Starting With Curious

There are a number of striking features of the American healthcare system compared with those of other developed countries: the huge percentage of our GDP that goes to health (currently at 17.9%); the enormous gap between our spending and health outcomes (i.e., the apparent lack of value); and the tremendous health disparities in this country compared with others.  We have recognized these disparities as a particular problem in Milwaukee, and one of our strategic priorities is to address those disparities in our community.

Our approach has been essentially two-pronged.  We are addressing access to care in a variety of ways, including directly providing medical and dental services in underserved communities (e.g., Next Door Foundation), providing school nurses, and a CMMI-funded initiative to provide community health navigators and other wrap-around services.  We are also working with community partners to address risk factors for poor health outcomes as varied as obesity, bullying, and unsafe sleep practices.

Increasingly, though, there is evidence, as summarized in a recent Robert Wood Johnson Foundation report that health disparities are not the result only of differential health care access among the poor, but of poverty and racial bias themselves.  There are several lines of inquiry.  One is the role of environment (and specifically prenatal exposures) on epigenetic effects.  Adverse effects believed to be related to epigenetic changes that are more prevalent among infants of poor women include obesity and psychiatric, behavioral, and learning problems.  Another is the role of “toxic stress,” which is the result of repeated, unmitigated stress responses in infancy and early childhood – stresses that may result from both conditions of poverty or racial discrimination – leading to long-lasting effects on physical and mental health.  The AAP has identified both of these as strategic focus areas.

Even more intriguing is evidence that while poverty may be a contributing factor, the level of income inequality is more important than the absolute amount of poverty.  In other words, while poverty does lead to less health care access, less health care utilization, and more exposure to risk factors, these factors combined account for only a portion of the observed disparities.  Indeed, higher degrees of income inequality appear to predict worse health among not only the poor, but among the wealthy.  At least part of this seems to be related to the fact that when there are big gaps between the rich and the poor, the very phenomenon of feeling poor contributes to the toxic stress.  At the same time, the wealthy tend to be more resistant to public expenditures that benefit poor and rich alike.

If this is even partly true, it suggests that addressing health disparities will require addressing income disparities.  Talk about a Herculean effort! We’ve always recognized that we cannot solve the problem of health disparities alone, which is why we have partnered so broadly in that effort.  But how can any organization, or even a coalition, hope to make a dent in the basic American economy and culture?

That’s why I found this article on newborn care in Finland so intriguing.  It suggests that small efforts to level the field can matter.  Basically, all new mothers in Finland receive a maternity package.  Unlike in the US, where kits may be given out by hospitals but vary widely, it’s the same for all Finnish moms.  The kit comes in a box and includes breast feeding information, along with bodysuits, a sleeping bag, outdoor gear, diapers, bathing products for the baby, as well as bedding and a small mattress – the mattress is designed to go into the box, which serves as a crib!  And the culture is such that everyone uses it.  Mothers have a choice between the kit and a 140 euro cash grant; 95% choose the kit.  Imagine how things might be different if all babies in the Milwaukee area, whether they live in Lindsay Heights or Whitefish Bay, napped in the same type of box.  Of course, that would require a cultural change that could be even harder to achieve than income redistribution.  The Finns note that part of the appeal of the maternity kit is the fact that it symbolizes equality.  But when it comes to children, there is a strain of American culture that supports that: for example, the traditional commitment to universal public education dating back to the first years of the Republic.

Our health disparities are a daunting problem.  Could the answer lie in a box?

When I came here in 2000, we had two physician assistants working in the emergency department (one of whom recently retired).  A couple of years later, I hired the first nurse practitioner. (She’s still with us, and recently got her Doctor of Nursing Practice degree.)  We now have a dozen advanced practice providers in emergency medicine, and they see roughly 20% of our patients either alone or together with a physician.  Our APPs not only provide excellent patient care, but they participate in the education of students and residents.  Our approach has been one of a team of professionals, with complementary if somewhat overlapping roles.  This growing role of APPs is paralleled in the practice as a whole.  One-third of the CSG membership now consists of advanced practice providers.  In many of our specialties, they are a critical part of our workforce, a great example of our values of collaboration and innovation.  Nationally, nurse practitioners, physician assistants, pharmacists, and other providers are increasingly seen as a way to address shortages of physicians, and to attempt to maximize value by providing high quality care at a lower cost.

Interestingly, despite our commitment to innovation, academic centers in general, and children’s hospitals in particular, seem to have been slow to adopt this innovation.  About five years ago a colleague did an informal survey of nine academic pediatric EDs.  We were one of only five that used APPs at all, the only one that used them in both the main ED as well as a “fast track,” and had 50% more APP coverage than the next highest.

The growth of the APP role has not been without controversy, both in our practice and in the larger community.  There has been a good deal of media discussion lately about scope of practice, quality, cost, and other issues related to the appropriate workforce composition.  Two recent articles shed some light on some of the tensions involved.  A paper in NEJM reported on a survey of nearly 1000 primary care providers, approximately equally split between physicians and nurse practitioners.  They appeared to do similar work:  when asked about the services they provided, NPs and physicians generally reported a similar distribution except that physicians were much more likely to provide care of patients with chronic conditions that were not yet well controlled. Yet there were large differences of perspective between the groups.  For example, while large majorities of both agreed that NPs should be able to practice to the full extent of their training and education, only 17% of physicians believed NPs should lead medical homes, vs. 82% of NPs.  Physicians were far more likely to endorse the concept that physicians provide a “higher quality of examination and consultation”; 66% of physicians agreed with this statement, while 75% of NPs disagreed.   And on the issue of pay, only 4% of physicians believed that NPs should be paid the same as physicians for providing the same services, compared with two-thirds of nurse practitioners.

What about patients and families?  A study in the June issue of Health Affairs examined preferences of 2000 adults, the vast majority of whom had had prior experience with both physicians and advanced practice providers.  When asked about which type of provider they would prefer if both were available, 50% had a preference for a physician, 25% for an APP, and 25% no preference.  Perhaps as a sign of evolving attitudes, younger respondents were more likely both to have had a prior experience with an APP and to prefer one.  And when specific clinical scenarios were probed, in which there was a trade-off in terms of timeliness – in one case, a choice between seeing an APP the same day or a physician the next day for worsening cough, and in the other seeing an APP the next day vs. a physician in 3 days for chronic persistent headaches – 60-67% preferred to see the APP sooner.  This all suggests that APPs are highly acceptable to patients, especially if it means more timely care.

Taking the holistic view of quality as care that is effective, efficient, timely, safe, patient-centered, and equitable, it appears that APPs have an important role to play in assuring that quality, especially in an evolving healthcare environment.  There are legal and attitudinal barriers to maximizing their potential, but I’m proud that CSG has been a leader among academic pediatric enterprises in innovating and embracing APPs as part of our team.

I will admit that over the course of my career, I have not always been compulsive about cleaning my hands on the way into and out of each and every patient encounter.  My “road to Damascus” moment came several years ago, when I was seeing a child with a hernia in the emergency department.  The visit involved not just our team, but some consultants as well.  At the end of the visit, the mother found me and said, “Congratulations.  We saw six different doctors, and you were the only one to wash his hands.”  All I could respond with was, “That’s truly appalling.  I’m very sorry for that.”  I wish I could have said I didn’t believe it, but sadly, it’s all too believable.  Our own audit data show that, while there is variability across types of providers and different settings, as well as over time, as an organization we consistently fall short of our target of 90%, much less 100%.  Admittedly we’re not alone.  Several studies have demonstrated compliance rates as low as 10%.  Still, our performance is disappointing.

I have to admit, I don’t get it.  First of all, I owe it to my patients not to transmit germs from one to another.  It’s a critical part of patient safety.  More importantly, I owe it to myself.  Just the thought of the billions of microbes crawling on every surface in our facility is enough to drive me to the nearest sanitizer dispenser.  Surely we all understand the importance; it’s not the days when Semmelweiss was trying to convince his colleagues that there was a link between hygiene and puerperal fever.

So what are the barriers?  In the past, there were some real issues.  Soap and water aren’t as toxic as the carbolic acid Semmelweiss used, but they can be very hard on the skin – I can recall days in the winter when I’d come home from a shift with my hands cracked and bleeding.  And sink placement wasn’t always conducive to “washing in” and “washing out.”  But with the newer generation of waterless sanitizers, and dispensers galore, it’s far easier for the providers.  It’s just not that hard.

Our improvement strategies so far have been focused on education and prompts.  There are signs, posters, pins, badge holders, screen savers, etc.   If anyone ever noticed them, at this point they are frankly part of the background noise.  For a while we tried to empower families and staff to remind providers.  Once or twice I’ve seen a parent ask someone to wash their hands, but it’s a rare occurrence.  (Several people have put out videos on the importance of handwashing.  While amusing, I have to question whether a YouTube clip, no matter how many hits, has ever changed behavior of a large number of people.)

Increasingly, hospitals are becoming more heavy handed in their approach to improving hand hygiene.  A recent New York Times article discusses the types of surveillance being used.  For example, at North Shore University Hospital in New York, a video camera is activated when someone enters an ICU room.  Hand cleaning is observed and monitored (from a video center in India!), and aggregate statistics on performance posted on an electronic board on the unit.  As reported in Clinical Infectious Diseases, compliance went from 6.5% to 89%!  A less Big Brotherish but high tech approach is used at another hospital, where a radiofrequency tag in each provider’s ID badge communicates with a sensor on the sanitizer dispenser.  If the wearer does not clean her hands, the badge vibrates to give a gentle, private reminder.

I’d hate to think that’s what it takes to get health care providers to wash their hands.  We all know it’s the right thing to do, and it’s been made as easy as possible to comply with.  Perhaps everyone needs to be mortified by a family’s reaction the way I was to imprint it on us.  In any case, please – WASH.  The infection you prevent may be your own.

Not too long ago, I was recommending an ultrasound for a child with suspected appendicitis, when the father asked me what it was going to cost.  I no longer find this terribly surprising, as it seems to occur more and more (albeit still pretty infrequently).  But as usual, I had no idea.  Not only because in general I’m unaware of what our standard charge is for most procedures and treatments.  But also because even if I did, it wouldn’t answer his question – I’d still have no idea what it was going to cost him.  To answer that, I’d need to know what his insurance is, what our negotiated rates are with that insurer, his deductible and co-pay, etc.  I couldn’t answer his question even if I wanted to.  So I basically pleaded ignorance.

There has been a lot of publicity lately about the disconnect between the so-called “chargemaster” price and what insurers and individuals actually pay, as well as the huge variation in both standard charges and actual prices between hospitals even in the same city.   This has generated call calls for more transparency, in response to which providers have typically done what I did, citing the complexity of answering that for a given individual.  But that is increasingly unacceptable to our families, who have to pay increasing out-of-pocket costs.  A few things on the horizon are making it harder for us hide behind that excuse.  A hospital in Miami announced recently that it would publish not only its sticker price, but also its negotiated rates with various payers.  Insurers are also making it easier for individuals to look on line to see what it will actually cost them to have various procedures from different providers.  In our own region, United Healthcare has billboards advertising their health cost calculator, and the GE Health Choice plan (their AACN product) has a similar Web site.

I’m not a huge fan of rank consumerism in health care.  But we have to start being prepared to think about how we’re going to answer that question “What’s this gonna cost?”

Some days we feel like we can conquer the world and make it a better place; others, we’re lucky to get out of bed and take care of our basic bodily needs.  To get through life, we need aspirations – lofty things to drive toward – while at the same time having a sense of reality so we aren’t crushed every time we don’t quite get all the way there.

Our organization’s vision is lofty: that the children in Wisconsin will be the healthiest in the nation.  But our strategies for getting there are pragmatic and measured.  We can’t get there overnight, and we can’t get there alone.  But that doesn’t stop us from trying.

Similarly, our organizational values are a mixture of lofty and more mundane.  Patrick Lencioni, in The Advantage: Why Organizational Health Trumps Everything Else, talks about three types of organizational values.  Core values are those that describe the behavioral traits actually inherent in an organization.  Our examples might include Purpose and Collaboration.  I believe that we are truly mission-oriented, and that virtually all the people who work here share that sense of purpose and work together to achieve it.  Permission-to-play values are the minimum behavioral standards required to be a part of the organization.  Those who don’t share these values should not be brought into the organization, or may need to leave.  Integrity would fall into this category.  Then there are aspirational values, the characteristics an organization wants to have and believes it needs, even if it isn’t quite there yet.  For us, that value is Health, characterized as “We Are At Our Best.”

This one has generated a lot of discussion.  Some of the feedback has been that this is not a value we consistently live up to and embrace.  If we look at the guiding behaviors listed under this value, one can certainly argue that is true.  How many of us can say we have harmony in our work and personal life, or that we lead a healthy lifestyle?   Most of us probably wish we could do better.  Does our organization really provide the most support possible for that kind of health?  While it does a lot to promote the health of our people, honestly, it could also do better.

The fact that Health is more of an aspiration rather than a core value does not diminish its importance, nor does it argue for taking it off the list.  Indeed, Lencioni suggests every organization should have at least one aspirational value, because by definition they need to be purposefully cultivated.

This value is one that is especially personally important to me.  For one thing, I am serious about my own health.   There is a growing body of evidence that a healthy workplace with a healthy workforce is more effective.  Finally, if we think about the shadow we cast for patient and families, we need to model our own health if we hope to promote theirs.

So what would Children’s look like if health moved from being an aspiration to being a core value?   Perhaps we would promote physical activity by making stairs more visible and accessible, organizing more group exercise opportunities like today’s walk around campus, or incentivizing people to bicycle to work.  (FYI, it’s national Bike to Work Week.)  We would promote rest and rejuvenation – which have been shown to increase effectiveness and productivity – through breaks and vacations (real ones, no email).  We would increase our efforts at sustainability, since a healthy environment is critical for healthy people.

Sure, this sounds a little pie-in-the-sky.  That’s what it means to be aspirational.  We’ve laid out a strategy to work toward the healthiest children in the nation here in Wisconsin.  What would it take to have the healthiest workforce in the nation here at Children’s?  I’ve shared a few thoughts – what are yours?

As adherents to evidence-based practice, we are used to paradigms changing.  From leeches to surgery for low back pain, the medical literature is filled with things that seemed sensible and theoretically sound, but that on rigorous study turned out not to be correct.  This is why providers need to keep up on the literature.  But there are caveats.  First, we must balance an openness to changing practice when the evidence supports or even demands doing so, with a healthy skepticism and critical evaluation of the evidence to be sure we draw the right conclusions from what are often imperfect studies.  We can all think of examples of papers that at first blush appeared to be true landmarks, only to have substantial flaws revealed, or be contradicted by subsequent data.  In addition, data are merely facts; to become information, data must be interpreted, and those interpretations can be subjective.  Finally, most progress in health care is at best incremental.  It is rare that any one study singlehandedly changes what we do.

A recent paper in the New England Journal of Medicine has been hailed by at least some commentators as one of those rare solo game changers.  In my mind, though, I believe its data are being widely misinterpreted.  I am referring to the study of the Oregon Medicaid Experiment.  Briefly, in 2008, Oregon was expanding its Medicaid coverage for childless adults.  However, there was less funding available than originally intended, so they allocated the coverage to the applicants using a lottery.  This was the holy grail of health services research – a randomized controlled trial (albeit a naturally occurring one) of insurance vs. no insurance.  Such rigorous study designs almost never occur in the area of health policy.  This was a rare opportunity to answer the question of how insurance coverage affects utilization of services and, most importantly, health, without the confounding and other flaws that occur when, for example, comparing different states with different levels of coverage.

The authors found that when comparing those who were randomly selected to get coverage with those who remained uninsured, those with Medicaid used more health services.  This is perhaps not terribly surprising.  But after two years of follow up, while the newly insured had lower rates of depression and less financial stress, there were no differences in several measures of health status including prevalence of diabetes and hypertension, cholesterol levels, or hemoglobin A1c levels in diabetics.  These results are consistent with one of the only other RCTs of insurance coverage, the RAND study of the 1970s.  All subjects in that study had coverage, but with varying levels of cost sharing.  Better coverage led to more utilization, but without any clear overall difference in health status.

Some commentators, particularly those opposed to the Medicaid expansion included in the Affordable Care Act, have touted these studies as proving that comprehensive health insurance in general, and Medicaid in particular, do not work.  Many others have pointed out specific flaws with the study that might limit this conclusion.  But I think there are two additional major errors of interpretation here that we might heed.

What if the proper conclusion is not that health insurance doesn’t improve health, but that heath care does not improve health?  After all, in both studies there were more doctors visits, prescriptions, etc., but no better health status.  That might be a leap, but we do know that not all medical interventions (tests and treatments) are beneficial.  Moreover, medical care is but one determinant, and a minor one at that, of a person’s health.  Finding that having insurance by itself does not decrease the rate of diabetes isn’t terribly unexpected.  But one potential lesson to draw from the Oregon study – and, I believe, and important one – is that health insurance is being spent on the wrong things.  If health coverage, and health care, are to have a positive impact – if they are to have value – what we do may need to be more focused on prevention, on promoting adherence on the part of both patients and providers to proven management strategies, and on care coordination.

The second thing to keep in mind is that health is not merely the absence of disease.  The World Health Organization, among others (including the American Academy of Pediatrics) support a more holistic view of health: a positive state of physical, mental, and social well-being.  Yes, the lucky people who received Oregon Medicaid had similar rates of several measures of physical health.  But they had lower rates of depression and of economic stress.  If we had some composite measure of the comprehensive meaning of health, insurance would undoubtedly have been shown to improve it.

Surely at least a few of those who pay for health care will look at this study and draw a similar conclusion.  If they pursue evidence-based policy making, they will develop ways to move models of care and payment in that direction.  Fee-for-service may become the bloodletting of the health payment world.

People often ask if my kids are pursuing a career in medicine.  As it turns out, neither of my sons is going into anything even remotely related.  They’ve never really had the inclination, and I’m certainly not the type to push them into anything.  But when someone learns that my boys aren’t following in my footsteps, the follow up statement is often something along the lines of “I hear a lot of doctors are pretty unhappy with how things are going, and say they wouldn’t do it again. I guess it’s not surprising you would discourage your children from being a physician.”

That’s when I get defensive.  I actually love what I do!  If anyone has an interest in medicine, I would absolutely encourage them to pursue it.  After a number of these conversations, I started to wonder if I was crazy.  But now there is data to suggest I’m not alone.  A recent survey, the Gallup-Healthways Well-Being Index, shows that physicians rank highest or all occupations in terms of overall well-being.  (It’s like we’re the Denmark of occupations.)  The findings are based on over 170,000 interviews in 2012 with working Americans.  Physicians had the highest overall well-being index (78.0 on a scale of 100), followed by teachers at 73.5.  The survey includes 55 items measuring respondents’ physical, emotional, and fiscal well being.  Physicians scored highest (95%) in their belief that they “use their strengths to do what they do best every day” (followed by nurses at 92.7%), and near the top in being treated by their supervisors as a partner.  Physicians also scored at or near the top in measures of physical health, such as exercise, healthy food consumption, obesity.

This is not to deny that physicians are under a great deal of stress as we move through as rapidly changing healthcare environment.  Moreover, dissatisfaction appears to be particularly high in certain specialties, where changes in work patterns and reimbursement may be leading to lower pay and more difficult working conditions.  But overall, the evidence is that for the large majority of us, we still find that being a physician remains a rewarding way to fulfill our goals of making a difference in people’s lives.

I’m not disappointed that my kids are following different paths – I’m thrilled they have passions and they are pursuing them.  But I’m certainly not sorry with the path I’ve chosen, and I’d gladly do it again.

If medicine is a team sport, then integrity is the force that holds the team together.  In our statement of core values, integrity is characterized as “We build confidence and trust in all interactions.”  Integrity is often defined in terms of trust or honesty.  But it is really much more.  The word derives from the Latin root integer, meaning whole, or complete.  Integrity embodies the concept of consistency, the parts being in harmony with the whole: for example, consistency between words and actions.  In that sense, the link to honesty is clear, and is exemplified in the associated behaviors “I follow through on commitments,” and “I give and receive feedback honestly.”

But how does this notion of integrity as honesty explain “I listen to others to gain understanding,” or “I am committed to service excellence”?  This follows from a more expansive view of consistency, not only between words and actions, but between our actions and our inner principles, beliefs, and values.  Integrity is the pillar that supports our other values of purpose, collaboration, health, and innovation.  If we act with integrity, then what we do is motivated by our devotion to these other values, by our vision of the children in Wisconsin being the healthiest in the nation.

We cannot collaborate if we do not listen for understanding, if we do not assume good intent.  When we fail to assume good intent, then our action is not consistent with our values – we lack integrity.

A key behavior is “I treat others with dignity, compassion, and respect.”  Doing this, in turn, requires understanding those with whom we interact.  It means trying to put ourselves in their place, trying to see the world through their eyes.  This is particularly critical for our patients and families.  Acting with integrity requires empathy.  For a compelling look at approaching others with empathy in a health care setting, see this Cleveland Clinic video.

Integrity doesn’t just apply to us as individuals.  Our organization must also have integrity.  Patrick Lencioni, in his book The Advantage: Why Organizational Health Trumps Everything Else, states “An organization has integrity – is healthy – when it is whole, consistent, and complete, that is, when its management, operations, strategy, and culture fit together and make sense.”

For us as individuals, and collectively as an organization, integrity is absolutely critical.  Lack of integrity leads to failure – it is, literally, dis-integration.  “A house divided against itself cannot stand.”  But we can also look at this more positively.  When we have integrity, we are whole, we are healthy.  As Gandhi said: “Happiness is when what we think, what we say, and what we do are in harmony.”

For some time now, those interested in promoting safety in healthcare (such as our recent visitors from the Solutions for Patient Safety collaborative) have recognized that creating a high reliability environment and a culture of safety require a focus on the systems within which people operate, rather than on the individuals themselves.  Checklists, hard stop alerts, pre-filled syringes, all are examples of system design that “nudge” us (gently or firmly) away from things that might harm patients.

But when it comes to the effectiveness domain of quality, we still tend to focus on individual solutions – e.g., publishing systematic reviews or clinical guidelines, education – in the hope that providers will do the right thing. In reality, though, translating research into practice tends to be slow, sometimes painfully so.  Some recent publications shed some light on some of the barriers.  Pediatrician and New York Times columnist Pauline Chen wrote about barriers to clinicians acting on comparative effectiveness research results.  Citing a study in Health Affairs, she notes several factors that impede the ability of such studies to change practice: financial incentives that promote the status quo; limited applicability of study results to real world populations; ambiguity of study results (e.g., conflicting studies, subgroup differences); cognitive biases (e.g., the belief that more care or more expensive care equals better care); and limited use of decision support tools.

Changes in the health care payment environment may alter the financial incentives, and ongoing efforts to improve the design and conduct of comparative effectiveness research, such as those sponsored by the Patient Centered Outcomes Research Institute, will address the second two points.  Another recent article in Health Affairs sheds some light on the issue of cognitive biases.  Drawing on experience with behavioral economics, the authors discuss the two cognitive systems that affect behavior – the automatic and the reflective.  While the latter is driven by rational thought, the former is driven by heuristics, mental short-cuts that allow us to react rapidly to an onslaught of multiple, simultaneous inputs.  While they often serve us well and keep our brains from being overwhelmed, these heuristics are subject to a variety of biases and errors.  One example is “availability bias,” where things we have encountered most recently assume greater importance than they warrant based on actual probability.  The point of the article is that, if we hope to change clinical practice behavior, we cannot rely strictly on education – which utilizes the reflective system of processing – and instead use approaches that acknowledge and account for the biases inherent in the automatic thought processing we all use in our day-to-day practice.  For instance, behavior is often driven by perceived norms; we want to do what others in a similar situation would do. (“I believe most people would get a CT in a patient with a new onset seizure.”) The problem is, we don’t always know what those norms really are. (How often are CT’s actually done in such patients?)  If we knew what the norms are, we might be more inclined to change what we do to conform.  Another example is how our perception is altered by the messenger.  They cite a study where 82% of physicians said they trusted a guideline from their professional organization, while only 6% supported the same guideline said to come from an insurer.

One particularly important behavioral promoter of change is making the desired activity the default.  Enrollment in retirement plans and organ donation are both dramatically higher when someone has to opt out rather than opt in.  Similarly, generic prescribing is higher when that is the default.  This is a system change that can be used to drive evidence-based practice.  So is decision support, the fifth barrier to translating research into practice.  Building the evidence into the same tools we use for documenting and ordering is an important way to promote the use of that evidence.  Taking a systems approach will help as we attempt to improve quality in all of its domains, including effectiveness and efficiency as well as safety.

I’ve never been one of those people who really bought into the “baseball is a metaphor for life” thing.  But the longer days, melting snow, and opening day have got me thinking about one aspect of baseball that does resonate: teamwork.  While individual accomplishments are recognized, everyone on the winning team gets a World Series ring, even the guy with the lowest batting average, or the third left-hand reliever on the list.

As a team sport, even baseball pales in comparison to medicine, especially academic medicine.  Nothing we do can be done by one individual acting alone.  This is why one of our core values is Collaboration: “We work together to care for children and families.”  To be a team means more than just a group of people working in the same area.  Among the important things that transform a group into a team are common purpose, mutual respect, and collective responsibility.  All the members of the team are working toward the same goal – the health of a child, meeting the needs of a family, understanding a disease.  Sometimes it means putting off one’s own goals, at least temporarily, like a sacrifice bunt to advance another team member into scoring position.  It means each team member doing what she or he does best to lead to the shared outcome, regardless of the “credit” that may be given.  In turn, each team member respects the unique contribution of the others.  On a functioning team, diversity (of skill, talent, background, perspective) is a core strength.  An all-star team composed entirely of pitchers will never win.  In the end, all the team members share in the credit for success, or the responsibility for failure.  Members of teams don’t hog the limelight and they don’t point fingers.

Because we work in such a complex environment, we recognize the many teams each of us is on.  It might be the group of care providers in the clinic or OR.  It might be the individuals working on a research project.  The leadership team of a service line.  The members of a committee.  Leaders from our various campus partners like MCW, CHW, CSG.  The partnership between a family and a provider.  The list is nearly endless.  But all of these are teams, and all have in common those key features of collaboration: common purpose, mutual respect, collective responsibility.

So while I have always been terrible at baseball (I was actually held back in Little League!), I am grateful for the spirit of teamwork and collaboration I have found in academic pediatric medicine, and in particular here at Children’s Hospital of Wisconsin and Medical College of Wisconsin.