. Plus, it demands a piece of one's soul. Future doctors, nurses, and other health specialists always have been chosen not just for their smarts but also for their humanitarian values. They must be kind, merciful, and sympathetic to those they care for, whether the patient is old or young, rich or poor, appreciative or ornery.
Money is not an unimportant issue in the practice of modern medicine. Professional ethics dictate that payment must be secondary to the first interest of doing what's right for patients. Yet mercy and money have always been a tricky combination. In his famous almanac, Ben Franklin had a few gibes for doctors of his day: "God heals and the doctor takes fees." That hint of resentment came at a time when doctors were close to beggars and medicine a trivial part of the nation's economy. Today, the medical professions surely help the good Lord out, but the financial cost is mighty. Healthcare consumes 1 out of every 7 dollars of our national economy, and, as policy wags note, most of it is driven by the physician's pen.
There is an old saying that a physician is one upon whom we set our hopes when ill--and our dogs when well. That's easy to do, since at any one time most people are well and there's a certain suspicion about hefty resources being consumed by the ill. The steady, four-decade rise in health insurance costs, both government and private, has made modern healthcare possible. But at the same time it has introduced a new and less solicitous interest in between doctor and patient--that anonymous, often heavy-handed "third-party payer" holding most of the dollars.
Doctors have gripes galore about the third parties looming large at the bedside and in the examining rooms who effectively drive care by setting fees, dictating benefits, even making medical decisions such as whether a patient can have an extra hospital day or be allowed an MRI. It's legitimate for payers to question expenses, but it's also hard for the solo practitioner to stand up and be heard in this environment.
That brings us squarely to the question: What is replacing our romantic notion of the solitary, autonomous doctor? Ideally, one would hope for an integrated team working together on behalf of common medical goals, with the patient at the center. This, as opposed to what so often happens today: a loosely allied group of independent, unrelated practitioners drawn together in a defensive huddle to meet the needs of insurance contracting and managed care.
The integrated team model has been around a long time, but it is still the exception in today's private medical practice. It was pioneered by the Mayo Clinic more than 80 years ago. The architect was the surgeon W. W. Mayo, who was fond of saying, "No man is big enough to be independent of others." Mayo and his two surgeon sons, Will and Charlie, developed a model of "cooperative individualism," in which top-notch physicians from all disciplines were carefully selected to work together in salaried positions. Salary was key, because it meant the docs were not answerable to accountants for their medical decisions, and it was understood upfront that some of their fees would be plowed back into the institution. Many in the medical field saw such a cooperative venture as downgrading the medical profession, by making doctors cogs in a wheel. Ironically, the problem today is that all too many individual practitioners see themselves as little more than cogs--but in a broken wheel.
Sidelines. The clinic model, or some variation of an integrated team, is just what medicine needs today. It will work, however, only if it comes with the purpose and the faith that this will bring better care of the patient and enable the squeezed practitioners to remember what brought them to medicine in the first place. Indeed, the 21st century finds physicians and their patients struggling to meet the medical and economic demands that necessitate team-oriented healthcare. Here we might learn a thing or two from America's most favorite spectator sport, football, and one of football's best, Coach Bill Belichick of the New England Patriots.
Belichick astounds the sports world by his ability to build a Super Bowl-winning team of solid but not splendiferous players. His strategy seems simple: Accentuate any given player's strength, and manage around the weaknesses, something you can do if you have a versatile team. He is proud of his team for being made up of unselfish guys, who work hard, respect him and one another, and on the field are committed only to winning. A group of comparable or even higher-quality athletes, unable to consistently work in unison, would be self-defeating.
That is a lesson for the kind of teamwork that is essential in the medical field now and as we look ahead. It comes with benefits, including pride in doing better for patients, intellectual stimulation, fewer administrative hassles from the third parties, and more reasonable work hours. And, as in football, a successful medical team's glue is that intangible called faith--in one another and those they serve. That timeless ethos is captured in words penned by the Cleveland Clinic's late surgeon George Crile Jr. in 1955:"No physician, sleepless and worried about a patient, can return to the hospital in the midnight hours without feeling the importance of his faith. The dim corridor is silent; the doors are closed. At the end of the corridor in the glow of the desk lamp, the nurse watches over those who sleep or lie lonely and wait behind closed doors. No physician entering the hospital in these quiet hours can help feeling that the medical institution of which he is part is in essence religious, that it is built on trust. No physician can fail to be proud that he is part of his patient's faith."
This story appears in the January 31, 2005 print edition of U.S. News & World Report.