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.