From age six through high school, I played baseball. Playing baseball ended, rather abruptly it seemed, when I went to college, but the lure of the game has always remained. To my colleagues, it must seem that I can hardly understand the world without the comfort of baseball analogies. I was thrilled when my son Ryan, age 12, saw the movie Moneyball and told me that he wanted to see it again, with me. For my son, the movie is a drama about baseball and a true story related to players that he has heard about. Ironically, my baseball-smitten mind instead saw a story about leadership and organizational structure. I saw struggles easily recognizable and relatable in our medical culture.
In baseball (as represented in this movie), there are five groups of stakeholders: the fans, the players, the coaches and scouts, the baseball administrators (general manager), and the owner. By analogy, in medical systems there are: the patients, the clinicians at the point of care, the medical leaders (such as department Chairs), the organizational administrators, and the big boss (CEO, president).
In Moneyball, the main character is Billy Beane (played by Brad Pitt). Mr. Beane is a former player who had an unsuccessful playing career and is now a general manager (GM) for a “small market” baseball team in Oakland trying to compete against the overwhelming bankroll of teams like the New York Yankees. He is the “hero” who decides to implement a new strategic paradigm for evaluating players and for actual strategy on the field. Mr. Beane, as GM, see the players like spoiled children and the coaches and scouts as fools who are stuck in old-fashioned ways of thinking about the game. Inspired by some fresh quantitative metrics that seem clever and well-suited to the challenge of trying to succeed as a small market team, Mr. Beane and his brilliant assistant GM force their hand on the players directly, circumventing the coaches. They have some amazing success, but do not ultimately achieve their goal of winning the World Series.
As I considered this analogy between the baseball hierarchy and that of medical systems, I found myself yearning to upgrade the attitude and approach of not only the GM, but also the players and coaches. The GM was correct in being innovative and challenging the status quo, but he failed to lead, choosing instead to aggressively exercise his authority and behave as a bully. The coaches and scouts seemed stubborn, resistant to change. And certain players did seem spoiled and entitled. The entire baseball hierarchy would have benefitted from a heaping serving of equipoise. That is, rather than being so enamored of their way of doing things and perceiving the world, they needed to take a deep look at some unfamiliar ways of thinking and doing their work, and consider alternative approaches. With mindful reflection and equipoise, they might discover that their mutual interests could be better served working in concert (achieved through dialogue) rather than each entity acting in its own perceived self-interest.
In science, we understand and treasure this notion of equipoise, but outside the confines of an experiment, the principle can slip away from our awareness. This leaves us vulnerable, at all levels in the medical hierarchy, to falling short of our goals and even losing sight of the real goals due to arrogance or fear. Respectful interactions between all levels and all individuals, courage, creativity, equipoise, and ultimately teamwork are attributes that enrich the probability of fully realizing the healthiest goals.
Michael Fisch is an oncologist who blogs at ASCO Connection, where this post originally appeared.
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