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

Dialogue

Person: Can you help me?

Me: I believe that is why I am here, ready with a new treatment, a loaded gun and many tricks up my sleeve.

 P: Is it always this hard?

 M: Yes.

 P: Is there hope?

 M: Without it, we will not survive.

Imagine this dialogue that starts in the pit of someone’s stomach, a mixture of fear, anger, hope, and courage.  I partake in it and I do not dismiss it. Have you ever been afraid?  Where the walls caved in and it seemed confusing? Where what consumed others felt petty, trivial and meaningless. When you sit on the edge of a diagnosis of cancer and are worried about yourself, your family and your loved ones. This is the human I meet, sometimes confused, often afraid, and always hopeful. This is the person from which courage emanates. With this person, I stand united.

Cancer: I am here.

Me: Who are you? And why have you invaded us?

C: I am a product of survival, a state, a process. Who are you?

M: I am here to kill you.

These are my words when I look at cancer, the perfunctory introductions. A long battle is about to ensue. This is the enemy I know well. On this battlefield, a new sword has to be forged, to fight in the face of fear, uncertainty, and discouragement.  Every day a different person walks into my life and stands stronger against this common threat. Our unique existence, our individuality is a paintbrush that brings to life our depths and our dreams. In life, we march only forward regardless of how timid we feel or where our hearts want to be. I sharpen the reality that was thrust upon this person with my words. My patient stands steadfast in trust and belief.

And the dialogue resumes………

 Me: Which way this time? Cancer, are you ready?

 

Cage.

It’s about a mile walk from my clinic to my office. A small part of that walk is outside. Grey was the sky, a cold wind penetrated my shirt but not enough for a jacket I thought. A light drizzle of rain. I guess this is the “Ambience” of this blog. I sighed deeply as I walked, the conversation of the day speaking inside me. I could feel each step, each bone in my body ached. And I walked distracted.

“I am sorry but your insurance will not accept me treating you on this clinical trial.”

Shell Shocked.

I did not go into medicine to be forbidden to treat someone with what I felt would be the best option for them. I imagined myself a rare bird stuck in a cage realizing the boundaries of the system that I existed in.  My wings unable to soar. My perceived freedom now defined by outward forces beyond my control. I felt the bars close in and force my decisions. A slave to the system that I have now discovered is not  easy to navigate. “This is all I have to treat you with”.  I did not even want to be in the room anymore as I spoke to this human. Where did my compassion go?  I longed for the freedom to decide the best treatment. I wanted to soar and my anger rattled me.  I flew into the bars wanting them to bend. I felt the imposition of the system. Where are the tools to help my patient today?  This is coming from someone who does not take “no” lightly.

I walked to my office, and talked to my boss. An incredible man to say the least. He let me talk. Like a cushion he absorbed this shock. This is not the first time that this has happened.

I have always liked the political cartoons of the past. They speak volumes in pictures. Intelligently portraying the issues of the time. I sat and read some of the “Far Side” cartoons on my couch. Humor a mature psychological defense mechanism like an old teacher showing the way.

Here is my picture for you- “Imagine”:

That despite this cage; this bird today sang.

I still found a way to deliver my care.

Mo