Response to the 2012 Question of the Year
Today we, as a nation, realize that our health care system is not functioning at acceptable levels of cost, quality, or outcomes. Individual excellence is necessary but not sufficient to deliver high-quality health care, to effectively train the next generation of health care providers, and to perform cutting-edge research. Each “organization” (defined as a group of clinicians, educators, or researchers, large or small) and each health system—local, regional, and national—must also perform to its full potential. In short, all components of the health care system must achieve interactive excellence, as well as individual excellence, if we are to produce better results.
Academic medicine has long rewarded and recognized individual achievement. Medical school applicants are largely selected based on their individual grade point averages and MCAT scores. Faculty are promoted based upon their individual accomplishments in research (and sometimes teaching). In the past, when most physicians practiced alone or in small groups and research was conducted in small, discipline-based laboratories, rewarding individual accomplishment was adequate as a paradigm of performance excellence.
However, the health care environment is rapidly evolving. Local hospitals and health systems are combining into larger consolidated organizations. Physicians are increasingly practicing in large groups, often as employees of health systems. Research is often conducted in large multidisciplinary teams. Given these trends, which are likely to continue and even accelerate under health care reform, it is clear that the delivery of high-quality health care demands interactive excellence among individuals, teams, and organizations. It is no longer enough to improve the performance of individual care providers; we must also improve the performance of care delivery teams, provider organizations, and health care systems.
We in academic medicine bear a special responsibility in this new quest for interactive excellence. While we must continue to celebrate individual accomplishments, our missions—training the next generation of providers, conducting research to discover breakthroughs in preventing and treating disease, and caring for many of the nation’s most vulnerable patients—require that we step forward and develop new ways to promote and recognize collective accomplishment. This transition will be challenging; our paradigm of individual excellence is deeply rooted in the culture of academic institutions, and most of our students, residents, and faculty were raised and still function in this paradigm. We believe the key to ensuring that our health care system performs to its fullest potential is to develop incentives that promote collaborative effort and teamwork. We must provide each individual with the requisite tools to create a new future for the U.S. health care system, such as the team skills inherent in interactive excellence. But this is not enough. We in academic medicine must also lead by example, practicing the effective leadership and system-based thinking that we expect of our students, trainees, and employees.
Effective leadership has five components. They are visioning, modeling, managing, measuring, and appreciating.
- Visioning: Effective leaders articulate (not once, but repeatedly) a vision of a better tomorrow and the path that will get us there. In the case of academic medicine, that vision incorporates patient-centered teamwork.
- Modeling: Actions speak louder than words. Effective leaders demonstrate daily the team skills they exhort others to develop and employ. If we believe humility is an important quality in clinicians, then leaders need to model humility as well.
- Managing: Effective leaders apply the basic tenets of good management, establish clearly defined roles, responsibilities, and reporting relationships, and demand congruency between accountability and authority. Effective managers provide appropriate and adequate support to each subunit and subunit leader.
- Measuring: Effective leaders understand and apply the principles and practices of scientific, evidence-based performance improvement.
- Appreciating: Words like incentivizing, recognizing, and rewarding are often used but tend to imply a top-down authoritative structure. Appreciating conveys the reality that faculty and staff accomplish the mission. A leader’s role is to support and appreciate those who accomplish the mission.
If the next generation of physicians grow up in an academic environment with this kind of leadership, they will be better prepared to replicate it within our health care system. However, the converse is surely also true—If they’ve never seen or experienced it, they are unlikely to be the agents of change our health care system so desperately needs. So now is the time for academic medicine to step forward. Our health care system, and indeed our nation, needs our help. Let us lead by developing our health care system to its full potential by expanding our vision to include that of interactive excellence.