Toby Cosgrove, M.D., CEO of the Cleveland Clinic, has some things to say to his colleagues in American medicine that are both exciting and alarming, for them and for the general public.

In his recent book The Cleveland Clinic Way: Lessons in Excellence from One of the World’s Leading Healthcare Organizations, he covers everything from the need for more transparency with patients to the difference between providing wellness and sick care.

With 157,000 hospital admissions and five million outpatient visits per year, 3,000 physicians in 130 specialties, and 11,000 nurses, it is the second-largest group practice in the U.S., next to the Mayo Clinic. Cosgrove has a huge clinical database to inform his recommendations for improving healthcare.

But the odds of his even becoming a doctor seemed pretty remote when he was growing up, even though he wanted to be one from age eight, after watching a surgeon prepare to operate.

Born in 1940, he came from a high school in Watertown, Mass., where only 13% of the students went to college.

He had trouble studying because he suffered from dyslexia, which wasn’t diagnosed until he was 32 (the subject of a chapter in Overcoming Dyslexia by Sally Shaywitz, M.D.).Cosgrove still relies on assistants to help with spelling and sentence structure.

On the other hand,he was good at basketball throughout his school years, which would teach him the value of teamwork.

At Williams College in Williamstown, N.Y., he majored in history because he hated the chemistry, the favored pre-med prep. He took the bare minimum of technical courses and got Ds in French.

Cosgrove did so badly on tests for admission to medical school that 12 turned him down, finally convincing the University of Virginia to let him in. He didn’t do well academically, but thrived in clinical work. In his senior year, a famous surgeon he met during clinical rotation at Boston Children’s Hospital offered to mentor him.

“I was really determined to succeed academically, but it was a struggle,” he told “I Speak of Dreams,” a blog about dyslexics. “But dyslexia favors spatial relationships and is an advantage in surgery.”

Cosgrove served an internship at the University of Rochester and a year of residency before being sent to run an Air Force hospital in Da Nang during the Vietnam War, earning a Bronze Star on a combat mission.

On his return and newly confident, he applied to finish his surgical residency at top-rated Massachusetts General, but was rejected. He wouldn’t take no for an answer, however, pestering the department chairman’s secretary and had his mentor put in a good word. He ended up ranked 13 in his residency group of 13.

For the next six months, he was out of work and wrote a book on surgery. Finally, down to his last $3,000, he received a job offer from the Cleveland Clinic in 1975. At the time, there were 140 doctors there. By 1989, he was the chairman of the department of thoracic and cardiovascular surgery.

He became known for two things. One was his workhorse schedule: he often did 13 surgeries a week and he has a career total of 22,000 operations.

He also built a reputation for inventiveness. Dyslexics naturally see things from a different angle than others and a bicycle gear gave him an idea for a better surgical clamp. An embroidery hoop inspired a ring to repair heart valves and he now has 30 patents. At 62, feeling he was getting a bit old for intensive surgery, he began looking for venture capitalists to launch a new career in innovative medical devices.

Then he was offered the CEO job in 2004 and set about revolutionizing an already highly-developed system. In his book, he discusses the lessons as a guide for other practices (while empowering patients in the process):

*Group practices provide better—and cheaper–care.

*All patient interactions need to be monitored and recorded for quality.

*Medicine must constantly innovate.

*Both the mind and the body need to be treated.

*Wellness depends on healthcare, not sick care.

*Care should take place in a variety of settings (home, outpatient clinic, etc.).

*Treatment needs to be customized for each patient.

*All elements of a medical system need to collaborate.

Integrated, Multidisciplinary Teamwork

The last point could be considered the linchpin for the greatest cost-effective improvements. Regardless of the nature of the practice, how up-to-date its technology is, or the philosophy of the physicians, no single practice can have all the expertise that is optimum for complicated cases.

People are living longer, but most haven’t takenresponsibility for their health very seriously, as the dramatic rise in obesity indicates. There are also thousands of new drugs since any doctor graduated from med school, as well as an explosion in medical literature (1,500 articles appear each day somewhere in the world).

But rather than feeling overwhelmed, generalists, specialists, and the support system can embrace this as an exciting opportunity for everyone to learn and achieve better results by working more closely together. The Cleveland Clinic has taken many steps to improve collaboration.

First, it has designed buildings and pathways to make interaction between caregivers more likely. There is a two-block-long skyway between the inpatient and outpatient facilities, with everyone passing back and forth. Lobbies are filled with impromptu brainstorming sessions. Medical conventions and continuing education sessions spill over, injecting outsider perspectives. Networking is encouraged, whether in person, by phone, email, in a webinar, or even at social events.

Second, as of 2008, the Clinic eliminated departments as the primary organizing units. Departments tend to encourage internal discussion, but in the new institutes for a particular organ or disease, teamwork is raised to another level.

“The forces that might have been aligned against this change are powerful, such as inertia and the temptation to continue doing things the way they’ve always been done,” Cosgrove wrote. “In 2007, the Department of Urology wasn’t ‘broken.’ It was the largest and most specialized urology practice in the world and was ranked number two in America by U.S. News & World Report.”

But the new Urological and Kidney Institute brings together urologists (surgeons dealing with the urinary system and reproductive organs) and nephrologists (who provide nonsurgical treatments for kidney problems). They get additional help from the Cancer Institute, Imaging Institute, and the Ob/Gyn & Women’s Health Institute, or elsewhere.

So if a patient is suffering from prostate and kidney cancer, incontinence, sexual problems, or other related issues, they don’t need to check in with an entirely different system for each problem. Wait times for treatment are less, there is no duplication of services, and communication between caregivers is better.

Take a case of prostate cancer. The urologist would use an ultrasound machine to take images, a physicist could calculate the dose of radiation seeds to go into the prostate, and the therapist would then place them safely.

Five years after the unification of services, the Clinic’s ranking for both urology and kidney disease rose to number one for the first time.

Another example is the hybrid operating room. The ones at the Clinic have all the necessary imaging devices, including 3D, CT, MRI, and digital x-ray machines. There are robot arms, specialized equipment, and monitors for everything. Cosgrove says these rooms “look like the command desk of a science fiction starship.” The doctors working in them often have more than one specialty and can blend their knowledge and skills in unusual ways.

The third way the Clinic encourages collaboration is that it does not simply provide a setting for different disciplines to work together, but hires people who love collaboration.

“There is a natural gulf between specialties, but true creativity in medicine doesn’t take place within disciplines so much as it does at their boundaries,” he wrote. “Instilling a culture that encourages creativity will lead to the creation of exciting new treatments that save lives.”

Modeling the Future of Medicine

In interviews with professional magazines, Cosgrove has discussed some of the other things Cleveland Clinic is doing that are fairly unusual. “Our model is our secret sauce,” he says. Some of the highlights:

*All physicians are on salary, so there is no incentive to do more or less to care for a patient in terms of earnings.

*That might lead to complacency, except that there is no tenure: everyone is on a one-year contract and the amount of pay depends on annual peer reviews.

*The way all professionals are treated and the opportunities they have result in a turnover rate of just 4%.

*In 2012, the Clinic eliminated $150 million in purchasing costs.

*It recently spent $170 million on a data center, something many practices could not afford to do, so consolidation or cooperation will drive the need to lower costs.

*Some 12,000 lab tests deemed unnecessary have been eliminated.

*Over 96% of drugs prescribed are generic when they are available.

*It encourages collaborative innovation, with the result that it has managed the issuing of 300 patents over the past decade, with 1,700 more in the pipeline, while spinning off 55 start-ups.

*It incentivizes all of its caregivers to commit to personal wellness, including quitting smoking, exercising, eating healthy foods, and losing weight.

*It distributes 50,000 books a year with statistics on its healthcare outcomes, even when they are below average (which is rare). This holds staff accountable, informs doctors and management on how improve them, shares best practices, and helps patients decide who will give them their care.

Finally, Cosgrove argues that healthcare is looked at far too much as a negative cost. In fact, the extension of life and improving health mean people are being productive longer, paying more taxes, and consuming more, raising the gross domestic product and creating more jobs.

In June 2014, he was considered to head up the Veterans’ Administration during its crisis over long waiting times, but declined because he said he has so much work left to do at the Clinic.

His vision for the future of American medicine is just what the doctor ordered.

Real Life Lessons

*Ten heads are better than one, so bring them together to solve difficult challenges.

*Your customers may know things you’ve been too busy to hear about.

*Traditional American medicine can learn a lot from global best practices.

*The best long-term strategy for any profession is transparency and candor.

*There is nothing too perfect that it can’t be improved by someone who looks at it from a different perspective.

Submitted By

Scott S. Smith


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