Tag: Lewis Thomas

Under One Roof: What Can we Learn from the Mayo Clinic?

The biologist Lewis Thomas, who we've written about before, has a wonderful thought on creating great organizations.

For Thomas, creating great science was not about command-and-control. It was about Getting the Air Right.

It cannot be prearranged in any precise way; the minds cannot be lined up in tidy rows and given directions from printed sheets. You cannot get it done by instructing each mind to make this or that piece, for central committees to fit with the pieces made by the other instructed minds. It does not work this way.

What it needs is for the air to be made right. If you want a bee to make honey, you do not issue protocols on solar navigation or carbohydrate chemistry, you put him together with other bees (and you’d better do this quickly, for solitary bees do not stay alive) and you do what you can to arrange the general environment around the hive. If the air is right, the science will come in its own season, like pure honey.

One organization which clearly “gets the air right” is the much lauded Mayo Clinic in Rochester, Minnesota.

The organization has 4,500 physicians and over $10 billion in revenue from three main campuses, and it is regularly rated among the top hospital systems in the United States in a wide variety of specialities, and yet was founded back in the late 20th century by William Worrall Mayo. Its main campus is in Rochester, Minnesota; not exactly a hub of bustling activity, yet its patients are willing to fly or drive hundreds of miles to receive care. (So-called “destination medicine.”)

How does an organization sustain that kind of momentum for more than 150 years, in an industry that's changed as much as medicine? What can the rest of us learn from that?

It's a prime example of where culture eats strategy. Even Warren Buffett admires the system:

A medical partnership led by your area’s premier brain surgeon may enjoy outsized and growing earnings, but that tells little about its future. The partnership’s moat will go when the surgeon goes. You can count, though, on the moat of the Mayo Clinic to endure, even though you can’t name its CEO.

Pulling the Same Oar

The Mayo Clinic is an integrated, multi-specialty organization — they're known for doing almost every type of medicine at a world class level. And the point of having lots of specialities integrated under one roof is teamwork: Everyone is pulling the same oar. Integrating all specialities under one umbrella and giving them a common set of incentives focuses Mayo's work on the needs of the patient, not the hospital or the doctor.

This extreme focus on patient needs and teamwork creates a unique environment that is not present in most healthcare systems, where one's various care-takers often don't know each other, fail to communicate, and even have trouble accessing past medical records. (Mayo is able to have one united electronic patient record system because of its deep integration.)

Importantly, they don't just say they focus on integrated care, they do it. Everything is aligned in that direction. For example, as with Apple Retail stores (also known for extreme customer focus), there are no bonuses or incentive payments for physicians — only salaries.

An interesting book called Management Lessons from the Mayo Clinic (recommended by the great Sanjay Bakshi) details some of Mayo's interesting culture:

The clinic ardently searches for team players in its hiring and then facilitates their collaboration through substantial investment in communications technology and facilities design. Further encouraging collaboration is an all-salary compensation system with no incentive payments based on the number of patients seen or procedures performed. A Mayo physician has no economic reason to hold onto patients rather than referring them to colleagues better suited to meet their needs. Nor does taking the time to assist a colleague result in lost personal income.

[…]

The most amazing thing of all about the Mayo clinic is the fact that hundreds of members of the most highly individualistic profession in the world could be induced to live and work together in a small town on the edge of nowhere and like it.

The Clinic was carefully constructed by self-selection over time: It's a culture that attracts teamwork focused physicians and then executes on that promise.

One of the internists in the book is quoting as saying working at Mayo is like “working in an organism; you are not a single cell when you are out there practicing. As a generalists, I have access to the best minds on any topic, any disease or problem I come up with and they're one phone call away.”

In that sense, part of the Mayo's moat is simply a feedback loop of momentum: Give a group of high performers an amazing atmosphere in which to do their work, and eventually they will simply be attracted by each other. This can go on a long time.

Under One Roof

The other part of Mayo's success — besides correct incentives, a correct system, and a feedback loop — is simply scale and critical mass. Mayo is like a Ford in its early days: They can do everything under one roof, with all of the specialities and sub-specialities covered. That allows them to deliver a very different experience, accelerating the patient care cycle due to extreme efficiency relative to a “fractured” system.

Craig Smoldt, chair of the department of facilities and support services in Rochester, makes the point that Mayo clinic can offer efficient care–the cornerstone of destination medicine–because it functions as one integrated organization. He notes the fact that everyone works under one roof, so to speak, and is on the payroll of the same organization, makes a huge difference. The critical mass of what we have here is another factor. Few healthcare organizations in the country have as many specialities and sub-specialities working together in one organization.” So Mayo Clinic patients come to one of three locations, and virtually all of their diagnoses and treatment can be delivered by that single organization in a short time.

Contrast that to the way care is delivered elsewhere, the fractured system that represents Mayo's competitors. This is another factor in Mayo's success — they're up against a pretty uncompetitive lot:

Most U.S. healthcare is not delivered in organizations with a comparable degree of integrated operations. Rather than receiving care under one roof, a single patient's doctors commonly work in offices scattered around a city. Clinical laboratories and imaging facilities may be either in the local hospital or at different locations. As a report by the Institute of Medicine and the National Academy of Engineering notes, “The increase in specialization in medicine has reinforced the cottage-industry structure of U.S. healthcare, helping to create a delivery system characterized by disconnected silos of function and specialization.

How does this normally work out in practice, at places that don't work like Mayo? We're probably all familiar with the process. The Institute of Medicine report referenced above continues:

“Suppose the patient has four medical problems. That means she would likely have at least five different doctors.” For instance, this patient could have (1) a primary care doctor providing regular examinations and treatments for general health, (2) an orthopedist who treats a severely arthritic knee, (3) a cardiologist who is monitoring the aortic valve in her heart that may need replacement soon, (4) a psychiatrist who is helping her manage depression, and (5) and endocrinologist who is helping her adjust her diabetes medications. Dr. Cortese then notes,”With the possible exception of the primary care physician, most of these doctors probably do not know that the patient is seeing the others. And even if they do know, it is highly unlikely they know the impressions and recommendations the other doctors have recorded in the medical record, or exactly what medications and dosages are prescribed.” If the patient is hospitalized, it is probably that only the admitting physician and the primary care physician will have that knowledge.

Coordinating all of these doctors takes time and energy on the part of the patient. Repeat, follow-up visits are done days later; often test results, MRI results, or x-ray results are not determined quickly or communicated effectively to the other parts of the chain.

Mayo solves that by doing everything efficiently and under one roof. The patient or his/her family doesn't have to push to get efficient service. Take the case of a woman with fibrocystic breast disease who had recently found a lump. Her experience at Mayo took a few hours; the same experience in the past had taken multiple days elsewhere, and initiative on her end to speed things up.

As a patient in the breast clinic, she began with an internist/breast specialists who took the medical history and performed an exam. The mammogram followed in the nearby breast imaging center. The breast ultrasound, ordered to evaluate a specific area on the breast, was done immediately after the mammogram.

The breast radiologist who performed the ultrasound had all the medical history and impressions of the other doctors available in the electronic medical record (EMR). The ultrasound confirmed that the lump was a simple cyst, not a cancer. The radiologist shared this information with the patient and offered her an aspiration of the cyst that would draw off fluid if the cyst was painful. But comforted with the diagnosis of the simple cyst and with the fact that it was not painful, the veteran patient declined the aspiration. Within an hour of completing the breast imaging, the radiologist communicated to the breast specialist a “verbal report” of the imaging findings. The patient returned to the internist/breast specialist who then had a wrap-up visit with the patient and recommended follow-up care. This patient's care at Mayo was completed in three and one-half hours–before lunch.

So what are some lessons we can pull together from studying Mayo?

The book offers a bunch, but one in particular seemed broadly useful, from a chapter describing Mayo's “systems” approach to consistently improving the speed and level of care. (Industrial engineers are put to work fixing broken systems inside Mayo.)

Mayo wins by solving the totality of the customer's problem, not part of it. This is the essence of an integrated system. While this wouldn't work for all types of businesses; it's probably a useful way for most “service” companies to think.

Why is this lesson particularly important? Because it leads to all the others. Innovation in patient care, efficiency in service delivery, continuous adoption of new technology, “Getting the Air Right” to attract and retain the best possible physicians, and creating a feedback loop are products of the “high level” thought process below: Solve the whole problem.

Lesson 1: Solve the customer's total problem. Mayo Clinic is a “systems seller” competing with a connected, coordinated service. systems sellers market coordinated solutions to the totality of their customers' problems; they offer whole solutions instead of partial solutions. In system selling, the marketer puts together all the services needed by customers to do it themselves. The Clinic uses systems thinking to execute systems selling that pleasantly surprises patients (and families) and exceeds their expectations.

The scheduling and service production systems at Mayo Clinic have created a differentiated product–destination medicine–that few competitors can approach. So even if patients feel that the doctors and hospitals at home are fine, they still place a high value on a service system that can deliver a product in days rather than weeks or months.

[…]

Patients not only require competent care but also coordinated and efficient care. Mayo excels in both areas. In a small Midwestern town, it created a medical city offering “systems solutions” that encourage favorable word of mouth and sustained brand strength, and then it exported the model to new campuses in Arizona and Florida.

If you liked this post, you might like these as well:

Creating Effective Incentive Systems: Ken Iverson on the Principles that Unleash Human Potential — Done poorly, compensation systems foster a culture of individualism and gaming. Done properly, however, they unleash the potential of all employees.

Can Health Care Learn From Restaurant Chains? — Atul Gawande pens a fascinating piece in the New Yorker about what health care can learn from the Cheesecake Factory.

Lewis Thomas on our Social Nature and “Getting the Air Right”


“What it needs is for the air to be made right. If you want a bee to make honey, you do not issue protocols on solar navigation or carbohydrate chemistry, you put him together with other bees (and you’d better do this quickly, for solitary bees do not stay alive) and you do what you can to arrange the general environment around the hive. If the air is right, the science will come in its own season, like pure honey.”
— Lewis Thomas

***

In his wonderful collection of essays, The Lives of a Cell, the biologist Lewis Thomas displays a fairly pronounced tendency to compare humans to the “social insects” — primarily bees and ants. It's not unfair to wonder: Looked at from a properly high perch, are humans simply doing the equivalent of hive-building and colony-building?

In a manner Yuval Harari would later echo in his book Sapiens, Thomas concludes that, while we're similar, there are some pretty essential differences. He wonders aloud in the essay titled Social Talk:

Nobody wants to think that the rapidly expanding mass of mankind, spreading out over the surface of the earth, blackening the ground, bears any meaningful resemblance to the life of an anthill or a hive. Who would consider for a moment that the more than 3 billion of us are a sort of stupendous animal when we become linked together? We are not mindless, nor is our day-to-day behavior coded out to the last detail by our genomes, nor do we seem to be engaged together, compulsively, in any single, universal, stereotyped task analogous to the construction of a nest. If we were ever to put all our brains together in fact, to make a common mind the way the ants do, it would be an unthinkable thought, way over our heads.

Social animals tend to keep at a particular thing, generally something huge for their size; they work at it ceaselessly under genetic instructions and genetic compulsion, using it to house the species and protect it, assuring permanence.

There are, to be sure, superficial resemblance's in some of the things we do together, like building glass and plastic cities on all the land and farming under the sea, or assembling in armies, or landing samples of ourselves on the moon, or sending memoranda into the next galaxy. We do these together without being quite sure why, but we can stop doing one thing and move to another whenever we like. We are not committed or bound by our genes to stick to one activity forever, like the wasps.

Today's behavior is no more fixed than when we tumbled out over Europe to build cathedrals in the twelfth century. At that time we were convinced that it would go on forever, that this was the way to live, but it was not; indeed, most of us have already forgotten what it was all about. Anything we do in this transient, secondary social way, compulsively and with all our energies but only for a brief period of our history, cannot be counted as social behavior in the biological sense. If we can turn it on and off, on whims, it isn't likely that our genes are providing the detailed instructions. Constructing Charters was good for our minds, but we found that our lives went on, and it is no more likely that we will find survival in Rome plows or laser bombs, or rapid mass transport or a Mars lander, or solar power, or even synthetic protein. We do tend to improvise things like this as we go along, but it is clear that we can pick and choose.

With our basic nature as a backdrop, human beings “pick and choose,” in Thomas's words, among the possible activities we might engage in. These can range from pyramid building to art and music, from group campfire songs to extreme and brutal war. The wide range, the ability to decide to be a warring society sometimes and a peaceful society sometimes, might be seen as evidence that there are major qualitative differences between what humans do as a group and what the social insects are up to. Maybe we're not just hive-builders after all.

What causes the difference then? Thomas thought it might well be our innate capacity for language, and the information it allows us to share:

It begins to look, more and more disturbingly, as if the gift of language is the single human trait that marks us all genetically, setting us apart from all the rest of life. Language is, like nest building or hive making, the universal and biologically specific activity of human beings. We engage in it communally, compulsively, and automatically. We cannot be human without it; if we were to be separated from it our minds would die, as surely as bees lost from the hive.

We are born knowing how to use language. The capacity to recognize syntax, to organize and deploy words into intelligible sentences, is innate in the human mind. We are programmed to identify patterns and generate grammar. There are invariant and variable structures in speech that are common to all of us. As chicks are endowed with an innate capacity to read information in the shapes of overhanging shadows, telling hawk from other birds, we can identify the meaning of grammar in a string of words, and we are born this way. According to Chomsky, who has examined it as a biologist looks at live tissue, language “must simply be a biological property of the human mind.” The universal attributes of language are genetically set; we do not learn them, or make them up as we go along.

We work at this all our lives, and collectively we give it life, but we do not exert the least control over language, not as individuals or committees or academies or governments. Language, once it comes alive, behaves like an active, motile organism. Parts of it are always being changed, by a ceaseless activity to which all of us are committed; new words are invented and inserted, old ones have their meaning altered or abandoned. New ways of stringing words and sentences together come into fashion and vanish again, but the underlying structure simply grows, enriches itself, and expands. Individual languages age away and seem to die, but they leave progeny all over the place. Separate languages can exist side by side for centuries without touching each other, maintaining their integrity with the vigor of incompatible tissues. At other times, two languages may come together, fuse, replicate, and give rise to nests of new tongues.

The thing about the development of language is its unplannedness. There's no language committee directing the whole enterprise. Not only is language innate, as Noam Chomsky and his student Steven Pinker have so well proven, but it's extremely flexible based on the needs of its users. All the strange things about our language that seem so poorly drawn up were never drawn up at all. (What kind of masochist would put an “s” in the word lisp?)

***

One commonality to the social insects that Thomas does see is something he calls Getting the Air Right – his description of a really productive human group as a direct reflection of a really productive bee colony. In this case, he's talking about getting great science done, but the application to other human endeavors seems clear.

The following piece, pulled from his essay titled Natural Science, is worth reading and re-reading closely when you're tempted to “command and control” others around you.

I don't know of any other human occupation, even including what I have seen of art, in which the people engaged in it are so caught up, so totally preoccupied, so driven beyond their strength and resources.

Scientists at work have the look of creatures following genetic instructions; they seem to be under the influence of a deeply placed human instinct. They are, despite their efforts at dignity, rather like young animals engaged in savage play. When they are near to an answer their hair stands on end, they sweat, they are awash in their own adrenalin. To grab the answer, and grab it first, is for them a more powerful drive than feeding or breeding or protecting themselves against the elements.

It sometimes looks like a lonely activity, but it is as much the opposite of lonely as human behavior can be. There is nothing so social, so communal, and so interdependent. An active field of science is like an immense intellectual anthill; the individual almost vanishes into the mass of minds tumbling over each other, carrying information from place to place, passing it around at the speed of light.

There are special kinds of information that seem to be chemotactic. As soon as a trace is released, receptors at the back of the neck are caused to tremble, there is a massive convergence of motile minds flying upwind on a gradient of surprise, crowding around the source. It is an infiltration of intellects, an inflammation.

There is nothing to touch the spectacle. In the midst of what seems a collective derangement of minds in total disorder, with bits of information being scattered about, torn to shreds, disintegrated, deconstituted, engulfed, in a kind of activity that seems as random and agitated as that of bees in a disturbed part of the hive, there suddenly emerges, with the purity of a slow phrase of music, a single new piece of truth about nature.

In short, it works. It is the most powerful and productive of the things human beings have learned to do together in many centuries, more effective than farming, or hunting and fishing, or building cathedrals, or making money. It is instinctive behavior, in my view, and I do not understand how it works.

It cannot be prearranged in any precise way; the minds cannot be lined up in tidy rows and given directions from printed sheets. You cannot get it done by instructing each mind to make this or that piece, for central committees to fit with the pieces made by the other instructed minds. It does not work this way.

What it needs is for the air to be made right. If you want a bee to make honey, you do not issue protocols on solar navigation or carbohydrate chemistry, you put him together with other bees (and you'd better do this quickly, for solitary bees do not stay alive) and you do what you can to arrange the general environment around the hive. If the air is right, the science will come in its own season, like pure honey.

Still Interested? Check out another great biologist, E.O. Wilson, writing about his experiences in science, or yet another, Richard Dawkins, writing about why chain letters work as a method for understanding natural selection.