The Silo Effect

by Gillian Tett

  7

  FLIPPING THE LENS

  How Doctors Tried Not to Behave Like Economists

  “I like to turn things upside down, to watch pictures and situations from another perspective . . . [and] see how things behave if you change the point of view.”

  —Ursus Wehrli. Swiss comedian and artist

  THE MOOD IN THE LECTURE theater at Harvard Business School was earnest and respectful. Sitting in the rows of seats, arranged in a horseshoe shape around a dais, were some of the most ambitious young people in the world. Attending Harvard Business School typically costs at least $100,000, and competition to win places is fierce.1 The students have sky-high expectations of themselves and speakers who visit that famed lecture hall. And the man chosen to address the students on that day in early autumn 2006 was dazzling.2

  A tall, imposing figure with a craggy face and big ears, Toby Cosgrove, sixty-five,3 was one of most famous heart surgeons in world. During the first few decades of his career, he had shot to glory in the medical world as a pioneering cardiothoracic surgeon who had operated on more than 22,000 patients and filed thirty patents for medical innovations.4 But in 2004 Cosgrove was appointed CEO of the mighty Cleveland Clinic in Ohio, one of the biggest medical centers in America, with an operating budget of $6 billion and staff of 40,000.5 The clinic was ranked among the best in America in numerous fields, including Cosgrove’s speciality of heart surgery. It offered cutting-edge treatments at prices that were better than those of most competitors. People from around the world flocked to use its services. It was, in short, a model of how a twenty-first-century hospital should operate, at least in the eyes of Harvard Business School.

  So the students listened with awe as Cosgrove explained how Cleveland Clinic worked. He was a good speaker, who exuded firm, natural authority, leavened by flashes of dry, self-deprecating wit. What most people did not know was that Cosgrove was also dyslexic. In his teens and early twenties he had struggled at school. But he had battled through this handicap to become a surgeon by virtue of ferocious willpower and a photographic memory. “Dr. Cosgrove is a brilliant man, the most ambitious person in the world since Alexander the Great,” Bruce Lytle, a fellow heart surgeon at Cleveland Clinic sometimes joked. “That is good—you need those people to change the world.”

  After Cosgrove finished his speech to the Harvard students, he took questions. The first few were admiring. But then a young, slim brunette woman named Kara Medoff Barnett, who was sitting in the second row of the auditorium, stood up. “Dr. Cosgrove, my father needed mitral valve surgery. We knew about Clevelend Clinic and the excellent results you have. But we decided not to go there because we heard you had no empathy. We went to another hospital instead, even though it wasn’t as highly ranked as yours.”6

  There was a startled pause. Barnett pressed on, looking Cosgrove in the eye. “Dr. Cosgrove, do you teach empathy at Cleveland Clinic?”7

  Empathy? Cosgrove was a loss. During his decades-long battle to become a star surgeon against fierce odds, Cosgrove had spent numerous days honing his technical skills. But he had never given much thought to empathy. It sounded hippie, if not self-indulgent. “Not really,” he mumbled vaguely, and switched the subject.

  The next day he left Boston, and tried to brush the incident off. But that odd little encounter kept buzzing through his mind. Dr. Cosgrove, do you teach empathy? Ten days later, it popped into his head again, in the unlikely setting of Saudi Arabia. The top managers of Cleveland Clinic were keen to expand in the Middle East, since it had a pool of wealthy clients. So Cosgrove decided to attend the official opening of a new hospital in Jeddah. To mark the occasion, the Saudi king and crown prince hosted a ceremony, along with many local dignitaries, and the new head of the hospital gave a passionate speech.8 “This hospital is dedicated to the body, spirit and soul of the patient,” he declared.9 As he spoke, Cosgrove glanced across to the Saudi king and noticed, to his complete surprise, that tears were rolling down his face.10 He felt a frisson. We’re really missing something here. He was used to thinking about medicine in dry, technical terms, or a delineated bundle of specialist skills. He did not usually think about the whole “soul.”

  But were specialist skills really enough? The question kept buzzing around in his mind. On paper, Cosgrove knew that Cleveland Clinic was an excellent medical center, or at least it was if you looked at it using the type of mental map that doctors used. There were world-class surgeons, physicians, nurses, psychologists, and physiotherapists; there were divisions of Anesthesiology, Pediatrics, Medicine, Surgery, Pathology and Laboratory Medicine, Post-Acute Care, Regional Medical Practice, Nursing, and Education. To name but a few of the specialist teams.

  But was this what sick people really wanted? Was it the best, most effective, or cheapest way to do medicine? Cosgrove was starting to have doubts. Doctors visualized medicine as a collection of technical skills. Patients did not. When people were sick they did not say “I need a cardiothoracic surgeon” or “Take me to a cardiologist.” Instead they would declare “My chest hurts,” or “I am having a seizure,” or “I can’t breathe,” or “My stomach is in pain,” or simply “I feel unwell.”

  In some sense, that differences in perception exist about medicine should come as no surprise. When anthropologists first started to study non-Western cultures in the late nineteenth century, they realized that different societies view the body and define sickness and health in subtly varying ways. Then, as anthropology expanded in the twentieth century, a sub-discipline emerged called “medical anthropology,” which examines how health is perceived, experienced, and implemented in different communities around the world. This discipline, which is one of the fastest growing areas of anthropology, argues that health is not really a matter of biology, or not just science. It is a cultural phenomenon too. Our physiology might be universal. But concepts of “sickness” can vary between different cultures, and within the same society.

  In the last two decades, this idea has had a growing impact on the development and assistance work that multilateral development institutions and nongovernmental organiations do in poor parts of the world. Jim Yong Kim, the head of the World Bank, is a medical anthropologist who has a doctorate in anthropology but is also a qualified physician. He has used these two different skill sets to develop research into the spread of diseases in poor communities, and promoted this interdisciplinary approach at the World Bank. Kim’s colleague and friend Paul Farmer, another medical anthropologist, has pioneered health care experiments in places such as Africa with the group Partners in Health. He has also tried to promote this idea in elite American universities such as Harvard, where he is a professor. Numerous other examples exist in different corners of the developing world.

  However, medical anthropology has hitherto had less impact on the core of Western medicine. Medical anthropologists have tended to work in a corner of academia, or silo, that is far removed from high-flying surgeons such as Cosgrove. But as Cosgrove pondered his encounter in the Harvard lecture theater, he began to play around with some ideas that are the core of medical anthropology. What would happen, he wondered, if he tried to “flip the lens,” and defined medicine as patients, not doctors, experienced it? What might that mean for how a hospital was organized? In the years before Cosgrove’s encounter at Harvard, some doctors in Cleveland Clinic had already been discussing making tweaks to their hospital structure. Innovations in medicine were breaking down the traditional distinctions between surgeons and physicians, and many doctors at the hospital thought that it was time to rethink the structure of some of the departments. But Cosgrove did not just want to fiddle with the organizational chart. He wanted to rethink medicine in a more fundamental sense and question the very foundations of doctors’ specialist silos. In essence, he wanted to do what the bankers and economists that I described in Chapters Three and Four respectively, had not done, namely examine the classification systems that skilled professionals use to arrange the world.

  He kn
ew it would be difficult. Doctors (like economists) spend years training in specialist fields and wield power precisely because few nonspecialists understand what they do. “There is a whole guild system that defines who doctors are, and that guild system is very strong,” Cosgrove later observed with a dry laugh. That is true of most professions. At the Bank of England and Federal Reserve before 2008, economists had stayed inside their specialist silos and assumed that the business of regulating nonbank financial groups was an activity that lay outside the economics sphere. Similar patterns are seen in numerous other corners of business life, particularly when the activity is so technically complex that it is difficult for outsiders to understand what is going on, far less challenge it. The elite of any society rarely have any incentive to challenge the status quo, or the taxonomy.

  But Cosgrove was a determined man. So, a few months after his fateful encounter in Boston with Barnett, Cleveland Clinic embarked on an experiment. It was an initiative that ended up being somewhat controversial in the medical world, capturing the attention of Washington’s White House. But it also had implications that extend well beyond the medical world. What the Cleveland Clinic story shows is that if you want to combat the problem of silos, you do not always need to shuffle people around between different departments, organize corporate retreats, or encourage people to take radical career breaks (as I have described in the last two chapters). Another way to tackle the issue is to encourage people to reflect on their classification systems and how they organize the world, or to even turn those taxonomies upside down. Mental reorganization can sometimes be almost as effective as structural change, particularly if those two shifts go hand in hand. And that lesson has big implications not just for doctors, but for economists, bankers, manufacturers, journalists, and numerous other skilled professionals. Not to mention sick people who just want to find a doctor with empathy.

  IN SOME RESPECTS, CLEVELAND Clinic is the perfect place for somebody to launch silo-busting experiments. The hospital has always had something of an unorthodox spirit. Its origins go back to the 1880s when Frank J. Weed, a successful surgeon, hired Frank Bunts and George Washington Crile, two newly qualified doctors, to create a small medical practice to serve the then booming market of Cleveland.11 In 1891 Weed died of pneumonia, aged forty-five, and the remaining men paid $1,778 to buy Weed’s offices, along with three horses, buggies, snow sleighs, and medical equipment such as “3 Nasal saws, 2 Intestinal clasps, 3 Bullet forceps, 1 Horse shoe turnica.,” according to the estate.12 The men then hired a third surgeon, William Lower, and the practice swelled, to become a thriving medical center in the Osborn Building in downtown Cleveland.13

  By 1914 the surgeons were at “a point in their careers when most physicians might be begin planning their retirement,” as the official history notes. But that year World War I broke out and Dr. Crile went to work in the United States Army Lakeside Hospital Unit in France.14 The two other surgeons also volunteered, and that experience changed their views on life and medicine.15 At that time, almost all doctors in American civilian life operated on a commercial, profit-seeking basis, where each doctor was an individual entrepreneur. But the army forced doctors to work in multidisciplinary teams in the military hospitals. And after tasting that approach, the three men became convinced that acting “as a unit” was not just sensible in war, but in peacetime as well. So when they returned to civilian life in Cleveland, the three surgeons reopened their clinic on a new model. Instead of operating as individual doctors, they arranged themselves as a partnership, sharing a fixed salary, and thus acting as a unit.16

  Cleveland Clinic was not the only American hospital that operated like that. Over in Rochester, Minnesota, two brothers, William and Charles Mayo, had established a similar hospital as far back in 1889.17 However, this approach was rare, since most American doctors disliked this system. “The founders of the early group practices were not popular with the medical establishment of their day,” Cosgrove observes. “They were called ‘medical Soviets,’ ‘Bolsheviks,’ and ‘communistic’ [sic]. Professional associations railed against what they termed ‘the corporate practice of medicine’ [and] when some physicians in Palo Alto attempted to form a group practice they were barred from their local medical association.”18

  But the clinic expanded, with an eager pool of patients. In the nineteenth century, Cleveland was one of America’s wealthiest cities, with a thriving industrial and agricultural base, and while the wealth was declining in the early twentieth century, the city still had many well-to-do professionals.19 In 1929, the hospital was hit by two blows. On May 15 of that year a pile of X-ray film that was being stored in the basement of the hospital caught fire. An explosion sent a cloud of toxic gas through the building, killing 123 people, including John Phillips, the head of medicine at the hospital.20 Five months later, the stock market crashed. The doctors slashed everyone’s salaries, took out loans financed by the surgeons’ own life insurance policies, and the doctors all worked overtime. By then, the septuagenarian Dr. Crile, one of the original founders, was almost blind with glaucoma. But after disaster struck, he returned to service and kept conducting operations, feeling his way around the patients by touch. By 1941 Cleveland Clinic had paid off its debts, and started to recruit again.21

  After World War II the hospital expanded. To do this it had to be inventive, since Cleveland was a city in decline. Early in the twentieth century Cleveland had been so wealthy that it had a famed Millionaire’s Row.22 By the 1960s, however, the city was blighted with such extreme industrial and economic decline that riots broke out in the downtown area around the clinic. Cars were burned, angry mobs roamed the street firing guns and throwing bricks. Indeed, the violence was so bad that Cleveland Clinic was used as a staging area for the National Guard tanks and military personnel called in to suppress the riots.23 But the clinic did not abandon the city. It remained in its original location, on the corner of 93rd Street and Euclid Avenue,24 and once the riots had subsided the doctors started buying up the newly vacant plots of land and looked for ways to grow.

  Then a crucial breakthrough occurred: René Favaloro, one of the clinic’s star surgeons, performed the world’s first coronary artery bypass.25 That attracted global attention and acclaim. As the coronary surgery unit expanded, the other areas, ranging from radiology to urology to gastroenterology, swelled too, attracting doctors and patients from across the world.

  In the 1970s, the hospital spread its wings beyond Cleveland. It established medical centers across the rest of Ohio, and brought nine regional hospitals into its orbit.26 In the 1980s it expanded into places such as Florida, where there was a big, wealthy, aging population in need of health care. The growth was so dizzy that by 1988 the hospital had become the city’s largest employer, with 9,134 staff, outstripping Ford Motor Company and LTV steel.27 By the end of the twentieth century, the roster had risen to 40,000.28 That made the hospital not just the largest employer in Cleveland, but the second biggest employer in the whole state of Ohio, exceeded only by Walmart.29 It was a stunning testament to how the fortunes of Ohio had changed, as its traditional mainstays of industry and agriculture had declined. But it was also a striking sign of how the whole business of medicine was changing. A century earlier, when the doctors such as Crile, Bunts, and Lower had created Cleveland Clinic, it had been easy to run the hospital as a unit. The operations were so small that everyone could cooperate with everyone else, face-to-face. It was possible to run a group of doctors by using “social grooming,” to cite the phrase beloved by the psychologist Robin Dunbar and Facebook. By 2000, however, Cleveland Clinic had become a vast, complex, bureaucratic behemoth. The Dunbar threshold of 150 had been breached many times over.

  To cope, the managers of Cleveland Clinic installed cutting-edge logistics. A network of elevated covered walkways enabled staff to move between the different buildings, even in the baking summer heat of Ohio—or the freezing winters, when snow blanketed the state. Suction pipes were installed between
the buildings to enable radiology scans, X-rays, and other documents to fly between departments via tubes. When digitization took hold in the 1990s, the suction tubes were supplemented with a vast web of electronic networks that passed messages around the building, tracking the operations of the hospital, and informing doctors, nurses, orderlies, and machines what needed to be done.30 Underneath the buildings, the hospital managers constructed a complex network of tunnels, along which unmanned trucks moved along tracks carrying essential supplies. The managers even created a vast fleet of unmanned robots in the tunnels programmed to ferry supplies between the different buildings. These robots were so sophisticated that they could restock items, keeping the systems running smoothly, with little human intervention. “Cleveland Clinic is a hospital trying to be a Toyota factory,” a Newsweek article declared in 2009.31 Or as a child might have said, Cleveland Clinic resembled the Willy Wonka Chocolate Factory in Roald Dahl’s book; a place dedicated to seamless connections, knitted together with a vast, byzantine web of suction pipes, robots, tubes, connecting machines, and IT systems.

  But while the logistics and robots looked impressive, there was a darker side to this success: the more complex that the technology and the bureaucracy became, the more the institution was in danger of succumbing to silos. In some sense, there was nothing intrinsically wrong with that. On the contrary, specialization is essential when operations are vast and complex. And Cleveland Clinic seemed to be working well. “In the U.S. News & World Report annual evaluation of hospitals, Cleveland Clinic had been recognized among the top 10 hospitals in the country every year the survey had been done,” the official history of the hospital noted in 2004, adding that “singled out for special recognition were cardiology (tops in the nation each year from 1995 to 2003), urology, gastroenterology, neurology, otolaryngology, rheumatology, gynecology, and orthopedics.”32 But because those specialist silos were so successful, they were also becoming more entrenched. In that respect, then, the hospital looked like numerous other large institutions basking in a period of success. Or it did until Cosgrove took over.