There should be no quarterbacks in health care

The seemingly irreconcilable conflict between the medical and nursing professions usually boils down to one question: who is in charge?  Physicians often use a football analogy: they are the quarterbacks of the team, calling the plays that others on the gridiron must follow, because of their greater training and skills.  Advanced practice nurses (APNs) respond: not so, we are also highly trained and qualified to call the plays and lead the team.

Instead of looking to football on how to organize the relationship between the medical and nursing professions and others on the health care team, baseball may provide us with a better example. Consider this.

Baseball is both a team and an individual sport.   In baseball, the final outcome depends on both the performance of the team as a whole but also, in any given situation, on the skills of the individual players: the control of the pitcher on the mound, the skill of the catcher in calling pitches and fielding balls in the dirt, the ability of the batter to wait for a pitch he can drive, the quickness of the infielder fielding a tricky one-hopper, or the outfielder positioning himself to make a running catch in the gap.  Each individual player’s contribution in each individual game situation determines what happens at that particular moment, but they can’t do it alone, it is the skill of the entire team working together that determines the outcome.  Does the pitcher make the right pitch to retire the batter, does the opposing team’s batter strike out or put the ball in play, if the batter puts it in play does the infielder field it cleanly and make a good throw, and if he does, will the pitcher get to first in time to take the infielder’s throw, beat the runner and get the out?

So it is with healthcare.  The skill and performance of an individual clinician, in meeting the needs of an individual patient at any particular moment and in any particular clinical situation, may determine the immediate clinical outcome.  But if the attending clinician doesn’t work well with others on the team, doesn’t have others backing her up, doesn’t rely on others with different skills as needed, something is likely to go terribly wrong for the patient.

Baseball has both generalists and specialists.  Baseball’s “generalists” are the utility players who are versatile because they can field any position, they may not be the best hitters but they get plenty of playing time because every team needs them to fill in when someone gets hurt or as late inning defensive replacements.  Baseball’s specialists include the elite “five-tool” players who do everything well (except maybe pitch): they can field, run, hit for average, hit for power, throw and catch the ball as well as anyone. Players like the Washington National’s young Bryce Harper.

Baseball has other specialists:  elite and middling starting pitchers, middle relievers, set-up guys, closers, base stealers, pinch hitting specialists,  defensive replacement outfielders, lead-off hitters, and of course, the everyday position players (like shortstops, outfielders, catchers, third basemen) who have to master the intricacies of their own positions in a way that no one else can.

The specialists and generalists on baseball teams are not substitutable for each other:  Try asking a skilled shortstop to replace a skilled catcher, or vice versa, and you’ll be looking for trouble.  They are both skilled at their positions but they have different skills that aren’t substitutable or equivalent.

So it is with healthcare.  Every healthcare team has specialists and generalists, each member of the them has his or her own role, each is skilled in what they do best and can’t substitute for someone with different skills, each knows they will be called upon when the patient’s situation requires their distinctive skills, and each knows that they can’t do it alone.  A neurosurgeon can’t substitute for an internist, or an internist for the neurosurgeon, or the advanced practice nurse for the internist, or the internist for the advanced practice nurse, all are needed to practice at the top of their skill level.

Baseball is situational and dynamic. In each particular game situation, you want the most skilled player available; your best power hitter when you need the three run blast, the guy with the highest on-base percentage when you need to get a rally started, the catcher who is most skilled at fielding balls in the dirt if you have a knuckleballer on the mound, your fastest runner to pinch run for a slow footed starting player, your lefty specialist brought in to get one player out, your best closer to end the game.  And when it is the equivalent of the game being on the line, you want your best five-tool player to be at bat or in the field, the one guy you know you can count on to get the job done.

So it is with healthcare. In each particular clinical situation, you want the most skilled clinician available, the trauma surgeon to treat trauma, the nurse educator to help the diabetic patient take control of her blood sugars, the neurosurgeon to operate on a life-threatening brain injury, the rheumatologist to take care of the lupus patient, the internist to diagnose and develop a treatment plan for the patients with the most challenging, presenting symptoms.   When it is the equivalent of the game being on the line, when it is a matter of life or death to someone, you want the physician who is the equivalent of the five-tool elite baseball player, the one with the highest skills needed to diagnose and treat that patient’s particular condition.   If it is a surgical procedure, you want the best surgeon with the specific training needed.  If it is a complex patient with multiple chronic conditions, you want an internal medicine specialist.  Calling Dr. Bryce Harper!

But you also want everyone else on the team to be performing at the top of their skills, because no one clinician can do it all.  Bryce Harper, for all his talent, can’t win games for the Nationals if others on the team don’t know their roles or aren’t performing as well they should (the Nat’s .500 underachieving record isn’t because Bryce isn’t doing his job well!).

In baseball, there is no one person in charge of everything.  The manager may ostensibly be in charge, but the manager doesn’t actually play the game, at least not since the days of player-managers like Pete Rose.  Managers rarely make decisions that determine the outcome of the game; instead, they count on their players to do what they have been trained to do. The best managers get the most out of the players by helping them think of themselves as being a team of equals (even though objectively, some are more talented than others).  Teams that are a collection of talented players with big egos but who don’t play well together won’t succeed over a long season.

Baseball also has its general managers, the front office guys who hire the managers and who draft and trade for players within a budget set by the owners, but they don’t call the shots on what happens on the field.  Baseball has its coaches, the grounds crew, the equipment guys, the supporting cast who help make the team succeed, they are in charge of their own areas of responsibility, but they don’t run the team.

So it is in health care.  Health care teams rely on their administrators, their finance people, their information system specialists, their front office staff, to make them as effective as possible.  They rely on each clinician on the team to know what to do in any given clinical situation and to take charge of a particular aspect of care as the situation requires.  Not because they have been anointed as to be in charge of everything, but because they are the most qualified to handle a given situation within their own expertise and domain, and then another member of the team may take charge for other elements of care within their own expertise and domain.

In baseball, everyone is ultimately accountable for the results: underperforming players are traded, cut or sent down: underperforming managers and GMs are fired; even talented players who don’t get along with others are off-loaded.  And baseball’s outcomes are constantly measured: team outcomes like winning percentages, games behind or ahead in the standings, team batting average, and team pitching earned run averages. Individual players’ performances are measured by batting averages, on base percentages, home runs, RBIs, slugging percentage, and individual pitchers by ERA, strikeouts and walks per inning, saves and blown saves, and so many more sabermetrics.  (And you think physicians have it tough today with the rudimentary performance measures applied to them?)

Of course, I know I am overplaying the baseball and healthcare team analogy to make a point.  There are big differences between what really is just a game (although for die-hard fans like me, the outcome of a baseball game can seem like a life and death situation!), and health care, where the performance of the team really can mean life and death.  And surely, it is much harder to measure the performance of the clinicians on a healthcare team than baseball players.

But I think there are lessons from baseball that are applicable to health care.  The best baseball teams are the ones who get most things right: they have the right combination of specialists and generalists, they have players that perform well as individuals but also as teammates, they have players with great talent but also versatile utility players who can do a bit of everything, they are dynamic and situational, matching up and using the specific talents of each of their team members effectively based on the changing game situation at a given time, they let everyone play and contribute to the best of their ability, and they don’t need to be told by their manager who is in charge, because they know that they all are responsible and accountable for what happens on the field.

Shouldn’t this be true of health care teams as well?  There are no quarterbacks in baseball, and maybe it’s time to put aside the concept that there should be quarterbacks in health care.

Bob Doherty is senior vice-president, Governmental Affairs and Public Policy, American College of Physicians and blogs at The ACP Advocate Blog.

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  • Steven Reznick

    Spoken like a true long term administrative policy expert who cares for no one. The American College of Physicians has done more to destroy general internal medicine in the last twenty years than any other entity including the non representative American Medical Association. Physicians, nurses, therapists, social workers, dietitians can work together for the patient’s benefit if their incentives are appropriately aligned. The incentive should be the patient always comes first. As the baby boomers age and develop more complicated and chronic problems it will take physicians with experience and training in dealing with multi-system disease to provide appropriate care. At some point a decision will need to be made. At that point its all about who the public wants making that decision. Compromise decisions by committee rarely provide the individualized care patients need.

  • DavidBehar

    Painful to agree with Steven Reznick, but I have to. Nurse practitioners are good for patients doing well, and who need refills every 3 months. Nurses are just not trained to diagnose, and initiate treatment for serious conditions. They may give advice about routine illnesses and injuries.

    I think it is easier to get into med school, than to get into training for NP. So anyone may just study hard, and attend med school here or in a foreign land.

    From another angle, the legal responsibility for medical error still rests with the doctors. If anyone wants part of that, welcome to it.

    • Fred Ickenham

      Paragragh 2 is exactly backwards. Otherwise I agree.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Baseball has rules and umpires and predefined schedules, and managers do decide who plays where and when, and often exactly what they throw, how they bat, and where they stand. And if the team does poorly, it’s the manager’s fault, as it should be.
    The quarterback in football has equally few decisions to make in most cases. There may be various degrees of autonomy for players, but there is always someone responsible in charge.
    So can we please just drop this cliché “team sport” analogy?

  • kjindal

    As so completely disappointed I have been with the ACP, AMA, ABIM, etc., this piece really still surprises me.

    “A neurosurgeon can’t substitute for an internist, or an internist for the neurosurgeon, or the advanced practice nurse for the internist, or the internist for the advanced practice nurse…”
    On what level can a board-certified Internist NOT do what an NP in internal medicine, geriatrics, or even cardiology or gastroenterology does? I supervise NPs in geriatrics (not voluntarily). Some are experience and excellent, others are new and humble, and others are stupid and arrogant. A completely mixed bag. But NONE of them think for a second that we are “equals” in judgment or responsibility. This dribble makes me sick.

  • ErnieG

    No disrespect, but this is the stupidest and least helpful posting I have read from an ACP officer. M. Gur-Arie, D.Behar, and S. Reznick are right.

  • FFP

    This buffoon’s salary is paid by all those “quarterbacks” he so easily dismisses.

    Not the first article along the same lines of NewSpeak kind of medicine. “Team care” – what a joke! I guess publishing this crap has to do with Kevin Pho’s career/business interests.

    • DavidBehar

      No. Kevin is just a New England, elitist, supercilious left wing ideologue, totally out of touch with the mainstream in the rest of the nation. This Blog is a left wing propaganda outlet, devoid of any balance, fairness, like a HuffPost of medicine. Trash.

  • azmd

    I scanned this piece to see if I could find any references to liability for adverse outcomes, but interestingly enough, I didn’t see any.

    Check back with me about all this when someone has figured out how responsibility for medical errors gets attributed equally to all members of the medical team and then I’ll be interested in reading about how we’re not the quarterbacks of the team.

  • LIS92

    The quarterback in football plays offense and has a great deal of control on how the play goes. The goal is to get the patient into the “health zone.”

    The baseball team as described plays defense and the pitcher has very little control on what happens to that ball once it’s hit. Of course he hopes it doesn’t get hit, but when it does, the defense goes into damage control mode. The goal is to stop the disease from running the bases.

    I think I would rather have a quarterback

  • southerndoc1

    That the ACP continues to pay Mr. Doherty to put out this kind of drivel is proof-positive of a profoundly dysfunctional organization.

  • Bob

    I went to a baseball game recently, I think to remind me of why I hate that game, which by the way I see as interesting as watching grass grow. The only similarity I see in it to my game of football is the one on one nature of the pitcher and batter, and make no mistake all games come down to one on one situations.
    Other than that a recent study showed 90% of the time by all baseball “players” is spent standing around doing nothing, which is kind of like medicine, as a recent visit by a relative to an ER brought back to me. There were many nurses and techs but only a single doc, and if he wasn’t the quarterback he must have been the owner, as nothing happened without his signal, and I felt confident in his play calling, having been the “the game” all my life. In all games, including life, most of the time is spent doing uneventful things, but when it gets exciting in those one on one moments, while all those I have personally had with injuries were “I’m a nurse”. But if it was a severe trauma I would have more confidence in hearing “I’m a doctor.” So let’s get busy and make more nurses and physicians as the “boomer ones” need replacing as they retire.

  • Dr. Drake Ramoray

    Your football vs. baseball analogy is exceedingly weak. The quarterback is good to nobody if the lowly lineman doesn’t block the defense. I’m not certain that quarterbacks are any more or less relevent than a strong pitching staff in baseball (yes this is multiple people) or an excellent goalie in hockey

    Furthermore the following statement. “Physicians often use a football analogy: they are the quarterbacks of the team, calling the plays that others on the gridiron must follow, because of their greater training and skills.” is only true if the quarterback has to consult with the PR/advertising arm of the team he plays for, who pays the bills, before he can get approval for any play (read treatment) that he wishes to execute on the field.

    This article is garbage, although not unexpected given the author.

    • Guest

      Tell us how you really feel… :)

    • buzzkillerjsmith

      Good to see you back, Dr. R., with fangs and claws intact.

  • buzzkillerjsmith

    My only consolation is that this guy could be with the AAFP, but isn’t.

  • meyati

    The best teams usually out spends the other teams to get the Dereck Jeters, Joe Montanas, Manny Ramirezes, and Brett Favres. Even Detroit pays a lot for Prince Fielder. Then you need to consider what league the team is playing in- major or minor? Give me Michael Oer of the Ravens any day-he protects the quarterback.

  • doc99

    You apparently never heard of the late George Steinbrenner.