Physicians are not all knowing

November 15, 2007

Medicine traditionally practiced and studied individually may start to resemble a business like style of running things or a committee, which requires working in a group to solve a problem. Dr. McDonnell's own medical school is starting to allow other staff members participation in the treatment of patients instead of one all-knowing physician.

Key Points

To me, it seemed that committees were for people who did not have enough to do to keep busy. They represented a forum for people who loved to hear themselves talk. Committees wasted time and prevented smart people from quickly seeing what needed to be done and doing it. They were an excuse to avoid making the hard decisions and taking necessary action.

My belief is that we doctors (especially surgeons) historically have been encouraged-and even taught-in medical school and residency to think of ourselves as individualists. People come to us with their problems, and we quickly gather the data, analyze all the information, prescribe the right medicine or do the right operation, cure the patient, and (feigning modesty) accept the praise of our grateful audience. In this classic model, the role of our supporting cast of technicians, nurses, anesthesiologists, and clinic staff is limited to carrying out our orders quickly and efficiently.

My sense is that, in the business world, much better appreciation exists for the value of group effort.

Traditional medical education involves enormous amounts of information being conveyed to medical students in lecture rooms. Then the students retire to some quiet place to read, think, and memorize in isolation to prepare for the examination.

In business school, concepts are shared in the lecture room, and then students divide into groups to analyze problems and "case studies," with the results presented by the group. Medical students are graded almost entirely independent of their classmates, whereas business students commonly share the grade given to the group.

By and large, in medicine we think in terms of great individual doctors-no doubt you can name some, whereas in business we think of great companies. Committees and work groups might be fine for companies to get their research and development, marketing, manufacturing, and sales people on the same page, but we in medicine often think in terms of an organization built entirely on the shoulders of one or a few doctors, and these great doctors would never waste their time in committees!

In business, an assumption exists that no single person knows everything. Many doctors, however, probably still think that admitting they don't know it all would be sign of weakness.

Dare I say it, some physicians (but fortunately not department chairs) have colossal egos, and as pointed out by Victoria Pasternak, membership on a committee that does something great will not get you a monument in your honor.

Changes ahead

My medical school is redesigning its curriculum, and one change being discussed is to think in terms of teaching doctors, nurses, and others how to work together in patient-care teams. Instead of the all-knowing physician deciding everything and writing the orders for everyone else to follow, the team (physicians, nurses, social workers, etc.) would review a patient's situation each day and agree on the treatment plan and objectives for that day. Everyone would hold one another accountable for achieving the agreed-on goals.

The results of using this model in the intensive care units at Johns Hopkins over the past couple of years have been a dramatic and statistically significant drop in hospital-acquired blood stream infections, shorter lengths of stay, and reduced mortality.

This is not to say that all committees are worthwhile. Service on a few American Academy of Ophthalmology (AAO) and university committees in my life truly was painful. But many other committees have accomplished some very worthwhile things. And service on a great AAO committee results in something even better than a monument: a letter of thanks from Dunbar Hoskins.

I wonder how key decisions are made in your practice-by a group (committee) or by a single all-knowing physician?

Peter J. McDonnell, MD director of The Wilmer Eye Institute, The Johns Hopkins University School of Medicine, Baltimore, and chief medical editor of Ophthalmology Times. He can be reached at 727 Maumenee Building, 600 N. Wolfe St., Baltimore, MD 21287-9278, Phone: 443/287-1511, Fax: 443/287-1514. E-mail: pmcdonn1@jhmi.edu

Reference

Pronovost P, Goeschel C. Improving ICU care: it takes a team. Healthc Exec. 2005;20:14-16.