the New England Patriots have been dominant appearing in 40 percent of the Super Bowls played and winning 3 out of 4. Nothing prior to 2000, would have suggested this superior performance with playoff appearances only six times from 1985 to 2000 and two Super Bowl appears, both losses. Their new head coach Bill Belichick hired in 2000 had a losing record in his prior stint at Cleveland. Their current quarterback Tom Brady was drafted in the second to last round.
So what was their secret for success? Nothing particularly earth-shattering. It was and still is a relentless focus on continuous improvement by practicing deliberately and explicitly. This is an important learning for the US healthcare system which consistently lags that of other industrialized countries when measured on quality outcomes.
In general, doctors don't focus on how medical care is delivered. We don't focus on our own continuous improvement, which is a far different philosophy than individual athletes in professional sports. In our profession and in our training, we also typically don't focus on ensuring that the care we provide is consistently reliable over a period of time with our diverse medical team.
Yet, success in the NFL is based on whether a group of individuals, which composition may differ annually, can execute the plan well every time.
For the team to do well, it first relies on the individual player to do well. Take the Patriots' quarterback Tom Brady. He is currently among the best quarterbacks in the NFL playing today. Some argue he may be the best ever to play the position. Was he destined for greatness early in his career?
No. In fact, Brady doubted his abilities early on while at Michigan. Change started to occur when he adopted a different mindset presented by one of his mentors, Michigan associate athletic director Greg Harden. It isn't about just talent that will result in success, but in fact a focus on improving one's skills which allow the possibility to be the best. Though he did succeed at Michigan, Brady was drafted in 199th by the Patriots in 2000.
What did he do? The future hall of famer simply did what he learned at Michigan - learn the position better than anyone else and be deliberate about his practice. His NFL rookie year was unremarkable. In the following year, as a second year quarterback, he started off slowly. He steadily improved to the point that when the Patriots were in the Super Bowl, he led the team to a final winning drive. Brady became the youngest quarterback ever to win a Super Bowl.
Despite reaching the pinnacle of a football career in January 2002, he hasn't stopped improving his skills. When asked recently to impart some wisdom to NFL quarterback rookie and Heisman trophy winner Cam Newton, Brady said this –
You always realize that you can always be better. You can always be a better friend, a better player, a better teammate, and always try to find ways to improve. I go out there and be the best teammate I can be; because the goal in life is to win.Yet how often do doctors work specifically on themselves and improve what they truly control, that is their own individual skills and talents? How often do we each work hard on improving our clinical acumen, communication skills, surgical techniques, or diagnostic skills? As doctors after we have finished our advanced training via a residency or fellowship program, we don't seek opportunities to improve skills we believe we have mastered. In fact, we bristle at continuous improvement as New Yorker writer and surgeon Dr. Atul Gawande notes in his article Personal Best.
Nearly every élite tennis player in the world [has a coach]. Professional athletes use coaches to make sure they are as good as they can be.Gawande tries an experiment and convinces a mentor, who he respects highly, to observe him in the operating room. Gawade reflected that in the debriefing with his mentor
But doctors don’t. I’d paid to have a kid just out of college look at my serve. So why did I find it inconceivable to pay someone to come into my operating room and coach me on my surgical technique?
That one twenty-minute discussion gave me more to consider and work on than I’d had in the past five years. It had been strange and more than a little awkward having to explain to the surgical team why Osteen was spending the morning with us. “He’s here to coach me,” I’d said. Yet the stranger thing, it occurred to me, was that no senior colleague had come to observe me in the eight years since I’d established my surgical practice. Like most work, medical practice is largely unseen by anyone who might raise one’s sights. I’d had no outside ears and eyes.Gawande observes that in health care
...the capabilities of doctors matter every bit as much as the technology. This is true of all professions. What ultimately makes the difference is how well people use technology. We have devoted disastrously little attention to fostering those abilities.So individually, each doctor can and should focus on improving his individual abilities and to know his position the best, to be a doctor's doctor.
But there is more. Health care isn't just about one position, one profession, or one doctor. Providing complex medical care is like leading a football team of 53 players of which only 11 are on the field at any given time to play offense, defense, or special teams. For success, each individual must do his job consistently and reliably every time. Anything short of that is incredibly obvious. Failings unfold weekly to tens of thousands of fans in the stadium and millions watching via instant replay, the internet, and ESPN. Success and failure is dictated by a win-loss record until the season ends and the cycle repeats itself.
The Patriots have been exceptional in the past decade not only because of having Tom Brady but also for the many other individual players who are focused not only on making their own skills better but to do so for the benefit of the team. Previous "troublemakers" and prima donna wide receivers Randy Moss and Chad Ochocinco, when joining the Patriots have been quiet, humble, hard-working, and focused on improving and contributing to the team. This team focus comes directly from the top with head coach Bill Belichick. Profiled recently by NFL films, note how he leads and prepares his team deliberately to think ahead, anticipate problems, and execute the plan consistently in practice. Though each player is a paid professional and should know the game instinctively, Belichick takes no chances. He says the following to players in practice -
I want to call out the situation, pay attention.The win-loss record as well as playoff appearances, conference championships, and Super Bowl wins are consistent with high performance outcomes. Impressive considering that every other team in the NFL has players and coaches each driven to excel. What might healthcare learn from the Patriots head coach?
I don't care whether you are part of it or not.
First and ten, plus 50, alert for what.
Ok, they have no time outs. The ball is on the one yard line. Tell me what is going to happen here.
We got 40 seconds and need a field goal, two minutes.
We good on every thing fellas? No questions? We're good?
(confiding to his son) - Those situations are just as good for the coaches as they are for the players. Makes everybody think about what I might want to call here.
Like [Tom] Brady he's thinking one thing, Billy (Patriots' quarterback coach) is thinking something. We want them both thinking the same thing you know.
Can doctors and staff work together and regularly drill on scenarios both likely and rare? Can we use checklists and protocols and modify accordingly much the same way a coach changes the playbook? In medicine, we assume that that everyone knows his task when it comes to code blues and emergency surgeries. We also assume that everyone knows his task when it comes to mundane stuff like drawing up medications or discontinuing orders in the hospital. We are then stunned when adult heparin is given to babies in the ICU and the blood thinner coumadin isn't stopped when a resident doctors is interrupted with a text message with significant consequences to the patient.
We often blame the individual rather than ask can it be about something else that increases likelihood for success?
We don't fully appreciate the discipline or the processes needed to create a highly reliable organization. What we don't have are physician leaders who can take the care we provide to the next level. Note the comments from Dr. Thomas Lee, network president of Partners HealthCare System and professor of medicine at Harvard Medical School in a podcast regarding his article in Harvard Business Review - Turning Doctors Into Leaders.
[Doctors are] taught to rely solely upon themselves. They don't necessarily work well in teams. They don't think about the bigger picture, because they've been taught to focus just on the patient in front of them.For the US healthcare system to improve and succeed in providing highly reliable and safe care to everyone, it will require individual doctors to be like Tom Brady and ask - is there something I can do even better? It will require some doctors to be like Bill Belichick and ask - is there a process and discipline I can provide to allow the team that I lead succeed?
...to respond to the pressures created by all this [medical progress which causes rising costs, quality challenges, and chaos that patients experience] is for providers to get more organized and adopt systems that will bring order to the chaos. But that takes leadership. It takes the kind of leadership where you can persuade clinicians to work together in teams, as in almost every successful business, they already do.
Doctors can and must lead the changes that everyone in the country wants from our health care system. There is no other group best suited to the task.
The question is - are doctors ready to step up?