Inner Thoughts


Better incentives, infrastructure key to unlocking collaboration

True collaboration should be embedded in the practice of medicine. It should be baked in, a given, something we don’t need to write columns on. Today, it’s not. In today’s health care environment, fully integrated, cross-disciplinary teams remain a work in progress. We need to move faster to better serve our patients.

Why? As with many things, there are financial reasons. There’s an incentive to be competitive with other caregivers because we get paid for services we perform. If your practice runs a test, that’s one test that my practice is not running and not getting paid for. Of course, we clinicians aren’t sitting around actively thinking that, but the structure of today’s predominant payment model and the way we physicians are trained makes it a natural, almost invisible, contributor.

These misaligned incentives, along with inconsistent infrastructure, put physicians in a tough spot. There’s a saying, “forgetting the face of your father,” meaning someone has lost touch with their roots. I worry we doctors have forgotten the face of our father, Hippocrates. We have built a system of care that is so complex it can at times be emotionally exhausting for all of us–patients and clinical staff.

Our patients come to us seeking advice and help. It shouldn’t be necessary for that advice to be linked to a relative value unit or monetary reward. Doctors want to provide a feeling of comfort and care, yet are losing that spirit because, when we walk out of the room, we often have to deal with redundancies and inconsistency and inefficiency within the system.

Collaboration will return if we can reset and reconnect to our purpose–bringing back the empathy, compassion, and spirit that sits at the heart of medicine. Collaboration happens when we all believe we’re doing it for a bigger purpose, something more than just revenue.

Think about it: the smartest people are scattered across the country. Instead of holding onto information because of the natural tendency towards tribalism, what if we shared it? What if we were able to view data together, at the same time? The problem will be solved–and probably relatively quickly. In this scenario, we see the shared purpose–the philosophical piece–and the tools/standards–the infrastructure.

I’m fortunate to work at University of Iowa Health Care, a place I believe provides an excellent case study in collaboration. People across our organization share information and are receptive to debate and counterargument. We’re unafraid to get around a table and see things through different perspectives. There’s an emphasis on teams, not on individuals trying to make a name for themselves.

Here’s an example: The sarcoma group here at University of Iowa Health Care was participating in a sarcoma clinical trial. For patients to participate, their eligibility had to be agreed upon by a radiation oncologist, a surgeon, a pathologist, and a couple of us oncologists.

A few weeks in, the clinical trial team called us and said, “You’re putting more patients than anyone into this trial. How are you doing it?” What they meant was, “How do you get opinionated, highly-educated leaders in their fields to agree so consistently?” Here’s the simple answer: We look at each patient’s care as a collaborative effort, and we decide as a group.

Our ability to make group decisions was built on a philosophy created long before we’d evaluated a single patient. We all knew the science of the trial, but beyond that, everyone on the board bought into a collaborative approach when they joined. We all agreed that we’d focus on the trial as an important resource for patients, that it represents a better treatment because at the time we didn’t have good answers. In other words, we had an agreement on the basic philosophy. Then, when two of us might argue, we could go back to the core values of mutual trust and respect for each other as professionals and people. That kept us from letting any one person’s opinion take on an outsized importance, which then lets us get to consensus quickly.

Which brings up a final point–relevant both to small teams and to our health care system as a whole. It’s the idea of delegation and specialization. Creating standards and a shared language requires an arbiter. In the oncology world, we have the American Society of Clinical Oncology, the National Comprehensive Cancer Network, and other groups to manage guidelines that help us navigate very difficult decisions.

Using oncology as an example, we need to allow others to be in charge. Today, instead of acknowledging, “Sloan Kettering is the best in sarcoma; let’s all let them guide best practices for the sarcoma world,” some might fight the idea and compete to displace them as number one. This is largely a waste. Delegation allows expertise to shine and specialization to emerge. It also allows for standardization, because only one group is creating the guardrails.

Ultimately, what we need to do as clinicians is create an environment that lets each organization, each department, and each provider operate at the height of their ability. Change the ecosystem, remove distractions. We need good leadership to see opportunities to make changes that remove burdens.

This is not to pass the buck onto a faceless administration or to call out executives (or department heads, or anyone). We all have some form of leadership role, and it is therefore incumbent on each of us to find those opportunities. We are responsible for managing our own ego and not just recognizing but celebrating the fact that others will supersede our abilities. Rather than defending against that reality, we should embrace it.

My hope is that we can bring a moonshot mentality to all of medicine. Not necessarily in terms of the solving-huge-problems (though that’s important), but in terms of collective action. Former Vice President Biden demonstrated this idea when launching the National Cancer Moonshot initiative: the focus was on collaboration as much as it was the scale of the problem being solved. Why not instill the same attitude across medicine, regardless of whether a program is a national initiative backed by prominent names or an intra-institutional research project? Why not spur collective action towards creating an industry-wide culture of collaborative care?

– Mohammed M. Milhem, MBBS

7 thoughts on “Inner Thoughts

  1. To my amazing doctor of science,
    I was just thinking today how I wondered if you were going to write another blog. I love the University of Iowa for this special reason of individuality. How you specialize your care for each person and how this would be awesome across the board. Keep up the great work and insight on the future Mo. You make the University of Iowa special and I am so lucky to have a doctor like you who always thinks of the other person first 💖

  2. Thank you for your wise and caring thoughts and for the outstanding care you provide. Lucky are those who are in your care for they not only have the best clinical advice but also someone who understands.

  3. Well said. Thank you all for giving us all your best. I hear often people asking what’s the best sarcoma center. The answer should be, the nearest one to where you live. If doctors shared information and questions liked you said they should we would all get the best treatment. Purple have asked me why I didn’t go to Mayo. My answer, “I’m a Hawk fan.” While that is true I actually say that Iowa has a great reputation in treating sarcomas. That’s good enough for me.

  4. Mo, you put my EXACT thoughts into words when you express how the University works as a team! I have explained this to many, but not NEARLY as eloquently as you have here!

  5. Thanks for sharing your best practices on working in teams , trust and collaboration . I hope to hear more about the Moonshot initiative in 2021

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