The Agenda - Total Teamwork

Teams of doctors, nurses, and technicians at the world-renowned Mayo Clinic bring new-economy practices to "old-fashioned" medicine.

Each afternoon, in a tiny workroom on the 12th floor of the Mayo Clinic, the battle against cancer begins with an argument. At 1 p.m., support staffers at the world-famous clinic in Rochester, Minnesota line the walls of the room with X-rays and cat scans from the current caseload. The space fills with a small crowd of cancer specialists, surgeons, residents, and nurses. For the next three hours, this talented team will debate the condition and treatment of the day's patients.

Today, for example, Dr. Lynn Hartmann, a medical oncologist, reviews the tests of a 65-year-old man with a possible kidney tumor. Hartmann is leaning toward conducting a relatively simple surgical procedure. But, as is typical of Mayo's century-old team approach, she asks fellow oncologists John Edmonson, 64, and Harry Long, 52, for their opinions. Joined by a nurse and a resident, these three physicians painstakingly trace the ghostly shapes on the X-rays, attempting to distinguish abnormal tissue from healthy tissue. Then, in a collegial but direct point-counterpoint exchange, all five of them debate the evidence. Their conclusion: The case requires a more complex treatment than the one that Hartmann initially favored. "I'll go talk to the family," says Hartmann, unruffled by her colleagues' having, in effect, overruled her opinion. As she heads for the door, a nurse checks the surgery schedule for an opening.

Every weekday, scenes like this are repeated all day long at the Mayo Clinic. They help to explain the institution's reputation for excellence in the world of medicine. At many top-ranked hospitals, a patient may spend weeks going from one specialist to another, receiving separate diagnoses and maddeningly divergent advice — only to wait even longer for surgery. At Mayo, specialists don't just visit the patient; they swarm the patient as an integrated team, diagnosing a complex problem, proposing treatment — and often slotting the patient for surgery within 24 hours of the diagnosis. "Many of our patients come from hundreds or even thousands of miles away," says Hartmann, an articulate midwesterner who came to the Mayo Clinic in 1986 for a fellowship and never left. "They can't afford to wait around."

Teamwork and speed aren't the only things that make Mayo different — or that account for its fame. (According to the clinic, the Mayo name is so famous that it's recognized by 85% of Americans.) Patients who walk into the Mayo Clinic in Rochester enter an environment of comfort and tradition that is worlds apart from the institutional atmosphere of many modern hospitals. Fine art hangs on walls throughout the clinic. In the waiting areas of each medical department, professional greeters ease new patients through the admission process, reassuring them in homey upper-midwestern accents. They greet returning patients by name. Doctors see patients in private offices — cozy spaces decorated with personal items — rather than in sterile white-and-chrome exam rooms.

The overall effect is one of orderliness, function, and, above all, vigor. Indeed, at a time when many other medical enterprises are either suffering a fiscal crisis (cutting staff and reducing services), or struggling with an identity crisis (wondering what is expected of a modern health-care unit), Mayo is the very picture of a robust organization. Today, nearly a century and a half after the Mayo family arrived in Minnesota, the nonprofit Mayo Foundation has revenues of $2.9 billion and a staff of roughly 30,500. There are seven Mayo facilities — including one in Scottsdale, Arizona; one in Jacksonville, Florida; and a brand-new state-of-the-art hospital in Phoenix — and each year, more than 400,000 patients visit one of them. The Mayo residency and fellowship programs are among the most sought-after in the world. Last year, nearly 7,000 people applied for slightly more than 360 positions.

How has Mayo been so successful? Having top-notch talent doesn't hurt. Mayo's medical staff is widely regarded as being among the best in the world. Mayo's administrators have invented (and reinvented) the business side of medicine. It was Mayo, for example, that developed one of the world's first systems of centralized patient records — a landmark organizational effort that is now evolving into a paperless data system that digitally stores records, lab results, and X-rays. Such efficiency-promoting innovations help explain how Mayo can keep costs low enough to admit patients from all income levels. In fact, while Mayo may have gained recognition as the clinic of the international elite — before his death early this year, for example, Jordan's King Hussein received treatment there — 97% of Mayo's patients are from the United States, and 35% are on Medicare. Notes Dr. Gerald Gau, 60, a cardiovascular expert in his 31st year at Mayo: "Medicare has been here twice now, trying to figure out how we can be so fast and efficient, yet treat our patients so well."

But at a deeper level, Mayo is successful because it has found a thoroughly modern way to practice "old-fashioned" medicine — and in so doing, it has refuted many assumptions about medical practice. For example, the economics of medicine have turned many doctors into businesspeople who must compete for patients and referral fees; Mayo's physicians earn a set salary and are first and foremost team players. In fact, doctors at the clinic refer to colleagues as "consultants" — a title designed to remind all Mayo doctors of their advisory role. One current trend in the health-care industry involves turning hospitals over to professional administrators; Mayo is governed by physician-led committees. Indeed, the bylaws of the Mayo Foundation require its president and CEO to be a physician.

More to the point, at a time when the conventional doctor-patient relationship has all too often devolved into a preprogrammed, one-way conversation in which physicians tell patients what their options are, Mayo grasps that today's patients not only want great care; they also want to know that they are being heard. At Mayo, patients are part of the team that treats them. "Patients have shown over the past decade that they want to become active participants in their care," says Hartmann. "They're on the Internet; they're doing their own research. By the time we see them, they're often fortified by an impressive body of information. What they're looking for is someone who can help them sort through that information."

In an industry that is dominated by increasingly powerful (and increasingly expensive) technology, Mayo's biggest innovation is its way of working — especially its way of working in teams. To be sure, other medical institutions use teams. But Mayo has incorporated collaborative methods into everything that it does — from diagnosis and surgery to policy making, strategic planning, and leadership. At Mayo, the art of medicine is the epitome of teamwork.

The Patient Is the Bottom Line

Back in the oncology workroom on the 12th floor, Hartmann's team is looking at the file of another patient: Martha, a woman in her late thirties, was recently diagnosed with a tumor in one breast, and tests show worrisome signs in the other. Martha's primary physician has referred her to Hartmann, who as "quarterback" will assemble the Mayo team, coordinate assessment and treatment, and act as an intermediary between Martha and other physicians.

Over the course of the afternoon, Hartmann assembles a team for Martha — one that includes a surgeon, a radiation oncologist, and a radiologist, as well as Martha's primary physician. Hartmann bases her selections on the nature of the problem, on the skill and experience of the available specialists, and on Martha's own preferences. "Some patients want a more autocratic relationship. They want to be told what to do," Hartmann says. "But most patients today want a more interactive style, so that they can be part of the decision."

Martha falls into the latter category. She expects to participate and is eager to move ahead — an attitude common among cancer patients, who often feel that time is short. Hartmann's first task is to persuade Martha to look at as many options as possible. "Very often, our role as physicians is to slow patients down," Hartmann says, "to help them understand that they have time to make a wise decision."

As it turns out, this decision — fast or slow — will not be easy: Martha has a family history of both breast cancer and ovarian cancer, and the tissue in her healthy breast is difficult to examine. "The mammogram is dense," Hartmann explains. In other words, the X-rays are hard to read — which makes it difficult for the team surgeon to tell whether the cancer has spread. Judging by the evidence at hand, the surgeon recommends removing both breasts.

Martha objects: She wants to explore alternatives for treating the ostensibly healthy breast. So Hartmann scrambles to recruit a new surgeon and to reopen the diagnostic phase. In other medical circles, such a move might be awkward or even politically perilous. At Mayo, it's just another part of the team approach. "This is a very smooth process," Hartmann explains later. "We work in teams, and each team is driven by the medical problems involved in a case and by the patient's preferences. Sometimes that means that a team must be expanded — or taken apart and reassembled."

Strange as such an open dynamic might seem to outsiders, it is precisely the approach that William Worrall Mayo envisioned more than a century ago, when he established a medical practice in southern Minnesota, in 1859. By the turn of the century, under the leadership of Mayo and his sons William Jr. and Charles, that practice had evolved into the Mayo Clinic. The remoteness of the location (even today, many patients, when they arrive in Rochester, think that they've landed at the wrong airport) caused the Mayos to place a premium on innovation and teamwork. The elder Mayo was an ambitious perfectionist and a champion of collective action, regularly preaching to his physician-sons, "No one is big enough to be independent of others."

After a twister devastated the Rochester area in 1883, the three Mayo doctors joined forces with the Sisters of Saint Francis, a local Catholic order, to create a new hospital. The resulting entity fused the Mayos' progressive, family-based collegiality — along with their employees' extraordinary work ethic — with the Catholic Church's organizational savvy. Soon the "Mayos' clinic," as it was called, had achieved national and international fame for its surgical procedures and for its research. By 1892, the Mayos were inviting outside physicians to join what was arguably the first-ever group practice.

From the start, collaboration was about more than a group of doctors who shared office space. The Mayos created a cohesive and participative environment that was built on philanthropic ideals and that was dedicated to the belief that medicine should benefit all of society. Physicians were expected to bring their individual talents to bear on the collective treatment of patients. The Mayos' view of the correct way to practice medicine was captured in an often-repeated precept: "The best interest of the patient is the only interest to be considered."

The motto became a Mayo mantra — and a standard against which every decision is tested, whether it involves conducting research or building a new hospital. In 1919, the Mayo brothers invested most of their personal savings into creating the Mayo Foundation; they put themselves and their staff on salary, thereby divorcing medical practice from personal gain.

Nearly a century later, financial considerations still play a much smaller role in diagnoses and in treatment decisions at Mayo than they do at most hospitals. For example, doctors in conventional practices often complain today that they are under increasing pressure either to cut costs by seeing more patients per day or to boost revenues by ordering unnecessary procedures. But such deleterious incentives don't affect Mayo Clinic physicians, who have the liberty — and the responsibility — to focus entirely on their patients. "I don't have to worry about issues like how many patients I see," says Hartmann. "At the end of the day, those issues simply don't affect my bottom line."

This economic arrangement exerts a powerful force on how teams work at Mayo. The incentive system that operates in many conventional medical practices creates perverse results: Physicians who are ostensibly collaborating are often actually competing with one another — for referrals, for financial gain, for political turf. The Mayo Clinic approach eliminates such ambiguity and prevents such conflict. Mayo physicians receive a set income. Consequently, they are willing to ask for and to give advice: They don't hesitate to call in a specialist when a case exceeds their own level of expertise. "We're very comfortable with calling colleagues for what I call 'curbside consulting,' " says Patty Simmons, 46, a pediatrician at Mayo. "I don't have to make a decision about splitting a fee or owing someone something. It's never a case of quid pro quo."

As a result, Mayo's teams can include physicians from various departments — without worrying about the financial conflicts that can hinder interdisciplinary collaboration. Hartmann, for example, can reach beyond the cancer specialists in her own oncology department and bring in internists, surgeons — even a psychiatrist or a member of the clergy. Anyone who might assist in dealing with any aspect of a patient's problem can become part of a Mayo team.

This lack of fiscal friction helps make possible the open debates that are a hallmark of Mayo-style teamwork. Consultants know that their recommendations will be rigorously questioned by team members and that this kind of careful scrutiny will yield more accurate diagnoses and more effective treatments. In complex cases, having access to a wide range of expertise becomes critical. "Sometimes you do a biopsy, and that's sufficient," says Hartmann. "But sometimes the problem is far more elusive and complex, so you acquire data until you are confident that you know what's going on and how you're going to fix it."

Back in the oncology workroom, Hartmann has recruited a new surgeon. After examining Martha, this surgeon advises doing a mastectomy of the cancerous breast only — provided that Martha follows up that procedure with chemotherapy. After consultation with Hartmann and other staff members, Martha agrees to this plan, and surgery is scheduled almost right away. The time from initial diagnosis to a final decision: less than two weeks.

"I take great comfort in the proximity of expertise," Hartmann says. "I feel much more confident in the accuracy of my diagnosis because I've got some very, very smart people right next to me who have expertise that I don't have."

The Culture of Care

For all of its prowess in science and technology, the Mayo Clinic owes much of its success to its culture. From the most senior surgeons to the greeters in the patient-waiting areas, everyone appears animated by the medical equivalent of high-school spirit: They all seem to take enormous pride in Mayo's greatness and to derive personal satisfaction from maintaining its stature.

How does Mayo maintain such a tight culture? By growing it. While Mayo does occasionally recruit doctors, much of its talent is homegrown — trained in its own highly selective medical school and in its residency programs. Last year, the medical school accepted only 42 new students and only about 5% of those who applied for a residency or a fellowship. From these highly selective programs, Mayo hires about 45 new physicians each year. The result: Mayo gets not only the most talented physicians but also the most "Mayo-ized" physicians — doctors who are fully acculturated to the Mayo system.

For Robert Brown, a 37-year-old neurologist, "Mayo-ization" began early. In his first year at the Mayo Medical School, Brown was already on a clinical rotation: With one or two other medical students, Brown teamed up with a Mayo physician. The students visited patients and reviewed one another's examinations and diagnoses. "From the start, you learn that amiable sharing drives the Mayo system of patient care," Brown says. "It's ingrained."

After four years of medical school, Brown entered the Mayo residency program in neurology. He and his fellow residents found themselves spending more than 100 hours a week in on-the-job training. That regimen involved engaging in education and research, serving on governing committees — and, above all, learning the Mayo approach to patient care. "The adage here is 'The needs of the patient come first,' and as a resident, you see that principle in action every day," Brown says. "You see the consultants and senior residents promoting it, even though they're extremely busy. Pretty soon, you start believing it yourself." So completely did Brown take to the Mayo-ization process that his department offered him a staff position — even before he had finished his residency.

But not everyone adapts so well. According to Mayo old-timers, the process is so exacting, and the culture so distinctive, that it usually becomes clear right away whether a trainee has the right attitude. "You can tell early on," says Brown, who now helps with Mayo's hiring process, "by how they interact with patients, by their enthusiasm for seeing extra patients, by their drive to find answers to puzzling clinical questions. You watch people, day in and day out, and you can quickly tell who has the attitude as well as the aptitude that Mayo requires."

Physician, Lead Thyself!

Medicine isn't the only team sport at Mayo. From the clinic's earliest years, nearly every element of its operation — from lobby decor and patient billing to surgical practice and market expansion — has been handled by committees of doctors. "We're a very horizontal organization," says Dr. Robert Waller, 62, an ophthalmologist who served as president and CEO of the Mayo Foundation until early this year. "We seek input broadly, and while that may cause us to take more time to reach a decision, it has served us well in the long term."

Almost from their first day at Mayo, many physicians have a seat on one or more governing committee. This early participation begins their training in Mayo's collaborative style. Committees also guide the clinic's promotion process — overseeing the appointment and advancement of managerially gifted doctors. That process is pivotal, since Mayo offers no tenure, and committees choose new chairs each year. (Even so, effective leaders tend to stay put: Waller was president and CEO for 12 years, and his two predecessors each served terms of roughly the same length.)

The consequences of this physician-directed, committee-style leadership can be significant. For example, while Mayo physician-administrators rely heavily on "lay" administrators for business expertise, doctors — people whose primary focus is on medicine — make all final decisions. Predictably, such consensus-driven management isn't very fast. Several years ago, says Waller, the foundation wanted to determine the ideal rate of growth for Mayo's various clinics. A task force was formed, and its members visited each clinic, holding exhaustive interviews with everyone from division heads and department chairs to individual staff members — a painstaking process that took months.

Yet as slow and frustrating as this style can be, it is widely acknowledged that Mayo could operate in no other way. Current business theory may insist that companies should be able to change quickly — or die — but Mayo clearly thrives by moving into new areas slowly and cautiously, balancing the need for new ideas with the bedrock requirements of safety and stability.

Once a decision is made, the Mayo organization executes it with the speed and effectiveness of a crack surgical team. But up to that point, Mayo operates in a way that reflects how physicians work and think: carefully, cautiously, and, above all, with a focus on getting things right the first time. "If you're a doctor and you come up with a great idea, do you go and try it out on a patient the next day? No," says John LaForgia, a spokesman for the foundation. "You have to make sure that it is ethical and effective and in the patient's best interest. That involves a scientific process and a lot of discussion with peers. We've extended that model to everything we do here."

At the same time, the clinic is acutely aware of the risks posed by such a deliberative style. A century-old organization with an outstanding track record is apt to feel little impetus to change — and therefore it runs the risks of complacency, inflexibility, and obsolescence. So Mayo, in its calm and careful way, constantly looks for fresh ideas. It scouts out such nonmedical companies as AT&T, 3M, and Xerox, looking for innovative practices, and it constantly monitors competing health-care facilities.

Several years ago, for example, when other hospitals began opening up women's-health centers, Mayo formed a committee to consider starting a center of its own. "We made multiple site visits, evaluating the drivers behind other hospitals' decisions to open women's centers," recalls pediatrician and committee member Patty Simmons. "We looked at the components of these centers and at what they were able to accomplish."

After all that, Simmons says, Mayo concluded that creating a separate women's-health center might undermine women's ability to benefit from the resources of the entire clinic. The Mayo Clinic approach to assessing a new initiative: "You should recognize what you already have and are doing well," says Simmons. "One hundred years of acclaim ensures that any proposal for change undergoes very critical analysis." And very few proposals pass that test.

This is especially true when the clinic is entering a new area. When Mayo decided to create new information systems for its clinics, a physician-led committee oversaw the development of each component of each system. In acquiring new software for ordering medical tests, for example, doctors made sure that it was built around patient care, rather than around accounting practices. John Camoriano, 42, an oncologist and hematologist at the Scottsdale clinic, who led the IT effort, says, "We had a healthy, 'jaundiced' view of what software can and cannot do."

To ensure successful results, physicians insisted on a three-stage release. "With each successive release, we wanted to incorporate criticism and feedback about the unexpected ways that people react to and adapt to software," Camoriano says. "Intensive doctor input delayed the release significantly — but that was worth it."

The Patient-Physician relationship

In the end, the true test of any new system or tool is its ability to enhance the primary element of the institution that it serves. At Mayo, the primary element is the doctor-patient relationship. New surgical techniques, new equipment, new drugs — all of these are important. But the Mayo staff has long held that the quality of the doctor-patient interaction determines both the success of treatment and the quality of the "Mayo experience." All aspects of a patient's care flow from that primary relationship, and every system at Mayo is designed to support and nurture it.

Ultimately, patients need to feel confident that they can take part in their own treatment — and that they can intervene when necessary, as Martha did when she objected to the proposed bilateral mastectomy. "Treating cancer is incredibly intense," says Hartmann. "It involves high emotions and life-threatening consequences, so there must be room for all opinions and for allowing patients the time and space that they need to find a practitioner with whom they feel completely safe."

Martha's surgery, which took place several months ago, appears to have been a success. Her chemotherapy is finished. "Her life is returning to normal," reports Hartmann. As it turns out, after continued discussion with Mayo doctors, Martha elected to have the second mastectomy, as a preventive measure. It was a hard decision, but in a more authoritarian setting, it would have been much harder.

To be sure, patients come to Mayo to receive superior treatment from a top-flight team of physicians. But what many patients are really looking for is an answer to the question "What's wrong with me?" "Patients know when something is wrong. That period of uncertainty is extremely difficult, and it requires a tremendous amount of energy — both physical and psychological," Hartmann says. "Even when they are getting very difficult news, I have had many patients tell me, 'Thank you. At least now I know what I'm dealing with. Now I can get on with it.' "

Sidebar

No health-care provider can claim to outperform the Mayo Clinic. Mayo's laboratories have made huge strides in the use of chemotherapy to treat cancer, and they have pioneered breakthroughs as important as the use of cortisone to treat rheumatoid arthritis. The Mayo name is so well-known that it is recognized by 85% of all Americans. But the facility is far from being a jet-setters-only medical center: 97% of its patients are from the United States, and 35% are on Medicare. From the collaborative practices of Mayo doctors to the management structure of the Mayo Foundation, teamwork is built into the clinic's way of working. Here are five of the principles that define Mayo-style teamwork.

1. No one is big enough to be independent of others.

This precept originated with William Worrall Mayo, the founder of the Mayo Clinic, and it calls to mind a guiding principle of the Internet: None of us is as smart as all of us. After more than a century of operation, the Mayo Clinic continues to make collegial interdependence a touchstone for how it practices medicine. A doctor at Mayo is free to draw on the knowledge and experience of the clinic's medical experts — or to add social workers, psychiatrists, or spiritual advisers to a patient's team. The patient's best interest — not the doctor's ego — comes first.

2. Teamwork is part of the culture.

At the Mayo Clinic, teamwork isn't an afterthought, an add-on, or a fad. It permeates the clinic's entire organizational culture. The Mayo experience sends a consistent and coherent message to everyone who works at the facility (including medical students and residents): You're expected to participate in the activities that run this place, and teamwork isn't optional — it's essential. Teamwork is built into the treatment of patients, and it's integrated into the clinic's fabric of governance.

3. Language matters.

The first time you visit the Mayo Clinic, you're likely to be confused by all of the talk about "consultants." The normal first reaction: Why does this place need so many consultants? But soon you'll realize that "consultant" is what doctors on staff call one another — because, at the Mayo Clinic, doctors are expected to consult with one another about their cases. This terminology reinforces the clinic's sense of openness and collaboration. Language makes a difference: Talk teamwork to get teamwork.

4. Money also talks.

Another Mayo Clinic innovation is its solution to the problem of money and medicine. For many doctors, medicine today is all business: Economic pressures drive them to order unnecessary procedures and to reduce the amount of time they spend with patients. At the Mayo Clinic, however, doctors are on salary — period. Freed from having to think about economic incentives, physicians can focus on providing quality health care through organization-wide teamwork.

5. The customer is part of the team.

Working as a team is only one part of the Mayo Clinic way. Equally important is recognizing that customers — or, in this case, patients — are part of that team. The Mayo Clinic's approach to health care allows patients to be involved in their diagnosis and treatment as much or as little as they want.

Paul Roberts (proberts@nwi.net) is a Seattle-based writer who contributes frequently to Fast Company. You can visit the Mayo Clinic on the web (www.mayo.edu).

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