Put patients first

Breaking down the boundaries of surgery and medicine makes sense
September 16, 2015

A decade ago, James Young, a genial British-born doctor, had one of the most prestigious jobs possible at an American hospital. His title was “Head of Medicine” at Cleveland Clinic, one of the biggest hospitals in the world; and since western medicine has traditionally been split into two branches—namely “medicine” and “surgery”—James was thus overseeing half the hospital.

But in 2007, James was sucked into an extraordinary experiment. Toby Cosgrove, a heart thorassic surgeon who runs Cleveland Clinic, declared that he was abolishing the Department of Medicine, to blend surgery and medicine into a single unit. Some doctors might have howled in protest.

But James did not. “I could see the sense of that,” he recalls, with a smile. These days Cleveland Clinic has turned the usual organisational map of medicine upside down. Instead of splitting its operations between “medicine” and “surgery”, it organises itself according to different body parts or ailments.

Instead of a “neurosurgeon” department that keeps itself apart from “neurology” and “neuro-radiology” and “psychiatry,” it has a single “brain” institute instead. The core goal is to structure the hospital around the way that consumers (that is, patients) experience medicine—rather than how providers (that is, doctors) have been trained. “A patient doesn’t go into a hospital and say ‘I want to see a cardiothorassic surgeon’—they just say ‘I have a chest pain’ or ‘my head hurts,’” as Cosgrove explains.

Welcome to a curious little experiment that British doctors and policy makers ought to watch. In recent years politicians and policy makers have fretted endlessly about the state of the National Health Service (NHS); there is concern about underfunding, inefficient processes and falling standards. But there is also another problem that does not get nearly enough debate: the problem of silos, or the way that medicine is organised into fragmented units, and specialist medical experts (or quasi tribes).

As medical bureaucracies keep swelling in scale, they are not just becoming more impersonal; they are also fragmenting people too. Similarly, as NHS hospitals embrace a policy of outsourcing and hyper streamlined efficiency, this tends to breed a world where people are only incentivised to care about what is directly under their nose. And this in turn can leave healthcare professionals operating with rigid labels and boundaries which are ill suited to the modern world.

After all, these days, medical techniques are advancing so fast that the boundaries that dominated a century ago can often seem out of date. (To cite one example, radical new techniques in the use of catheters in heart surgery have blurred the boundary between “physicians and “surgeons”.) Meanwhile, most medical innovations tend to occur when scientists jump boundaries.

When medicine is fragmented, it tends to be more costly—and ill-suited to what patients need. After all, the way that patients experience sickness and health does not sit inside one simple silo; it tends to cut across multiple boundaries. Delivering healthcare with rigid bureaucratic systems, in other words, tends to hurt the medical world; it also lets patients down badly, making it harder to restore people to health.

Breaking down the boundaries is certainly not simple. For one thing, it has a nasty habit of threatening power structures and vested interests. So much so, that when Cleveland embarked on the restructuring, the rest of the American medical establishment protested so vociferously that Cleveland was forced to reinstate some of the old structures, simply to ensure that medical students could get their qualifications.

But the resulting pattern has one big advantage: it forces medical practitioners to think constantly about how they divide up the world. Cleveland today uses many other tactics to redefine what medicine is “about”. There is an “Office of Patient Experience,” which upholds the idea that medicine should treat the mind and emotions too. To encourage doctors to take a more holistic approach to medicine, they have been sent to Disneyland for classes on “service”—and sternly told that they are also responsible for keeping the wards clean.

Patients are being given single internet portals to ensure they can control all aspects of their healthcare. Architects have designed the hospital to ensure that different medical staff constantly collide with each other. And when a patient arrives a hospital, a red coat “greeter” helps them navigate the bureaucracy.

Are these just cosmetic gimmicks? In some cases, perhaps. And they certainly do not always come cheap; Cleveland Clinic enjoys the luxury of attracting plenty of patients with generous insurance programs. But what British doctors might do well to note is that not only are Cleveland Clinic’s costs lower than many of its American rivals —reported levels of patient satisfaction have soared in the last decade too. So have the doctors, it seems: turnover at Cleveland is remarkably low.

And in that there lies a moral. Mixing the boundaries in medicine does not always fix the problems. But managers in the NHS, as in any system, need to challenge them, or at least ask whether the way that medicine is divided really makes sense for patients, not doctors. That is never easy to do. But it is a process that is crucial to make medicine efficient and innovative. And that is something that everyone thinks that the NHS needs to be.