The Agenda - Total Teamwork

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."