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

Eureka!

As I sat and watched, with awe, Vice President Biden’s summit speech on his vision of the cancer moonshot, I came alive and transformed… I felt empowered and validated. Oh the calamity of thoughts that went through my head. “By golly he’s got it!” Everyone has been there at some point, that delirium that accompanies figuring something out. “Eureka!” I thought. Mine hit all at once, and I have been reeling ever since that day of June 29th but my mind is settling to tell you a story. My friends, I am back, maybe not as often, but I will tell you I never left.

He sat across my stool afraid. He was bright eyed, sharp and thinking through the things I had discussed. “You are going to do what?” he asked, “Inject my sarcoma with a herpes virus?” I remained calm but my passion was bursting out of me because I was excited. This was my idea, an idea that has been brewing in my mind for the last 2 years, an idea that allowed me to use my knowledge to help someone, a clinical trial that I wrote. I don’t know how my patients do it; they find the wisdom, the courage, the generosity and open-mindedness to accept my words. Was it that I danced in front of him telling him about the science? Was it the cancer that inspired him to be creative? Was it his immense trust in me? It did not take him long to contemplate the proposal, to believe as he told me. Enter Subject 001.

Cancer, as VP Biden clearly remarked, is a threat the human race can unite to double the rate at which we make progress in trying to push and propagate the knowledge we have to solve its mysteries. As I reflect on this statement, the one person who comes to mind is subject 001- I get the equivalent feeling that we as humans were able to conquer space to get to the moon and back, I reflect on the day I put my patient on my trial, a trial that was unique in its rights, different and innovative. Subject 001 to me, is the first person on the moon. What a feeling!

Eureka! The day has come for us to find out that I am out of a job, that cancer has been cured, that the world is at peace, that we have overcome our fears and that we have won the war against despair. Yeah sure, we all dream. And maybe that is what makes us achieve our dreams; our hopes, our engagement and our efforts. Perhaps it’s a man standing up and saying, “What’s wrong? Why can’t we do this?” I sometimes recognize how hard it is for a General in the army to will his soldiers to go to battle. This is a war, an urgent need to develop cancer breakthroughs and a strong message for us to do things without submitting to bureaucracy, greed, and negative inertia.

“My patient is interested in joining this clinical trial” the bark of a General that does this daily. The coordinator picks up her task; she is as excited as I am. What drives people to work so hard behind the scenes to actualize a clinical trial still fascinates me. It is this ownership, this dedication that can turn the tables in this fight against this devastating disease… let’s not turn against each other, retard each other’s progress, allow politics and competition to stop us.

Don’t just sit there, do something! Don’t put it off for another day, don’t lean on reasons not to act, but rather seize the moment you are in and become part of the history-changing initiative, become a part of how we revolutionize cancer treatment.

Mo.