Why Understanding Teaming Is Critical for Health Care Leaders

Solving the American health care system crisis is among the most complex and important challenges facing this generation. Is it possible to provide high quality care with better access at a more affordable cost? Is this problem solvable or simply to complicated?  Though that answer is not yet clear, what is increasingly apparent is that a new type leadership is needed if there is any hope in achieving this goal.
Professor Amy Edmondson of Harvard Business school has crafted a practical evidenced based book on how leaders and organizations must approach the increasing complexity of problems they face. Unlike the mindset of execution, which was successful in the past, Professor Edmondson demonstrates that in an increasingly competitive global economy a different approach is needed.

Organizations must learn by teaming.

It is a must read for physician leaders or other leaders in health care.

She provides leaders a clear understanding of how individual and organizational psychology, the reality of hierarchical status, cultural differences, and distance can and do separate team members which can prevent successful teaming. Leaders can close these gaps by understanding the existence of these obstacles and by adapting their leadership style to support and facilitate teaming successfully. She demonstrates the challenges as well as the solutions where teaming has gone well and not so well (the "impossible" rescue of miners in Chile and space shuttle Columbia tragedy) with numerous case studies and insights.

Professor Edmondson also notes that leaders must also thoughtfully identify where the challenges they face fit on the Process Knowledge Spectrum (routine, complex, or innovation). Routine operations could be a car manufacturing plant where outcomes and certainty are known. At the other extreme, innovation operations, like an academic research lab, the outcomes and certainty are quite unknown. Hospitals are considered complex operations. Although the teaming framework applies in each of these three cases, the leader's specific behaviors and actions change. Having excellent outcomes and teaming necessitates matching the right approach to the correct operation.

Interestingly to maximize learning, conflict and failure are necessary for teaming to be successful. These can only occur if leaders create an environment of psychological safety. Learning thoughtfully from these failures and framing them as essential for continuous improvement and innovation is key for organizations to benefit from teaming.

Most importantly, the learning never stops.


Professor Edmondson provides many examples from health care as she has "spent an inordinate amount of time studying people in hospitals." In one example, she notes how two of four cardiovascular surgical teams studied successfully implemented Minimally Invasive Cardiac Surgery (MICS) because of how the leader framed the challenge. It was a shared learning experience. The other two teams failed because they focused on the individual surgeon rather than on the team. For doctors, being able to ask others for help is culturally difficult and yet vitally important given the increasingly complexity of hospitals and medical knowledge. She notes that the "single most powerful factor explaining success" among the the four teams was how the leader framed the challenge.

She notes that for 23 hospital ICU improvement teams, those most successful in changing were those "who engaged in the interpersonal learning behaviors crucial to teaming".

One of the three case studies is about leading teaming in a complex operations at Children's Hospital. The goal of Julie Morath, the chief operating officer, was to harm no patients and achieve a 100 percent in patient safety. She engaged her staff to solve the problems. She eliminated the tendency of the medical culture to view and blame a medical error as the fault of the individual. Instead via "blameless reporting", observers merely communicated what they saw and analysis followed. aBy creating a culture of psychological safety, the hospital learned from their "accident" and explored ways to improve the their care. As a result, the hospital became nationally recognized as a leader in patient safety.

"For over a century, we've focused too much on relentless execution and depended too much on fear to get things done. That era is over...human and organizational obstacles to teaming and learning can be overcome...Few of today's most pressing social problems can be solved within the four walls of any organization, no matter how enlightened or extraordinary... Generating ideas to solve problems is the currency of the future; teaming is the way to develop, implement, and improve those ideas."

Although at times, the conclusions from her twenty years of research and observation seem counterintuitive, her findings and stories woven into a actionable framework and structure makes Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy compelling. It is destined to be a classic reference for leaders today and in the foreseeable future as they lead their colleagues and organizations into confronting and solving increasingly complex problems and challenges.

Professor Edmondson hopes that her book will enable organizations to execute at a higher level only "when leaders empower, rather than control; when they ask the right questions, rather than provide the right answers; and when they focus on flexibility, rather than insistent on adherence... When people know their ideas are welcome, they will offer innovative ways to lower costs and improve quality, thus laying a more solid foundation for meaningful work and organizational success."

She succeeds at every level.

Will Doctors or Patients Bend the Cost Curve?

The American Board of Internal Medicine (ABIM) and nine other professional medical societies announced that doctors should perform 45 tests and procedures less often than currently done because there is no good medical evidence that they add any value. Specifically, a xray or other imaging for low back pain in an otherwise healthy individual or an EKG as part of a routine physical, just add a lot of unnecessary cost to the health care system as a whole and don't provide doctors or patients any meaningful information that would be helpful in improving health or arriving at the right diagnosis and treatment.

The ABIM partnered with Consumer Reports to create a new campaign called Choosing Wisely and are joined also by collaborators like employers (the National Business Group on Health, the Pacific Business Group on Health), hospital safety (the Leapfrog Group), and labor unions (SEIU).  The mission is simply to have doctors and patients deliver and receive care that is medically necessary, based on evidence, avoids harm, and minimizes duplication.

The real question is - will it work? Will doctors follow what their professional societies recommend?

Though Choosing Wisely is a laudable attempt to make medical care better quality, the truth is doctors won't likely follow these guidelines from their medical societies. If it was that easy, we would not have this problem! Even today, it is still a challenge for the medical profession to have all doctors wash their hands correctly every patient every time, get immunized routinely against influenza, or even not to prescribe antibiotics for coughs, colds, and bronchitis due to viruses! What is more disturbing is that doing these basic interventions did not impact a doctor's income. Some on the list of Choosing Wisely, however, will.

Take a look at the recommendations by the American Gastroenterological Association specifically around the need for repeat colonoscopy after a normal one.

Do not repeat colorectal cancer screening (by any method) for 10 years after a high-quality colonoscopy is negative in average-risk individuals.

Yet, if a doctor does fewer colonoscopies, which is the right thing to do, that also means his income will decrease. In the fee for service reimbursement system, doing fewer procedures means fewer things to bill for. As noted in a previous post, a new patient to my practice wanted a repeat colonoscopy 5 years after her prior one because it was recommended by her doctor even though she had no family history and a completely normal test!

Will patients protest if their doctors offer one of the 45 recommended tests, treatments, or procedures highlighted to be avoided? Are they ready for this new world? Perhaps according to the NY Times piece "Do Patients Want More Care or Less"? 

“People are more receptive to conversations about medical interventions having both pros and cons” says Dr. [Michael Barry, president of the Informed Medical Decisions Foundation, a nonprofit group that promotes sound medical thinking]. “Traditionally, newer and more aggressive interventions were often assumed to be better.” But there are hints of a shift, he says: “When patients are fully informed, they tend to be more conservative.”... [he] believes patients are ready to hear the message. He cites popular books like “Overtreated,” by Shannon Brownlee, and “Overdiagnosed: Making People Sick in the Pursuit of Health,” by H. Gilbert Welch. These are among a slew of books in recent years written by health experts on the dangers of the “more is better” attitude about health care.

Yet, we should also be skeptical about this perspective. Research has consistently shown that there is no value for an annual physical or check-up, yet how many people still have one "just to be safe?" Although there is a small number of patients who are empowered and question their doctors about the treatment plan, the fact is most patients expect their doctors to make the best choices on their behalf. If a doctor recommends an antibiotic for a sinus infection or suggests a MRI for low back pain, will a patient really say no? In general, it takes a doctor more time and energy to educate a patient on why an antibiotic or MRI isn't necessary, how an individual's personal experience is different than those of their friends and family who all got antibiotics and MRIs in the past, and to do so in a caring and compassionate way.

If we expect doctors or patients to bend the health care cost curve this way with more education, better communications, and encouraging patients to talk to their doctors about the appropriateness of care, we will fail.

But increasingly there is a trend I am seeing which will bend the cost curve. Patients are increasingly questioning the need for expensive imaging tests not because they want to only get the right care proven by evidence, but because they have high deductibles and copays that require hundreds of dollars.

This would be good news except now instead of having a conversation and an examination with a doctor to determine if a MRI is needed for back pain, more patients are now simply calling in and asking for a MRI. After all, isn't talking and touching a patient and the healing aspect of a doctor patient relationship simply antiquated in a time with technology? It is now taking more time and energy to educate a patient why an office visit actually is more valuable than imaging!

If there is hope to make care more affordable and of even higher quality, then it will be because doctors have shouldered this responsibility. Our commitment won't be the result of our professional organizations rolling out an educational component, or the media highlighting the "waste" in our system, but rather it will be questions each of us will need to answer. Is doing no harm also mean avoiding unnecessary testing? Will we do the right thing even when it is hard? If there should be some optimism, then it should be that the current and next generation of doctors will lead this change.

This spirit and responsibility is best captured by Dr. Bob Wachter, professor and chief of the division of hospital medicine. chief of the medical service at the University of California San Francisco Medical Center, chair-elect for the ABIM and the "father" of the hospitalist movement, in his keynote address to the Society of Hospital Medicine.

“We need to be great team players, but we also need to be great leaders,"

“We need to embrace useful technology, but we can’t be slaves to it … improve systems of care, but welcome personal and group accountability. Strive for a balanced life but remember medicine is more a calling than a job. And think about the patients’ needs before our own. These are core and enduring values even as we move into this new era.”

“We have big targets on us and I think they are appropriate,” said Dr. Wachter. “There are others who should have targets as well, but the main target has to be us. Change is impossible if we don’t embrace change.”

In the end, it will be doctors who can bend the cost curve.

Part II - What Doctors and Healthcare Can Learn from the New England Patriots

Although my team, the New England Patriots lost Super Bowl XLVI to the New York Giants in one of the most exciting and tense games in recent memory, reviewing both the pre and post game coverage provided even more learning for doctors and healthcare than my prior post. One can demand excellence and still fall short. When one fails to achieve the intended goals, the learnings can be as important if not more so than when one is successful. In the latter, you assume that you understand the reason for success. In the former, you must investigate to determine problems. It is the approach that matters.

CEO of the Patriots, Robert Kraft noted in a post Super Bowl conference that statistically every NFL team has a 6 percent chance of reaching the Super Bowl and consequently a 3 percent chance of winning. Over the past decade, the Patriots have been in half of them. An impressive statistic considering other teams have equally dedicated players and coaches who also are focused on success. So what makes the Patriots so successful?

One learning is the true meaning of teamwork. Sure football is a team sport, but are the players and coaches truly a tight knit team on the same page for excellence?  Prior to the 2002 Super Bowl, players were introduced onto the field individually by name. Hearing your name called out and then running out onto the field to a crowd of screaming fans undoubtedly is a thrill for every player, particularly when it is the Super Bowl. Yet for the Patriots that year, this was not the case. Earlier that season at an away game, a mix-up in the team introductions had the team unprepared. Instead of the usual player introductions, the team instead raced onto the field as a team rather than individually.

Then 9/11 happened. For the remainder of the season, the Patriots found it fitting to continue dash onto to the field as a team as the nation came to grips of an unspeakable assault on our country.

Hours before 2002 Super Bowl kick off, head coach Bill Belichick notified his team that the NFL and television network required that the team be introduced as individual players. To come out as a team would be in violation of policy.

What did the team want to do?

They ran out as a team. The first time ever that has occurred. As noted on ESPN by former 49er quarterback and football analyst Steve Young, that tradition has continued to present day and shifted the focus back from the individual to the team, the right thing for football.

And perhaps this is the right thing for doctors and the health care system. How often do hospitals and health care organize themselves around having the "best" doctor? How often do people ask, who is the "best" surgeon, internist, oncologist, cardiologist. Is medical care really about one person or is it about having the right team? Dr. Atul Gawande, author, New Yorker writer, and surgeon, noted in his commencement speech titled, Cowboys and Pit Crews, at the Harvard Medical School in 2011 that today.

“[Medicine’s complexity] has exceeded our individual capabilities as doctors…
The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves... But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to “protocol” the MRI.”

“...We don’t have to look far for evidence. Two million patients pick up infections in American hospitals, most because someone didn’t follow basic antiseptic precautions. Forty per cent of coronary-disease patients and sixty per cent of asthma patients receive incomplete or inappropriate care. And half of major surgical complications are avoidable with existing knowledge. It’s like no one’s in charge—because no one is. The public’s experience is that we have amazing clinicians and technologies but little consistent sense that they come together to provide an actual system of care, from start to finish, for people. We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.”

It really should be about the team and not the individual. This is particularly true when it comes to medical errors. When a wrong site surgery occurs or a medication is administered at a dosage that exceeds safe usage, the question in health care is - "Who is responsible?" As noted safety expert and UCSF professor Dr. Robert Wachter notes in a 2004 interview when a medical error occurs at a hospital -

"...people invariably point fingers at that place and person and lose sight of the systems failures that are really responsible. Look at it this way -- ask anyone if they've seen a medical error and they'll immediately tell you a story about one. Could it possibly be that all doctors and nurses are careless and stupid? Or, perhaps, does the ubiquity of the problem indicate that something deeper and far more interesting is going on?"

So in the true meaning of teamwork, should something happen, the team is accountable not necessarily the individual. The team owns the problem and does not leave the individual alone, unsupported, or in shame. Even after the most recent Super Bowl loss when many people picked up on individual player errors of dropped passes, including one from wide receiver Wes Welker, one of the most sure handed receivers in the NFL, which likely would have resulted in a Super Bowl win, no one from the team scapegoated him or others. As quarterback Tom Brady put it in the post Super Bowl press conference -

You win as a team and you lose as a team. Certainly it wasn't one play is the reason that we lost today. Everybody feels that we could have done more....

There was some missed opportunities.

When surveyed on the Boston Globe on who should be blamed most for the Super Bowl loss, quarterback Tom Brady, head coach Bill Belichick, the Patriots defense, or the receivers Aaron Hernandez or Wes Walker, the majority of votes distributed the blame evenly across the team. It was not just one person.

Yet in health care, we do a terrible job in supporting others when errors happen. We often assume the individual was at fault rather than a collective fault or system failure. Health care professionals who have dedicated their lives to saving lives are devastated. Some commit suicide after a medical error.

Finally the last learning is leadership, having a vision, and understanding what really matters. All season long as his young defensive unit was getting dogged in the press as being among the worst in giving up total yards to other teams, Belichick calmly noted that it wasn't about that statistic which mattered, but what was the win - loss column. Hard to argue with that as this team did make the Super Bowl.

Belichick is known to resist the status quo. He's a football coach, not a fashion model, yet was mandated by the NFL to wear Reebok sanctioned clothing on the sidelines to look nice. What did he do? He picked up the ugliest piece of clothing he could find, the hoodie.

There was no way to opt out of that deal so Belichick considered the fashion options laid out in front of him, and selected the most unstylish outfit, a grey hooded sweatshirt. He began wearing it each week. Only not before having the sleeves cut off to make it even less attractive.

“It’s comfortable,” Belichick said in explaining his fashion choice. “I carry my stuff in my pouch.”

What about chopping off the sleeves?

“I have short arms,” Belichick said.

The irony is the “BB hooded sweatshirt” became a hot seller. It was so bad, it was cool. It now comes in all sizes and colors, even women’s versions. They sell for about $80

As a coach and leader, he knows what really matters: putting his players in a position to win. This is what leaders do and what players and analysts noted repeatedly up to the game. Belichick does everything possible for them to succeed. Near the end of the game, Belichick understood that the Giant offense had a high probability of scoring a touchdown and he needed to give his future hall of famer quarterback Tom Brady time to score. So he asked his defense to let the go ahead touchdown to go through to allow maximum time on the clock.


Good move? Well the outcome and the win for the Patriots didn't happen. But, it was the right leadership decision and recognized by Giants quarterback Eli Manning, who "had ordered [Giants running back] Bradshaw to take a knee."

Do we in health care have these leaders who can create environments that allow doctors and other care providers the opportunity to be successful? Do we have leaders who truly have vision and know what really matters?

Even without a Super Bowl win, we can still learn a lot from the New England Patriots. A true culture of teamwork matters and exists when we can still support each other not when things go smoothly, but when things don't. We need to have leaders who not only have vision, but also the discipline to do the right thing and challenge conventional thinking and the status quo.

Only then can health care truly transform and be what Americans want and deserve. 

Though I look forward to next year, there obviously is much unpredictability in which team reaches the Super Bowl. I'm certain the Patriots will have another successful year.

Congratulations to the NY Giants and their team, coaches, and leadership.

Unlike football, where there is next year and they need to perform for a game at a time, for us we need to get a win with every patient everyday at every moment. Our performance can never lapse.
 

What Doctors and Healthcare Can Learn from Tom Brady, Bill Belichick, and the New England Patriots

As the new year starts, I'm eager for a fresh start and working on improving myself both physically and emotionally. I'm also eager for the NFL playoffs and seeing how my favorite team, the New England Patriots, fares under the leadership of Coach Bill Belichick and quarterback Tom Brady. Doctors and health care can learn much from their examples.

Over the past decade, 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.

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?

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

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.
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.

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?

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.

...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.

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?

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?

Go Pats!

Obama Rhetoric for Healthcare Reform Plan Is No We Can't

Bill Weir, anchor of Good Morning America Weekend, said this weekend about the healthcare proposals offered by Senator Obama and Senator Clinton in the following way.

Senator Obama's plan is "built on political realism."
Senator Clinton is "sticking to a plan that is built on idealism."

Ironic, isn't it? Senator Obama, who has great vision and inspires many, falls very short on his rhetoric of "Yes, We Can" when it comes to healthcare. Why is that? He promises a brighter future for all of us and says that he is the agent of change. He states that this generation must, like generations before, take charge and bring new hope to a country that badly needs it.

Yet, when it comes to healthcare insurance, which as a doctor I see as a necessity and not a luxury, he with his advisors instead opt for a piecemeal incremental plan rather than a politically risky plan that would mandate all Americans to purchase health insurance. How do you think people felt decades ago when they were told that their wages would be taxed to fund new radical programs called Social Security and Medicare? Was it the right thing to do? Was it politically difficult to have it implemented?

Leadership involves making good choices consistently over a long period of time. Obviously one can't be right all of the time. While Senator Obama argues that his decision against authorizing the use of force against Iraq shows good judgment, time will tell. One good or bad decision doesn't make a good leader but the number of decisions over time as leaders will be tested over and over again. His stance on healthcare reform, particularly for a Democrat, shows that he is very much like all other politicians in looking for political expediency rather than the idealism that he portrays in his public appearances.

This past weekend I was fortune enough to hear General Colin Powell speak about leadership. Although he didn't mention who he supported for the presidential nomination, he did note that the American public wanted a leader who had vision and who was experienced. He reflected on how Jimmy Carter, Bill Clinton, and the current George W. Bush, didn't have worldly experience prior to entering the White House. General Powell, however, had praise for George H.W. Bush, the 41st president, who was ambassador to China and also head of the CIA previous to inhabiting 1600 Pennsylvania Avenue. The elder Bush had world experience and a deep understanding on what can be done and what needs to be done. It is this kind of wisdom one hopes the American public will value as the next president.

How does this get back to healthcare? We need leadership in this country for both foreign and domestic issues. Healthcare reform will only occur if true leaders step forward and take risks because it is the right thing to do. Besides hearing General Powell, I also heard Professor Uwe Reinhart, healthcare economics expert at Princeton speak. As he noted in the ABC Good Morning Weekend video is regards to American politicians is that "they just don't have the guts. They are gutless wonders when it comes to healthcare." I hope he is wrong.