For our sickest patients, medical practice has become too complex for one physician to do it all. Mortality rates have fallen for many conditions and there is little doubt that routinization and super-specialization have contributed to improved clinical outcomes. Yet, some of the hardest-working physicians have responded to the demands of complex medicine by redoubling efforts to manage all aspects of care.
These physicians embody what we call heroic value. They feel compelled to make every decision for a patient, not trusting or relying on others in the care process, and have a deeply ingrained sense of personal responsibility. Indeed, these physicians work tirelessly to deliver excellent clinical outcomes. Through relentless personal accountability to high standards, they struggle to deliver these clinical results in the absence of what many would consider to be effective teamwork.
While we are deeply empathetic to the physician-hero’s pursuit of excellence, we submit that this practice pattern — which has carried over from a different era — has an adverse effect on value. This is because the denominator of the value equation — cost — can easily be increased when the physician-hero engages in workarounds at the expense of team-based best practices, thus reducing value, even if the numerator — outcome — remains the same. Clearly, not all patients are ideally suited to standardized care pathways, and innovation by experienced clinicians is necessary to improve outcomes; however, such innovation works best when integrated with team-based care models. Five conditions explain why effective teamwork is required to optimize costs for the delivery of complex care.
First, because the physician-hero controls almost all aspects of care, the cycle time on decisions becomes entirely dependent on that physician’s availability. Consider, for example, a patient on extracorporeal life support who no longer requires the life-saving technology but who waits for 24 hours to separate from the device because the physician who placed the patient on support and who desires to maintain oversight of care is unavailable. In a team-based system, the patient would receive the care needed at the time needed, even if it was provided by another member of the team.
Second, non-team-based health care tends to be laden with redundancies and inefficiencies to make up for the inability of any individual to be available for complex care 24 hours a day. Instead of relying on a team member with complementary skills — for example, an intensivist to coordinate ICU care — decisions are deferred to the individual physician who calls in consultants to manage different organ systems in which he or she may not have expertise. Such referral patterns can reinforce non-evidence-based practices if the preferred consultant defers to the physician’s practices that may not be grounded in clinical science in exchange for continued referrals. This contributes to waste and inefficiency.
Third, the stereotypical physician-hero can be demanding and intolerant of perceived oversight (perhaps in part due to the stress they place upon themselves), and such behavior can prompt significant staff turnover. Staffing changes exact a financial toll in the costs of replacing staff and onboarding them. Hours and hours must be reinvested in learning the nuances of how the physician-hero likes his or her patient cared for.
Invariably, systems that are dependent upon multiple physician-heroes create an environment in which staff cannot learn one standardized management process for a particular condition, but must instead apply the specific process that each physician-hero wants. This variability in managing a similar disease process often extends to requirements for a particular device or drug that the individual physician insists on using. As a result, multiple different devices, materials, and drugs that achieve similar results are stocked by the institution with a resultant increase in cost.
Fourth, in pursuit of the best care for their patients and the ability to provide it in real time, physician-heroes tend to not recognize the effect that their practice pattern has on occupying hospital resources. Take, for example, the cardiologist who does not relinquish his or her procedural time to another cardiologist because of only a potential need, but ultimately does not do a procedure. Another patient who could have received care earlier isn’t able to have the procedure and the institution also incurs the personnel costs associated with staffing that procedure room. Simply said, a team-based ethos that mandates flexibility in interventional room use and reallocates the time based on patient need would improve care and lower cost.
Finally, a system that accedes to the individual physician who does everything cannot capitalize on the collective intelligence that teams bring to care. Even the best physicians are occasionally wrong. Diverse and effective teams are more likely to develop novel solutions to commonly encountered problems that further improve outcomes and lower costs.
The idea that effective teamwork promotes safety and superior clinical outcomes is rational and widely held despite a lack of consistent data linking the two. In contrast, the notion that team-based care models lower health care delivery costs has received less attention, though the data are potentially more robust.
In sum, institutions that maintain the physician-hero model eventually experience fatigue from managing a service line that too frequently appears in crisis. Of course, changing this process takes time and if the financial rewards to the hospital are significant — as they often are with technically skilled physicians — the institution may try various workarounds and patches before concluding that the costs are not worthwhile. Unless the institution has a strong brand, rebuilding a service line may incur a reputational cost, as patients have little insight into the challenges described here and may simply react to the departure of a star performer.
Creating a culture of team-based care requires thoughtful leadership and a shift in focus from who is in charge to how patients’ care needs can be most efficiently met. The foundation of such an approach includes intensive communication and coordination. Senior hospital leadership must message unwavering commitment to these principles for culture change to be effective. Because these skills may not come naturally to the hero physician, he or she may need the assistance of mentoring and coaching programs to adopt practices that are better aligned with contemporary care models.
Health care is changing to focus on delivering high-value care. Cost optimization is a critical piece of this strategy. Like the institutions that they work in, physicians, too, must adopt models for delivering complex care that maintain excellent outcomes and optimize cost. We believe that effective teamwork is an indispensable element for a successful value-based care delivery strategy.
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Joyce Wahr
Perhaps the most important paragraph is this: Invariably, systems that are dependent upon multiple physician-heroes create an environment in which staff cannot learn one standardized management process for a particular condition, but must instead apply the specific process that each physician-hero wants. " These hero physicians become stuck in time, practicing what they learned 30 or 40 years ago. They intend to give best possible care, but instead are practicing woefully out of date, and harming patients. GREAT ARTICLE! Should become mandatory reading for every student.
May 25, 2018 at 10:55 am
Dr. Richard Tefo MD
This article appears have been written to fulfill a commitment for an article with little basis in reality. Please "Physician HERO" ? No one would disagree with the premise that the best chances of giving and getting good care is protocol driven and standardization. However the reality is that all too often the Critical Care physicians and the Hospitalists are spead thin and timely care is not a guarantee. In fact, you could say that patients remain on the vent longer because they wait for a respiratoy therapsit to be available. Why have such a patently straw man to make the point? Why not say we need protcol driven decisions. The training is this country is outstanding. The number of physicians I have met/worked with who aren't well trained has been near to zero. Does anyone actually practice for "40 years"? You are trying to make some valid ponts but the article is a joke.
May 25, 2018 at 9:31 pm
Art Pomerantz
35 years ago, the Cardiac surgeon, his partner and the PGY 3 and PGY 2 general surgery residents who made up his team were way more cost effective and outcome oriented than the present day army of intensivists, hospitalists and midlevel shiftworkers which now comprise the hospital team. Moreover that was also a time when the Cardiac Surgeon’s time also had considerably more economic value. What we have now seems to be an example of job sharing to justify inflated salaries and distorted benefits for corporate overseers.
June 05, 2018 at 2:42 pm
Rosemary Azzaro
As a patient, and as an advocate for my elderly parents, I have preferred a "gatekeeper" model for care. In my experience, that can only work if the gatekeeper has the ability to juggle and to engage with all physicians on a team. The thoughts in this article make a presumption -- that care organizations are teams and that all team members are capable of communicating. Would love to read/hear more about how that behavior becomes integrated in care models. Unless you are a very interested, engaged party to care (no matter what end of it) this can be difficult to achieve-- particularly in an outpatient setting. It is also difficult for older patients without "advocates" to negotiate care under many team members.
May 30, 2018 at 10:50 am
Deborah Gerber
Seems like you are making quite a generality about some physicians. I have been blessed to have an amazing group of physicians over a lifetime- specialists who have cared for me and actually cared to not usurp other specialists place but were able to understand and cared enough to explain broad test results, expedited procedures, etc. I have paid for good insurance understanding that physicians in a capitalistic society deserve to make a decent living. (My goodness, the leadership executives{who I might add are not responsible for life and death decisions or are awakened in the middle of the night} make millions of dollars a year!) I have had tests run within a week of concerning symptoms including therapeutic procedures and had all results within a week to 10 days. I am not wealthy or a special person. I do not expect physicians to be the social workers, clerks, administrators, navigators, scribes to all- we cannot prevent illness until physicians wake-up to the fact that patients must be educated and realize that some people just do not want to know and do not want to follow a healthy lifestyle nor be compliant. Why call someone who does what has to be done (likely because the "team protocol"is well-written but is likely not carried out consistently by even so called top-notch institutions) a "physician-hero". I believe those who are attacking some of these so-called "heroes" have realized that care is being comprised because we are not looking at the root causes of failed cost controls. It is not "Physician-Heroes"!
May 31, 2018 at 12:18 pm
Dike Drummond
The behavior this article is addressing is a fundamental feature of the conditioning of the medical education process. In my work with thousands of burned out doctors, the following four character traits are the ones most often magnified to dominate our professional persona
workaholic
perfectionist
super hero
Lone Ranger
These character traits are ground into doctors in training unless you begin to change the education process. Only when the conditioning of medical education sets the norm as collaboration, teamwork and cooperation ... will you see those behaviors in the average physicians practice.
Until that point in time, we must help them recover from their own residency induced "personality disorder" in order to both recover from burnout and build collaborative, team-based care.
My two cents,
Dike
Dike Drummond MD
CEO TheHappyMD.com
May 30, 2018 at 12:36 pm
Tom Morgan
I doubt that even the most "heroic" physician would argue against the importance of effective teamwork. The physician-persona non grata crafted in the article is a straw man - easy to cut down. The reader learns that the "physician-hero controls almost all aspects of care," aiming for excellence. But to what extent is the hospital administrator's need to control the "physician-hero" for the purpose of "cost optimization" the hidden agenda? The authors suggest that it is possible to "maintain excellence" while optimizing costs, but I'm not sure that's always what goes on nowadays. And when patients are harmed, it's still the physician and not some vague team, and certainly not the cost-cutting administrator behind the curtain, who is held responsible. Perhaps the physician-hero would change naturally if released from strict accountability for patient outcomes? Doesn't authority stem from accountability?
May 30, 2018 at 2:37 pm
Vikranta Sharma MD palliative care physician
article seems overly biased against physician involvement in patient care. Even as a Team member a physician has a significant positive input in guiding the care plan.
Take the physician input out or minimize it at the cost of individualized patient care.
Let us celebrate heroism in healthcare weather by a physician Or a nurse, social work or chaplain.
Did not expect such a negative article from catalyst. I am disappointed .
June 26, 2018 at 1:28 pm
Nestor A Ramirez, MD, MPH, FAAP
I agree with Dr. Dike Drummond's assessment. We do have a problem, but the solution(s) should be based on human humane interactions, and not handled mainly as an industrial issue based on the organization and its "costs... value-based care delivery strategies...brand ..service line" and other buzzwords. Physicians may be everything that was said, but above all they are individuals, persons, and hard-working human beings. They deserve better. Thanks.
Like Dike said, those are my $0.02 worth.
May 30, 2018 at 3:38 pm
Irwin K. Weiss, M.D.
As an intensivist I cannot agree more that expertise should be delegated to the experts. That being said the downside of team based care is that often I have seen both with family members and professionally that there is no coach. In other words, there is no physician or other health care provider who has had a long term relationship with the patient or family who knows the nuances, the likes and the dislikes of the patient, or even what has worked or what was tolerated in the past. In the team based approach discussed it not hard to imagine a patient or family bewildered by all of the people opining on their care but no single person who actually knows them. This is becoming more and more common as the outpatient physician in most situation does not care for their patients when they are admitted - there is no familiar face. This also can lead to errors in care as well. The team is not always the answer.
May 31, 2018 at 12:44 am
Lars Aanning MD
As a resident, I spent two months with an independent group of three general surgeons; every morning they made rounds on all their patients as a group, looked at X-rays together, and operated together with all three starting large operations, and two with more common procedures. They had standardized their operative techniques, and learned newer ones when one went off to any meeting. On weekends, one made rounds on all patients, who felt their care seamless. Their interaction with medical and other specialists was very positive. Best two months in my entire career...
June 08, 2018 at 10:17 pm
Michael Nurok, Thor Sundt & Bruce Gewertz
We agree that patients need one or more principal physicians in their care who can champion their cause and ensure that their individual wishes and preferences are respected. Still, as the complexity of the care we provide grows with advanced therapies, multiple treatment alternatives, and an aging patient population with increasing comorbidities, the important relationship with these principals must be embedded in an effective and coordinated system of care delivery. As the team assumes greater responsibility for the care of the patient, so must accountability be shared – not shunned. While not all care is amenable to standardization, that which can be should be, freeing mental time and space for effective care delivery systems to be agile enough to provide the specific treatments that complex patients need in a highly coordinated manner. And to be sure – this demands effective communication among members of the care team. The phenomenon we describe is real - the examples used came from real cases of physicians we have worked with in our leadership roles – as is the burden leading to burnout. We celebrate the devotion of physicians to their patients, and at the same time invite an insight that some of the behaviors we were taught in medical school have become maladaptive from a personal standpoint as well as an economic one. We invite a change in our culture.
June 11, 2018 at 1:45 pm
Kristina Philipson
I could not agree more with the authors. Physicians today have much more accountability than they can and should handle. I wonder whether there are legal accountability issues that would need to be resolved first if the culture is to change. If physicians are individually and legally responsible for outcomes, they are less likely to give up "their patients" and share control.
June 21, 2018 at 11:00 am