The Agenda - Total Teamwork

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."